Our Physicians and Our Profession Must Lead in Improving Our Health ...

Journal of the American College of Cardiology © 2010 by the American College of Cardiology Foundation Published by Elsevier Inc.

Vol. 55, No. 20, 2010 ISSN 0735-1097/$36.00 doi:10.1016/j.jacc.2010.04.002

VIEWPOINT

Our Physicians and Our Profession Must Lead in Improving Our Health Care System Arthur Garson, JR, MD, MPH,* Carolyn L. Engelhard, MPA,† John C. Lewin, MD‡ Charlottesville, Virginia; and Washington, DC Health care reform legislation has passed in Washington. The status quo was the worst of options, so this imperfect solution at least offers a sense of direction. As we know, true reform is about patients, practitioners, and the health of America. It is more important than ever for us as cardiologists to provide leadership by demonstrating our professionalism, most simply defined as “putting the patient before the doctor.” With professionalism as our banner, the advocacy for appropriate payment takes on an expanded meaning: not only should we be compensated fairly, but we must also be available to our patients in the appropriate location at the appropriate time. As a follow-up to reform, framing our discussions with legislators and regulators in terms of the health of America, and specifically the health and well-being of their friends and constituents, should at least cause health care decision-makers to pause and reflect on our important perspective. In addition to focusing on the relationship between doctors and patients, our expanded view of medical professionalism must now include a responsibility to communities and to society, with physicians as stewards of limited resources. Regardless of the timing of the rollout of the new health care legislation and regulation, we as physicians are poised to lead efforts in 5 areas of reform-minded health care delivery: appropriate services, “system professionalism,” a “National Institute for Keeping People Healthy,” covering the uninsured, and providing access for all with new approaches to workforce. Even in these unsettled times, we are challenged to lead, first for our patients, second for our country, and finally for ourselves. Appropriate Services The percentage of patients 20 years of age or older who received percutaneous coronary intervention (PCI) over the last decade varies greatly from state to state, ranging from 10% in Oregon to 29% in Iowa with no appreciable differences in outcome (1). More than half of Medicare From the *Office of the Executive Vice President and Provost and †Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia; and the ‡American College of Cardiology, Washington, DC. Dr. Lewin is the Chief Executive Officer of the American College of Cardiology. Manuscript received August 21, 2009; revised manuscript received April 1, 2010, accepted April 1, 2010.

beneficiaries receiving elective PCI do not fit eligibility according to national guidelines (2). This variation cannot be explained by severity of illness, age, other demographics, or patient demand (3,4). Two explanations have been offered: first, that there are “high use” parts of the country where the prevailing attitude in the medical community is to do more testing and more procedures. Nonetheless, these high uses either are in contradiction to published practice guidelines or are systematic misinterpretations of guidelines that are written as “may be indicated” (e.g., the American College of Cardiology [ACC] class II [4]) but are interpreted as “always do” (5). Second, given that the current payment system pays for every procedure, it is inescapable that financial incentives for physicians play a role in the higher use (6). Atul Gawande (7) has recently described the situation in McAllen, Texas, which has almost the highest priced medical care in the U.S., but in many cases, falls short of providing high-quality care. McAllen spends more than double per Medicare enrollee than most cities in the U.S., including neighboring El Paso. When confronted with the facts—that McAllen’s spending for medical services greatly exceeded the national average with nothing to show for it in terms of quality—the McAllen physicians and health administrators were shocked to find their utilization rates (and hence, costs) were so much higher. The experience in McAllen provides a good lesson in professionalism. Health care costs are a reflection of the individual decisions physicians make. The physicians in McAllen appeared to have little understanding of how their resource utilization compared with that of peers, or whether their patients had better outcomes. Our current reimbursement system does not distinguish between utilization and quality, and in fact rewards more tests and procedures. As was pointed out in McAllen, ignoring guidelines is either due to a lack of education or a display of behavior that is either unethical or scientifically unacceptable—and not professional. Such impressions left with the public and legislators provide a challenge to physicians to take a stronger leadership role in health care reform on behalf of our patients and of the profession itself. The ACC has a recognized history of working on quality initiatives such as generating clinical

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practice guidelines, defining appropriate use of medical services, and developing registries that allow hospitals and physicians to measure their performance and compare themselves with others. Current examples are the quality improvement programs Door-to-Balloon Alliance (8), which has markedly improved the care of myocardial infarction patients, and the Quality First Campaign (9), which aligns the provision of the very best care—not the amount— with creating greater quality and value for patients. All of these initiatives on the part of the ACC provide an ever-evolving “circle of quality,” which places us in a perfect position to advocate for patient-centered, evidence-based health reform. Clinically appropriate reductions in practice variation will also save money, helping to make sustainable the ethical imperative of expanding access to all citizens. The recent article by Fisher et al. (10) pointed out that medical inflation in the Medicare program increases in the U.S. at an average of 3.5% per year, and yet the increase for San Francisco is just 2.4% per year. If the average for the U.S. decreased to the rate for San Francisco, the savings would be $95 billion per year— close to what is needed to cover the uninsured. Certainly, practice variation by physicians does not account for all of these differences, but it is likely that it accounts for a good portion (10). As quality becomes more incentivized, it will be those physicians who now are ordering unnecessary tests and performing unnecessary procedures, even if for defensive purposes, who will bear the brunt of the reductions. This underscores the need for tort reforms as part of health system reform. We understand the dilemma that we face: provide more appropriate care and make less money. Our system of paying for procedures and tests, regardless of the necessity, creates incentives for physicians to overtreat (and for patients to demand more services), and this is the major reason for the calls to change the current fee-for-service reimbursement methodology. As we work together to redesign the payment methodology, we must develop it so that those who do the right thing do not make less money. The ACC is poised to take the lead in testing new payment methodologies so that physicians are rewarded for practicing appropriate, high-quality medicine; and the College has recently developed a methodology to reduce preventable emergency room visits and hospital readmissions (11). Changing the economic incentives through “bundling payments” for physicians and hospitals over an episode of care is gaining traction as a payment reform mechanism within health care reform (12) and is included as a demonstration project in the new legislation. Another way that has been proposed is to pay physicians a salary similar to the Kaiser Permanente system in northern California. Because approximately 50% of patients in San Francisco are cared for by Kaiser physicians, having a salary-based model may be partially responsible for the reduced medical care inflation noted in the Fisher article mentioned in the preceding text. At Kaiser, physicians’

Garson Jr. et al. Physicians, Profession, and Our Health Care System

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incomes are primarily fixed, but financial incentives are increasingly used to reward quality performance (13). Because of Kaiser’s robust information system, they are able to provide not only health outcome information about individual patients but they also have the ability to aggregate patient data into disease registries, which allows the physicians to compare their patients with other Kaiser patients and with national and international benchmarks (13). These types of comparisons prompt quality improvement actions, and studies suggest that if practices were highly integrated like Kaiser, in-patient spending in the Medicare program would be reduced in the U.S. by 29% (14). Integrated systems like Kaiser Permanente are examples of Accountable Care Organizations (ACO), in which quality and efficiency are rewarded based on providing multispecialty care indexed to evidence-based standards. Many experts believe ACOs have the potential to move medical practice to lower spending and better patient outcomes (12), and the new health reform legislation specifically mentions the establishment of ACOs in payment reform demonstrations. However, moving toward an ACO framework may be difficult as only a small proportion of physicians are members of traditional, large multispecialty group practices, a necessary ingredient (15). More than two-thirds of U.S. physicians practice in groups of fewer than 10 (16). The ACC has made a proposal to permit bundling to be done on the basis of groups of individual physicians as a glide path to true ACOs. Having physicians (and health systems) accept this new type of arrangement—accountability for the overall quality and cost of care for the populations they serve—may be the real test of our professionalism in the next decade. In addition to practicing appropriately, what else can we physicians do? We must adopt electronic medical records (EMR). It is clear that current EMRs are expensive in both time and money. We are at the “early Model T” stage, where few physicians and hospitals employ full EMR capability (17). But last year’s stimulus package makes it clear that in health care, the EMR “automobile” is the way to go—no more paper “horses.” There is an increased payment for adoption in the first few years, but a penalty kicks in after 5 years for those who are not using comprehensive EMRs. The EMRs will provide the data, when aggregated, that will help fuel the standardized guidelines process and make guidelines more personalized to a patient, but they will also require clinical decision support to improve quality at the point of care. Specialty societies, such as the ACC and the Society of Thoracic Surgeons, are well positioned to provide continuously updated decision support systems. With improved information on what works both from aggregated EMR data as well as comparative effectiveness (and comparative cost-effectiveness) data, many difficult decisions will be upon us as we move toward an improved system of care. Physicians, in conjunction with our professional societies, must be part of the national dialogue in deciding what should and should not be covered in the

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design of a basic health plan as a component of overall health reform, acknowledging that everyone cannot have everything. This concept is echoed in the ACC’s principles of reform (18). We must put our hats on as advisors to society alongside the general public, patients, the clergy, ethicists, and many others. But we agree with David Eddy (19) that while the physician at the bedside should be conscious of costs to eliminate waste (that which does no good or causes harm), she or he should not be in a position as a treating physician to make a decision for an individual patient based on cost if there is some benefit, (e.g., the $40,000 per month chemotherapy that prolongs life by weeks). Ultimately, coverage decisions should be made by expert groups that use the best science available to determine how best to use limited resources. Finally, when accurate performance data are available at the level of the individual physician, then we physicians must do a better job of holding ourselves accountable. Physicians should be willing to help those providers with unacceptable patient outcomes to improve. But for those providers who do not improve to the acceptable range, we must have the fortitude to tell them they can no longer perform that procedure or care for those types of patients. If we do, in addition to the improvement in patient care, malpractice lawsuits should decrease markedly. We should not require lawyers to police doctors.

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The National Institute for Keeping People Healthy The National Institutes of Health has numerous institutes, mainly devoted to the study of basic mechanisms of disease leading to better treatment and prevention of the disease. We need an additional institute, the National Institute for Keeping People Healthy (NIKPH), dedicated to keeping people healthy despite the presence of a chronic disease. Almost 44% of Americans have 1 or more chronic conditions. Among the Medicare population, 44% of the “younger-old” (⬍80 years) and more than half of the “older-old” have multiple health conditions that contribute to chronic disease (21). As we improve survival for heart disease and cancer, the prevalence of Alzheimer’s disease is projected to increase. Our health care costs are increasing because we have succeeded in keeping people alive but have not yet succeeded in keeping them healthy. We spend 10% of all our medical care dollars in the last year of life (22), and the longer we live, the more expensive it will be to die because the growth in medical care inflation continues to outpace baseline inflation. For every good reason, the NIKPH is an essential innovation: we keep people healthy for as long as possible before they die, improving the health of Americans. A potential motto of NIKPH could be “Early old age should last as long as possible and late old age should last 15 minutes!” Keeping patients—and by extension, society— healthy is a vital goal for our profession.

System Professionalism A 2006 survey by the Association of American Medical Colleges (AAMC) reported that 82% of female physicians and 66% of male physicians under the age of 50 ranked “time for family and personal life” as the most important factor affecting satisfaction with their career (20). Younger physicians want to go home at a reasonable time to be with their families, and that should be encouraged. Such an approach is likely to lead to less burnout of physicians. How can we reconcile this desire with the ethos of professionalism to “put the patient first”? This reflects a view of a changing health care system in which physicians can be viewed by patients and by themselves as professionals, working in the best interests of both patients and society, but also taking into account the observation that younger physicians place an increasing emphasis on lifestyle issues, preferring more personal time, fewer weekend responsibilities, and less on-call duty. In a “system professionalism” approach, popularized by the Blue Ridge Academic Group, the patient has a key physician, but in addition, the patient’s care is coordinated by a medical team, thus extending the professional norm of the physician-patient relationship by providing the patient with the support of a team of health professionals to coordinate their care while at the same time maintaining a relationship with a key physician. The patient-physician relationship is sacred— but new systems need to support that professional relationship.

Covering the Uninsured One of the “dirty little secrets” of the reform legislation is that 23 million Americans will remain uninsured in 2019 — and that may be a low figure— clearly appalling in the U.S. Being uninsured is lethal: uninsured adults have a 25% greater mortality risk than adults with health coverage (23). Although covering the uninsured is not directly the issue of cardiologists, as members of our community we can set examples for how Americans treat each other. This is a foundational aspect of the art of medicine. President Obama set the tone in his inaugural address: “It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours. It is the firefighter’s courage to storm a stairway filled with smoke, but also a parent’s willingness to nurture a child, that finally decides our fate” (24). Let us all work toward the day, hopefully soon, when the Congress votes into law basic health coverage for all Americans. It is the right thing to do. Providing Access for All Our health care workforce. Access differs from coverage. Coverage means that we have health insurance, whether private or public. Access means that we are able to see an appropriate practitioner at the appropriate time. Lack of

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access is also lethal: heart disease mortality is 29% higher in rural America compared with in cities. We need to change the model, starting with involving patients in their own care. It is our responsibility to be sure that all patients not only understand prevention and the implications of their possible diseases, but also take appropriate action on their own behalf to stay as healthy as possible for as long as possible. We must have more physicians and nurses—and not just primary care; we need teams linking primary care and specialists such as cardiologists. We will need to apply a team care approach in partnership with advance practice nurses, pharmacists, and others to address the challenge (25). As insurance coverage improves, and it will over a period of time, that will place an even greater strain on the system, such as has been evidenced in Massachusetts: with near universal coverage and 400,000 people newly insured, the waiting time to see an internist increased from 33 to 52 days (26). Recently, we had a discussion with 2 medical school chairs of family medicine at which they said, “A fair number of our patients could be taken care of by a good grandmother.” Does it take a physician or even a nurse to take care of a common cold or a stomach bug? We live in a society in which too many people seek too much care at times, although clearly others do not get enough. Trained community health workers (many of whom are grandmothers) have been providing such basic care for ⬎20 years with great success. We must take the words of the family physicians and put them into practice, whether by providing simple primary care or by providing frequent visits to patients with heart failure to remind them to take their medicine, possibly leading to reduced hospital readmission. Of course, community health workers will not replace the professionals, but they can work to fill a vital gap, especially as the recently uninsured seek care. Our Physicians and Our Profession Jordan Cohen, the president of the AAMC, put it best: “We should not accept without challenge what we know to be abominable just because it appears to be inevitable” (27). We all recognize that some parts of our system are abominable, but we must take the view that it is possible to work within it and in ways additional to the new legislation to help fix the system. We as physicians know the problems; we will likely have opinions on the solutions and should express them for our patients, for our country, and for ourselves. Our system must change. Exerting leadership to move medical practice and our entire health care system toward ever-improving, high-quality, and efficient care is best for the patient and for our profession. Reprint requests and correspondence: Dr. Arthur Garson, Jr., Office of the Executive Vice President and Provost, University of Virginia, Madison Hall 207, Charlottesville, Virginia 22904. E-mail: [email protected].


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