Putting Patients First: How to Improve Cardiovascular Outcomes and Reduce Cost in a Value-Based Care Setting

By Jana M. Goldberg, MD, FACC

June 26, 2023

I have been on both sides of the road, in a large, academic fee for service environment and on the frontline at a healthtech company, Heartbeat Health, anchored in a tech-enabled clinical cardiology practice. As a system, we have brilliant clinicians on the front lines and advanced therapies available, yet we are lagging in outcomes. How can we do better?

Despite progress in therapy, cardiovascular disease remains the leading cause of death and disability in the United States. Despite our progress, we are failing to help patients live longer and costs continue to rise. In Centers of Excellence around the country, we see a broad range of patients — those who present late in illness, losing the benefits of early intervention, as well as the worried well.

The increasing movement toward payment models supporting value-based arrangements as opposed to traditional fee-for-service arrangements show promise in changing our current delivery of care. To date, this has been largely focused on the primary care space with very little done in specialty care.

How is this unfolding in a specialty space, such as cardiology?

Current value-based care models for cardiology fall into one of three categories— episodic, primary care-focused longitudinal, and specialty care-focused longitudinal.

Episode-based models consist of bundled payments focused on episodes of care, typically triggered by an event such as a hospitalization. The Centers for Medicare and Medicaid Services’ (CMS) Bundled Payment for Care Improvement (BPCI) program and BPCI-Advanced are two examples of this for which the hospitals and practices share responsibility for total cost of care.  The list of episodes includes three cardiac conditions: acute myocardial infarction, cardiac arrhythmia, and congestive heart failure.

Another category is the primary care-focused longitudinal model. An example of this is the Medicare Shared Savings Program which allows providers to create an Accountable Care Organization (ACO). Payments are inherently based on the beneficiary experience, care coordination, and investment into high quality services. Data suggests that cardiology participation in these models leads to improved cost without the expense of clinical quality.

Specialized care-focused longitudinal models are the third example. Though there has been some work with cancer and kidney disease, there has been less done in the cardiovascular space.

Ultimately, the goal is to spend less money to achieve outcomes, efficiency, and patient satisfaction through coordinated team-based care, targeted interventions to overcome social determinant barriers, and uphold patient-centered approaches. There is promising data this approach may work, though its use in the cardiology space is still relatively young.

Now, reflecting back on the last several years, I understand what it takes to make the shift from volume to value. There are a few things that are critical if we want to make cardiovascular models succeed in this space. Here they are.

1. We must shift toward PCP-centric care. 

This means a couple things. First, as cardiologists we can no longer shoulder the burden of assuming ownership over all cardiovascular conditions. The Association of American Medical Colleges estimates that between primary and specialty care, there will be a shortage of 124,000 physicians by 2034. There is too much disease and the growing shortage of cardiologists cannot support it. 

We need to embrace collaborative care models which can expand PCPs’ capabilities by providing decision making support and lightweight guidance for lower risk cases. Further, as specialists, we need to be better communicators. 

Historically, communication between primary care and specialists has been horrible. I don’t throw this word around lightly. 

On top of hearing this repeatedly, there is actually data to support our failure to communicate. One study examined general practitioners’ and specialists’ perceptions of communication with each other. When asked if the specialist answered the PCP’s questions, 88% of specialists agreed while only 50% of PCPs thought that was the case. Further, when it came to receiving the specialist letter back in a timely manner, 62% of specialists thought this was the case, while only 23% of PCPs. 

Poor communication can lead to various negative outcomes including discontinuity of care, compromise of patient safety, patient dissatisfaction, inefficient use of valuable resources and increased cost. 

Patient care should never be a one way street. As the specialist, I can create a comprehensive care plan which I believe will work for a patient. However, if I fail to recognize that they have fallen ten times this year, struggle to pay for their prescriptions, and lack family support to care for them, I have done a complete disservice to that patient. What I should have done was hop on the phone with the referring PCP to develop an understanding of the full picture at which point I could have then incorporated their input into the plan. Or even better, facilitate data sharing to allow input from both sides to support the care plan.

To shift toward PCP-centric care, we must focus on changing the way we communicate with each other. 

2. We need to grow population level workflows to plug gaps.

We are missing several opportunities to intervene along a patient’s course of disease. We fail to identify and modify those at risk, fail to understand their goals, diagnose disease early, implement life-saving and quality of life improving therapies, and fail to recognize when palliative care may be the best treatment we can offer to a patient.

Graphic: Hoby Albright

Starting with prevention, we need to identify high risk patients and create standardized treatment plans. Identifying those at risk, implementing lifestyle therapies and applying guideline-directed therapy can reduce the odds of developing cardiovascular disease by 80%. 

We need processes in place to diagnose disease early and implement first line therapy. Take atrial fibrillation as an example. It is estimated that up to 23%, about 1.5 million, patients with atrial fibrillation are undiagnosed. Further, over half of patients living with atrial fibrillation are not on blood thinners to prevent stroke, despite being high risk. We need to systematically identify at a population level and treat early.

We also need to be cautious with applying new approaches to our overburdened system. Our clinical teams are overloaded with tasks and patient management. Clinical decision support tools built into the EHR can be helpful but need to be balanced against alert fatigue and streamline rather than disrupt workflows. To be successful, we need a combination of decision support, education, and clinical team support.

3. We need care pathways to support entrance and exit from specialty care. 

Depending on the time point in the course of a patient’s disease, there may be more or less need for cardiology involvement. We should utilize pathways to stratify patients, driving those who are sicker to cardiologists and advanced specialists, while supporting lower risk patients in the PCP setting. 

How can we achieve this? We need to educate and collaborate with primary care teams, including physicians and advanced practitioners, to give them the tools and empowerment to manage lower acuity patients. However, the infrastructure has to be there to support this process. The framework for this model has been proposed but there are few existing in the space.

Graphic: Hoby Albright

Let’s take heart failure as an example. A patient who may have structural changes of the heart but who has not yet developed symptoms (i.e. stage B heart failure) can be effectively identified and managed by a primary care team plus lightweight specialty support.

For those with symptomatic heart failure, we need an easy gateway for PCPs to engage with cardiologists and have support from a diversified team with varying expertise to allow for touch points needed to support the patient care journey. There is a trigger for entrance into the model, such as hospital admission or diagnosis, which provides more intensive management around time of event. Subsequently, there is a trigger to exit which allows for patients to go back to their primary care teams for continued maintenance. As cardiologists, we should support entrance and exit from this as needed. This will support the patient journey and cut costs.

Though the data on efficacy for these models is slim, we found that a virtual-first model for those with cardiovascular disease can lead to significant reductions in hospital readmission. Our randomized controlled trial recently showed that providing intensive medical therapy, frequent visit cadence to titrate medications, and remote monitoring led to reductions in all-cause and cardiac readmission by 40% and 53%, respectively.

Let’s take a later time point in the course of heart failure, stage D. We need to ensure that when a patient is stage D, they have access to advanced heart failure teams. If patients are not candidates for advanced therapies such as heart transplant or left-ventricular assist device (LVAD), we should recognize the value in goals of care discussions and shift to another pathway. For many of these patients, pulling in our palliative care partners and working collaboratively with PCPs to provide care according to a patient’s goals should be the top priority. 

4. We need data.

We need data in order to understand if what we’re doing is working, track to that, and make changes if needed. 

As an example, in order to be successful in a program like BPCI Advanced, the Yale Health System built and integrated clinical, operational, and financial data to drive data-driven decision-making. Understanding the “actionable spend” was defined to identify where investment and efforts would lead to rewards. Without this, we are left in the dark.

Our current disjointed systems make this a challenge but we have to get there.

Can we get there? Yes, but it’s going to take some work and a shift in mindset.

I feel optimistic that we are starting to understand the model needed to support a successful transition from a fee for service to value-based payment structure. 

In order to get there, we need to work together: specialists, PCPs, health systems, pharmacies, imaging centers, among our other patient-facing partners. The population is getting sicker and we’re not doing better, as evidenced by outcomes. We should continue to explore our partnerships and work together toward this common goal. 

Further, we need to support new models of care delivery. Healthcare needs to evolve or it’s going to fall behind. We need to support systematic approaches to cardiac prevention and complex care, partnering with those at the center of care, the PCPs. Let’s pivot to different models which allow us to support primary care networks to expand their care, leveraging cardiology for a range of lightweight to heavier care as it fits with the clinical picture.

We need to support virtual-first models for care delivery, as physician shortages will only amplify health disparities in the coming years. I feel confident that remote models and networks, such as ours, will allow us to open access to specialty care to those who otherwise would not have had access. Ultimately, we can and should reduce health inequities through these models. 

Like many of my colleagues, I can specifically think back to a case in the middle of the night — a heart attack that likely could have been prevented. Those cases add up — emotionally as a physician, on patients and their families, on the system dollars that we are spending. We can do better and supporting new models of care will likely get us there.

Jana M. Goldberg, MD, FACC is the National Medical Director for Heartbeat Health, a tech-enabled cardiology practice dedicated to delivering the most effective, efficient, and engaging cardiovascular care.

References:

1. McClellan MB, Bleser WK, Maddox KE. Advancing Value-Based Cardiovascular Care: The American Heart Association Value in Healthcare Initiative. Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006610.
2. Maddox KN, et al. Advancing Value-Based Models for Heart Failure: A Call to Action From the Value in Healthcare Initiative’s Value-Based Models Learning Collaborative. Circulation: Cardiovascular Quality and Outcomes. 2020;13:e006483
3. Centers for Medicare & Medicaid Services. Medicare Shared Savings Program: About the Program. 2023. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about.html. Accessed June 13, 2023.
4. Centers for Medicare & Medicaid Services. BPCI Advanced. https://innovation.cms.gov/innovation-models/bpci-advanced. Accessed June 14, 2023.
5. Sukul D, et al. Cardiologist Participation in Accountable Care Organizations and Changes in Spending and Quality for Medicare Patients With Cardiovascular Disease. Circulation: Cardiovascular Quality and Outcomes. 2019;12:e005438.
6. AAMC Report Reinforces Mounting Physician Shortage. 2021. Available at: https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage. Accessed June 14, 2023. 
7. Sutton RT, et al. An overview of clinical decision support systems: benefits, risks, and strategies for success. npj Digital Medicine (2020) 3:17. 
8. Vermeir et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015 Nov;69(11):1257-67. 
9. McClellan M, Brown N, Califf R, Warner J. AHA Presidential Advisory: Call to Action: Urgent Challenges in Cardiovascular Disease. Circulation. 2019;139:e44–e54.
10. Turakhia MP, et al. Contemporary prevalence estimates of undiagnosed and diagnosed atrial fibrillation in the United States. Clinical Cardiology. 2023 May;46(5):484-493. 
11. Zinzuwadia A, et al. The Impact of a Virtual Cardiology Program for Post-Discharge Patients with Cardiovascular Disease: A Randomized Clinical Trial. Presented at the American College of Cardiology Scientific Session. March 2023. 
12. Piña IL, Allen LA, Desai NR. Managing the economic challenges in the treatment of heart failure. BMC Cardiovascular Disorders. 2021. 21; 612.