Q-CareQ-Careandand

Physician Physician AccountabilityAccountability in in Health System ReformHealth System Reform

Board of Governors 9-07Board of Governors 9-07

Jack Lewin, MD CEO American College of CardiologyAmerican College of Cardiology

Health System Reform is Health System Reform is Essential and ImminentEssential and Imminent

Access, Quality, and CostAccess, Quality, and Cost

Environmental Trends• Exploding new technologies

• Government share of health care financing is increasing, as employer share declines

• Budget constraints may force government to shift from health care reform to pure deficit reduction, forcing further rationing and disparities

• Wal-Mart clinics, concierge care, and other unexpected developments

Ramp Up to the 2008 Ramp Up to the 2008 ElectionsElections

CV Environment

• Cardiovascular disease number one killer Cardiovascular disease number one killer • 43 percent of all Medicare dollars go to 43 percent of all Medicare dollars go to

cardiovascular related treatmentcardiovascular related treatment• Aging population demands more Aging population demands more

cardiovascular servicescardiovascular services• Looming shortage of cardiovascular Looming shortage of cardiovascular

specialistsspecialists• Personal health behaviors/risks further Personal health behaviors/risks further

increase future demandincrease future demand• Congress has directed DHHS (CMS) to Congress has directed DHHS (CMS) to

oversee performance and quality.oversee performance and quality.

Health System Reform

• Why reform is stalledWhy reform is stalled• Everybody must bring something to the Everybody must bring something to the

table table – GovernmentGovernment– PayersPayers– HospitalsHospitals– PatientsPatients– BusinessBusiness– Physicians and health care providersPhysicians and health care providers

Physicians and the Health Physicians and the Health Professions are NOT at the Professions are NOT at the

TableTable

• Single Payer ReformSingle Payer Reform

• Employer MandatesEmployer Mandates

• Individual MandatesIndividual Mandates

• Voluntary Reform ApproachesVoluntary Reform Approaches

• Reimbursement vs. AccessReimbursement vs. Access

Really Interesting QuestionsReally Interesting Questions

• Can Health Care Professionals—e.g. Can Health Care Professionals—e.g. Specialties like ACC---be Self-Specialties like ACC---be Self-

Regulating Entities?Regulating Entities?• Can Physicians Overcome Conflicts of Can Physicians Overcome Conflicts of

Self Interest to Do This Effectively?Self Interest to Do This Effectively?• Is Government Going to Take Over Is Government Going to Take Over

Quality Measurement Regardless of Quality Measurement Regardless of What the Profession What the Profession Does?Does?

What Should Physicians Bring to the Table?

• Individual and collective professional Individual and collective professional responsibility for quality and valueresponsibility for quality and value

• Care that isCare that is– Patient-centeredPatient-centered– Evidence-basedEvidence-based– Cost-effectiveCost-effective– Value vs. volumeValue vs. volume– Ethical Ethical

The ACC Approach:

Peer Review on a Peer Review on a Macro LevelMacro Level

QCARE• Continuous review of new scienceContinuous review of new science• Evidence-based guidelines and standardsEvidence-based guidelines and standards• Application of guidelines at the point of careApplication of guidelines at the point of care• Data reporting and collection of clinical data Data reporting and collection of clinical data

through registries (NCDR)through registries (NCDR)• Physician and hospital quality feedback and Physician and hospital quality feedback and

specific quality initiatives (D2B)specific quality initiatives (D2B)• Education and lifelong learning based on Education and lifelong learning based on

measured gaps in quality and performancemeasured gaps in quality and performance• Appropriate use of technology Appropriate use of technology • Evaluation to further goal of continuous Evaluation to further goal of continuous

performance and outcomes improvement performance and outcomes improvement

QCARE

Science

Technology

Evaluation

Standards

Education

Reporting

Quality Initiatives

QPatient Centered

Care

Improvement•D2B

Measurement•NCDR

Implementation - “Bridge”•Care Plans•Wall Charts•Standard Orders•Pocket Guides•EHRs with “Wikipedia” GL updates?

Guidelines/Standards•Guidelines•AC / PM

Do

Plan

Study

ActEducation

&Training

Education&

Training

QCARE in Action

Current InitiativesCurrent Initiatives

• MedicareMedicare• Private sectorPrivate sector• Professional accountability (QCARE)Professional accountability (QCARE)• Other Specialty partnershipsOther Specialty partnerships• NQF, NCQA, ABIM, AHRQNQF, NCQA, ABIM, AHRQ• Reality Testing*Reality Testing* * 100 years of life expectancy* 100 years of life expectancy

* Decline n Rates of Death and HF in ACS, ’99-’06 (Fox, * Decline n Rates of Death and HF in ACS, ’99-’06 (Fox, Eagle et al)Eagle et al)

* Financial Incentives for AMI care in P4P of no Avail* Financial Incentives for AMI care in P4P of no Avail• (Eric Peterson, JAMA 2007)

Getting to the Holy GrailGetting to the Holy Grail

• Expedited Guidelines and Clinical Expedited Guidelines and Clinical Consensus DocumentsConsensus Documents

• Ambulatory data collectionAmbulatory data collection

• EHR Adoption with Embedded GLs and EHR Adoption with Embedded GLs and Decision-Support SoftwareDecision-Support Software

• Financing comprehensive quality Financing comprehensive quality

ImprovementImprovement

What Are the Barriers?

• Suspicion about our ability to self-Suspicion about our ability to self-regulateregulate– ConflictsConflicts– Self servingSelf serving– Industry partnershipsIndustry partnerships

• Individual physician commitmentIndividual physician commitment• Significant resources needed to go Significant resources needed to go

from guidelines to practicefrom guidelines to practice• Time may be running outTime may be running out

How Physicians Can Change How Physicians Can Change the Future of Health Carethe Future of Health Care

Health care reform must focus on improving health and health care value for patients. Reform must be market based but physician led. Improving the value of health care is something only medical teams can do. Competition must be around improving results (outcomes). With such positive sum competition, patients will receive better care, physicians and providers will be rewarded for excellence, and costs will be contained. The goals must focus on increased value for patients; medical practice organized around medical conditions and care cycles, and a recognition that results (risk adjusted outcomes and costs) must be measured. If physicians fail to lead these changes, they will inevitably face ever-increasing administrative control of medicine. Improving health and health care value for patients is the only real solution. --Michael Porter PhD