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Impact of new US administration on cardiology practice, health care unclear
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The striking, recent Republican presidential victory, coupled with Republican control of both the U.S. Senate and House of Representatives and many state governments, portends profound but difficult-to-predict changes in U.S. health care policy. The future is especially unclear related to implementation of the winning candidates’ promises to “repeal and replace” the Affordable Care Act, or Obamacare; redefine Medicaid eligibility and benefits at the state level; convert federal funding of Medicare to a defined contribution structure; paying a set amount to individuals to help them buy insurance in an open market; create tax-advantaged health savings accounts; enable negotiation of drug prices; and, generally, deregulate a “free market” for purchasing health care.
Implications for Obamacare
It is safe to speculate that none of these initiatives will be accomplished quickly. Although repeal of Obamacare will likely be an early victory for the new administration, it will not be simple to replace it with programs to provide coverage for its 21 million current recipients, retaining desirable features such as inclusion of those with pre-existing medical conditions, continuing to allow adult children to remain on their parent’s policies until age 26 years and providing wide access to preventive medical services. Variations of innovative Medicaid plans such as Vice President-elect Mike Pence’s Healthy Indiana Plan, designed with the help of Indiana health consultant Seema Verma, MPH, recently named by the Trump transition team to be administrator of CMS, provide templates for alternatives to many provisions of Obamacare. Details to implement these replacement programs are a top priority but will still require months and years to complete.
Verma’s new boss, veteran congressman Tom Price, MD, R-Ga., an orthopedic surgeon, head of the House Budget Committee and incoming HHS secretary, has long supported proposals to repeal Obamacare and reduce federal spending for Medicaid. Price has also been critical of the work of the Center for Medicare & Medicaid Innovation (CMMI), which is responsible for the multiple trial programs being tested under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation. MACRA does not fall under the “repeal and replace” mandate perceived for Obamacare and will continue in some form for the foreseeable future, as it received widespread bipartisan support as a cost control measure when Congress repealed the SGR formula. Various provisions of payment models based on the Merit-based Incentive Payment System (MIPS) fee-for-service model would likely continue even if Medicare is privatized; Price has previously spoken against aspects of alternative payment models (APMs) for episodes of care that favor narrow networks of physicians to control costs, but all these measures are still in the developmental phase, subject to modification and re-direction, as well as migration to non-Medicare programs. It would be a mistake to assume that MACRA, value-based purchasing and bundled payments are going away. Further in the future are more dramatic plans such as those of House Speaker Paul Ryan, R-Wisc., to control Medicare spending by providing premium support for Medicare recipients to buy health insurance on the private market.
The AMA has endorsed Price as “a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs.” These are worthy nonpartisan goals.
CV professionals can act
The Republican victory offers an opportunity for CV professionals regardless of political leanings to effect much needed change in our health care policies to maximize efficient use of our resources to improve the health of our patients. CV medicine has been at the forefront of innovation, basing care on therapies that have been proven to work, leading the way to systematic implementation of standardized care. Optimizing patient outcomes is a more complex undertaking than optimizing the processes of care. Factoring in payment incentives that reward quality and value rather than volume of services is a new frontier, best approached deliberately and cautiously.
The American College of Cardiology, together with the American Heart Association and multiple other professional organizations, has decades of experience creating authoritative, evidence-based clinical guidelines and appropriate use criteria, and it has anticipated the need for comprehensive databases documenting clinical care delivery by creating the National Cardiovascular Data Registry in 1997. Multiple iterations later, the ACC is investigating innovative models of care delivery such as SMARTCare, designed by and for clinicians to leverage electronic health record (EHR) systems to deliver better, more appropriate, value-driven care, with the added hope of evolving the EHR from a burdensome, time-consuming annoyance into a useful tool that benefits patients and, not so incidentally, helps reduce unnecessary cost.
SMARTCare is a quality improvement project, funded by a CMMI grant to implement a suite of clinically validated decision aids at the point of care to improve the treatment of stable ischemic heart disease. The point-of-care decision aids and registries that make up SMARTCare are evidence-based and guideline driven, and provide immediate, actionable information to the clinician “at the bedside.” The ACC’s FOCUS tool, embedded in the clinician’s EHR, applies the appropriate use criteria (AUC) for various tests in “real time” as the test order is placed. Other software modules, such as ePRISM and eLUMEN, allow a more comprehensive consent process that informs the patient before their procedure and advises the interventionist before and during the procedure about individualized risk of contrast-induced nephropathy, bleeding risk, as well as the true benefits of drug-eluting stents vs. bare-metal stents for the specific lesions in the specific patient on the table. The goal of SMARTCare is to prove that when used together and used consistently, these and the other embedded software products (eg, ACC’s PINNACLE clinical data registry) that make up the project will simultaneously improve outcomes, increase patient satisfaction and reduce costs. SMARTCare, a 3-year demonstration project, will end in September 2017. Results should be illuminating one way or another. Demonstration projects such as SMARTCare are worthy of our continued support so that we may intelligently approach the future with innovations in care of proven worth.
Effective solutions needed
Cardiologists, their patients and voters, in general, share a sense of frustration with the current state of the American health care system: Too much time spent with record keeping, not enough face time with patients, expensive insurance premiums with spotty and uneven coverage, high patient copayment requirements, limits on access to care as well as a lack of trust in the government, the pharmaceutical industry, for-profit insurance companies and large institutions. The cost of our health care is staggering and continues to increase, as 10,000 Americans enter the Medicare age group every day. Poor- and middle-income patients struggle to pay for medical care as costs continue to increase more rapidly than incomes.
Innovative and effective solutions to these problems will require civil discourse, compromise and sacrifice by us all. We cardiologists are properly focused on delivering evidence-based, high value cost-effective care to each of our patients, insisting that all be treated with dignity and respect, placing patients’ interests before our own. Amid great change, some things should not change — the bond between physicians and patients is one.
- For more information:
- Joshua D. Liberman, MD, FACC, and L. Samuel Wann, MD, MACC, FESC, are cardiovascular specialists at Ascension Healthcare Milwaukee. Wann is also Section Editor of the Practice Management and Quality Care section of the Cardiology Today Editorial Board. The authors can be reached at 2350 N. Lake Drive, Suite 400, Milwaukee, WI 53211; email: samuelwann@gmail.com.
Disclosure: The authors report no relevant financial disclosures.
Perspective
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Richard A. Chazal, MD, FACC
Our job is to try and work with whatever administration or Congress is in place, regardless of any elections, to try to do our very best to continue to prosecute the idea that good patient care is the ultimate goal, and our vehicle is to help our membership accomplish that.
Were anticipating that the new administration is going to make significant changes to the Affordable Care Act. The college has gone on record of being supportive of the concept of access to care for patients. Exactly how that is accomplished from a legislative standpoint, I think we have to be supportive of whatever legislation comes out of Congress and out of the White House at any time. A principled position has to be in support of good care for patients.
We are certainly very hopeful that there will continue to be substantial funding for prevention and treatment of heart disease, which is still the No. 1 killer in the United States. We are hopeful that Congress and the White House will be sensitive to this and will continue funding.
Perspective
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Steven R. Houser, PhD, FAHA
The new president and Congress have a tremendous opportunity to advance a culture of health that guarantees all Americans have access to the very best medical care, strong prevention measures, and research that provides innovative treatments. The association has long advocated for health care that is effective, equitable and excellent, as outlined in our principles. We believe patients must remain the first priority if the current system is overhauled because everyone in our nation deserves access to affordable insurance coverage and quality care.
Additional emphasis on prevention and investments in it will be key to reducing health care costs and designing a sustainable system that ensures that every American has affordable high-quality medical care.
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