ACC16: Cardiology, it's time to embrace population health
As the healthcare industry continues its course toward value-based care, population health is the topic de rigueur. No doubt, HHS’ announcement last year to set a goal tying 50% of fee-for-service, Medicare payments to value through alternative payment models by the end of 2018 has helped move the needle toward more preventative care. At the American College of Cardiology’s (ACC) 65th Annual Scientific Session & Expo, ACC President Dr. Kim Allan Williams addressed attendees in his hometown of Chicago highlighting ACC’s new strategic focus on prevention and touting how cardiology can affect population care.
Before launching into his address, attendees were treated to a video presentation from first lady Michelle Obama, developer of the childhood obesity prevention program Let’s Move. “Preventing conditions like cardiovascular disease starts early with the habits we instill on our kids from the food we serve them to the physical activity they do or don’t do everyday,” the first lady said, adding, “Healthcare providers…are absolutely critical in these efforts because people look to you for the information they need about their health and their family’s health.”
Current cardiovascular conditions not a promising picture
With the exception of a lull between 1918 and 1919 thanks to the Spanish flu pandemic, cardiovascular disease is consistently the leading cause of mortality in the U.S., Dr. Williams noted. He warned “if we don’t gain control,” cardiovascular mortality is projected to increase from 17 million in 2013 to over 23 million in 2030.
He stated the good news is most cardiovascular-related deaths are preventable but “success lies in our power to work together as a community, globally.” He noted ACC and its 52,000 members are in a great position to advocate for policies to provide cost effective care. Williams also took a stab at current drug pricing models. “No one should have to pay half their salary for just basic medications,” Williams said, adding such policies only serve to increase healthcare disparities.
But at the moment, the landscape doesn’t look great. Findings from a recent study published in Mayo Clinic Proceedings found less than 3% of Americans exhibit a “healthy lifestyle.” Such a lifestyle is defined as:
- Never smoking;
- Regularly exercising (at least 150 minutes a week);
- An appropriate BMI (under 20% for men and under 30% for women); and
- A healthy diet.
In the Simon Dack Lecture during the opening presentation, Dr. David Nash, founding dean of Thomas Jefferson University’s Jefferson College of Public Health in Philadelphia echoed those findings by stating 40% of all deaths can be attributed to four determinants:
- Physical inactivity;
- Alcohol; and
- Unhealthy diet.
Regarding population health, an individual’s location may be more important than genetics. Using public data from the Robert Wood Johnson Foundation, Nash shared different life expectancies in the Washington, D.C. metropolitan area based on location. The data show individuals in both Montgomery and Fairfax countries on average live to be 84 years old while those in the district proper on average live to be 77 years old.
“Your zipcode is your healthcare destiny,” Nash said.
But the population health issue isn’t regulated to geographic borders. As Williams noted, noncommunicable diseases (NCDs) know no such border and are a global issue. In 2015, 42 million deaths were associated with NCDs and 21 million of those deaths were associated with cardiovascular diseases, Williams stated.
Nash added the public perception of population health is mired in confusion. “We have a gigantic population health challenge ahead,” he said.
Attendees were hit by a three-pronged call to action from the opening speakers. First, Michelle Obama stated attendees need to be leaders in their communities to:
- Educate parents;
- Emphasize the importance of prevention; and
- Advocate for better health policies at all levels of government.
Williams stated cardiology’s focus must be expanded. “If we are truly to remove cardiovascular disease as the leading cause of mortality around the world, we must shift the paradigm from treatment to prevention and begin moving toward population health,” he stated.
As can happen when discussing moving toward value-based efforts, money entered the discussion. The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) is poised to change how providers get paid. In an earlier interview at this year’s HIMSS conference, Arien Malec, ONC Health IT Standards Committee Co-Chair and VP at RelayHealth, told Healthcare Dive, “Every dollar for how you’re going to get paid by CMS is going to change and the measurement year is earlier than you think.”
“MACRA will undoubtedly have profound impacts on U.S. healthcare delivery,” Williams stated during his opening presentation. The switch from volume to value has been set in motion and he stated quality reporting is here to stay and will be a critical part in provider payment models moving forward “regardless of how the details unfold.”
“No outcome, no income…That’s what MACRA is all about,” Nash stated, adding transparency is “the only way we’ll achieve true professionalism [but] we’re well on our way.”
How will cardiology get there? As Nash states, first things first, there needs to be more agreement. For example, unexplained clinical variation needs to be reduced as does slavish adherence to professional autonomy. In addition, more measurements should be utilized to help close the feedback loop.
Nash notes this will require the current medical education model to be changed. Education surrounding behavioral economics and nutrition will need to be placed into the medical education continuum, Nash stated.
While the content within the medical education model has clearly changed a great deal, the general structure has largely remained unchanged. To that end, American Medical Association President Dr. Steven Stack told Healthcare Dive in an earlier interview, "We are working doggedly and aggressively to completely reinvent the model of medical schools so hopefully at the end of a decade, in which we're only roughly in our third year, we will have been able to reinvent the medical school model so that physicians of tomorrow come out with a different, better tailored skillset and knowledge base to help them in today's health system which is very different than it was in 1910 when the current model was created.”
The overarching takeaway from the presentation was it’s critical for cardiologists to take a bigger role educating patients as well as the broader public about how their lifestyle impacts their heart and their overall health. And cardiologists need to get more involved in health policy. Using the example of the mandatory bundled joint payment model, Nash said in three years, there could be bundled payments for congestive heart failure. “That, colleagues, is where we’re heading…The people who write the rules are not in this auditorium,” Nash stated. “We need to be a part of that conversation moving forward so we can participate in aligning physician compensation with population health.”
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