Our December 2009 Cath Lab Digest article entitled “State of the Union: What is Keeping You Up at Night?” made some predictions about the future of healthcare. One prediction was that a new focus on prevention and chronic disease management would surface through the emergence of substantial programs aimed at changing the existing acute care paradigm. Do not call me Carnak the Magnificent yet, but such a trend has already begun to happen.
Statistics show that age-adjusted death rates from cardiovascular disease are declining across the country, causing persistent speculation as to why. Is it because Americans are adopting healthier lifestyles — giving up fast food and hitting the gym on a more regular basis? Or perhaps this can be attributed to increasing compliance with prescribed statin therapy? No matter the reason, the irony is that historically much attention and spending has been focused on the acute care side of cardiovascular disease, while not enough attention has been given to the lifestyle modifications and proven preventative treatments that are essential to increased overall cardiovascular health. Wouldn’t placing increased emphasis on the preventative side of the equation make more sense than spending ever-increasing amounts of care delivery time, organizational budgets, and other important resources on this incurable disease once it’s already occurred? We believe the answer is a resounding yes!
The current cardiovascular epidemic peaked in this country in the mid-90s as a result of a large group of post-WWII generation Americans (the ‘baby-boomers’) with unhealthy lifestyles reaching the at-risk, over-45 threshold for cardiovascular disease. Smoking, poorly controlled hypertension, unhealthy eating, and untreated diabetes significantly contributed to a never-before-seen wave of coronary artery disease (CAD), which is still rampant today. In fact, in the United States and throughout the western hemisphere, atherosclerosis is the culprit for approximately 85% of all cardiovascular disease that presents in one form or another.
Fortunately, today’s baby boomers appear to be adopting healthier lifestyles — they smoke less, and better-manage their cholesterol and high blood pressure in addition to eating better and moving more, all of which results in greater longevity despite the persistently high incidence of CAD. Thus, although CAD remains prevalent, Corazon believes this trend toward preventative care and lifestyle modification can work to delay the need for treatment and improve the quality of life for many who suffer from this disease.
Another prediction in our 2009 article was related to Accountable Care Organizations (ACOs) in the context of preventative medicine. Our forecast was that ACOs would be developed in order to administrate bundled payment demonstration projects that pay for “episodes of care.” We anticipated that payment rates would become lower than the existing average and would provide payment for hospital and physician services that cut across the full continuum (pre- and post-acute care). Likewise, rewards would be provided for efficient organizations, while inefficient providers would be penalized.
These financial rewards and penalties are being structured. Prevention has indeed taken on a new focus as a result of healthcare reform and the April 2011 release of the Department of Health and Human Services/Centers for Medicare and Medicaid Services (CMS) proposed Accountable Care Organization regulations. Although the details regarding how the Shared Savings Plans will be operationalized are a bit unclear, the overall program goal of assigning accountability for quality and cost, using incentives to improve the health and well-being of the beneficiaries, is evident. The patient-centered medical home — a cornerstone of the ACO model — has its roots in a high-quality primary care model that can be focused on risk screening and risk modification as a means to keep people well.
Corazon anticipates that enhanced care coordination between the primary care physician (PCP) and CV specialists will become increasingly essential to achieving desired quality outcome metrics. Likewise, the identification of additional community resources to support the work of the PCP and various specialists will be another important element in the new wellness and prevention paradigm.
Nationally, there has been renewed energy to endorse and incentivize physicians and patients to adopt treatment guidelines for primary and secondary prevention. Experts predict that the new ACO regulations will provide a beginning framework to shift the focus of care from payments for acute episodes of care to payments (and incentives) for primary and secondary preventative care.
Widely endorsed primary prevention strategies in the adult population have been succinctly outlined by the American Heart Association (AHA). The goal of primary prevention is for the adult population to understand their risk for cardiovascular disease and routinely have their risk factors assessed by their primary care provider. Secondary prevention strategies focus on identifying and treating patients with cardiovascular disease or those patients with very high risk of developing CV disease.
Risk intervention strategies as identified in Table 1 focus on smoking cessation, blood pressure and cholesterol control, healthy eating, and exercise and weight management. The goal of preventative healthcare today should be to keep people out of the cath lab. Though significant strides have been made in recent years, as evidenced by the declining CAD incidence rates, we still have many steps to take in order to align incentives across hospital departments. Corazon believes we need to continually work to shift the healthcare paradigm with regard to how we deliver care, allocate dollars for coverage, and incentivize the population to not only strive for, but also attain, a healthy lifestyle. This must truly be a collaborative effort among varying physician specialists, bedside care providers, C-suite administrators, and other key leaders.
Controlling cardiac risk factors so people are healthier is the most important strategy — it really is that simple. However, embracing this basic concept at every level of the organization can prove to be the most difficult hurdle to overcome. Additionally, prevention tactics will only work if there is an equal commitment from the patient as well. Embracing lifestyle changes, partnering with physicians and healthcare providers, and an ongoing focus to adopt these evidence-based wellness strategies will be essential to create lasting personal and community impact on overall health.
As the cliché states: an ounce of prevention is worth a pound of cure. Prevention can be our most valuable wellness strategy, but will require a continual shifting of priorities, incentives, and perspectives within the scope of cardiovascular care delivery. Though mortality rates for CAD are on the decline, the numbers are still far too high. The only place we have to go is ... DOWN.
Sue is a Senior Vice President at Corazon, offering consulting, recruitment, and interim management for the key hospital service lines of heart, vascular, and neuro specialties. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Sue, email firstname.lastname@example.org.
This article was published with permission from Cath Lab Digest 2011;19:35–36.