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Health Care Reform For Imagers:

Finding a Way Forward Now

Pamela S Douglas, MD, MACC, FASE, FAHA Ursula Geller Professor of Research in Cardiovascular Diseases

Duke University

Past President, American College of Cardiology

Past President, American Society of Echocardiography

Relationships With Industry

Abiomed Achillion Atritech/Boston Scientific BMS CardioDx Edwards Lifesciences Elsevier Gilead

HeartFlow Ikaria Miracor Novartis RESmed Roche UpToDate/Kluwer

I have no industry relationships relevant to this presentation. My institutional salary includes fixed compensation for performing CV imaging. All relationships with industry are below and online: http://www.dcri.duke.edu/research/coi.jsp

Health Care Reform: What is it?

Provider leadership

Payment reform

Care delivery innovation

Team care

HIT-Informatics

System redesign

Quality

Patient empowerment/Support

Population health

Universal insurance

Data

CV Health Care is Changing

How Do Others Frame This Issue?

• Institute of Medicine: Dimensions of Quality

– Safe

– Effective

– Patient-centered

– Timely

– Efficient

– Equitable

• Institute for HealthCare Improvement: Triple Aim

– Population health, Individual experience of care, Cost

How Will Health Care Change?

Current Future Paper records Electronic Health Record

Provider autonomy Appropriate use; Formulary

Autocratic MD Team based care

Evidence based medicine Outcomes based care

Clinical ‘giant’ Benchmarked data

Reputation Public access and rankings

AMC and inpatient-centric Coordination across settings

Few full service providers Community tertiary care

Physician driven Patient centered

Insensitive to cost Cost accountability

Fee for service P4P; Bundled; Tiered; ??

Hospital vs MD Accountable Care Organization

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Health Care Reform Implementation: A Mixed Blessing ?

• ↓ reimbursement

• MD-hospital integration

• Pre-certification

• Credentialing

• Cost cutting

• Staff reductions

• Technologic advances

• New drugs and devices

• Personalized medicine

• Quality focus

• Value not volume

Health Care Reform: How Can Imagers Create Opportunity?

The best way to predict the future is to create it OR….Skate to where the puck will be.

Imaging health care reform focus areas

•Quality

•Access

•Cost

•Value

• Leadership

JACC Imaging 2013; 6:385

Health Care Reform: Quality

• Implement imaging guidelines and standards

• Structured reporting

• Develop databases to track quality and volume

• Quality across the entire chain of imaging care

• Use quality benchmarks to achieve consistency and adherence; Ongoing quality improvement programs

• Provide accountability and transparency

Imaging Guidelines and Standards

• Combined efforts of experts and organizations

• Most focus on image acquisition and interpretation

• Balance between comprehensive and practical

• Foundation for lab improvement

• Foundation for conversations with non-imagers: administrators, referring MDs, payers, etc

• Know them! Use them!!

• Prediction: Mediocre work will become more obvious and less acceptable

Structured Reporting and Lab Databases

• Meaningful use is here

• Structured reporting

– Data elements

– Permissible values

– Relational data base

– Interoperability

• Decision support and AUC compliance

• Databases: info needed to track and improve quality

– Structure, Process, Outcomes

– Sample metrics: Timeliness, Reproducibility/accuracy, Safety

– Other uses: document your quality for others’ decisions

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Douglas et al JACC 2006;48:2141-2151

Patient Test selection

Image acquisition

Image interpretation

Results communication

Out- comes Costs

Test performance Appropriate use Outcomes

Why Adopt a More Global Definition of Quality?

• Lab operations is a limited view

• In addition:

– Right test for the right patient at the right time

– Interface btwn lab and referring physician

– Service to pts and MDs

• Opportunity to improve care outside the lab

– ↑ correct diagnosis rate, ↓ downstream testing

– ↑ health status ?

• Imaging cannot impact outcomes unless it is well performed and integrated into care

National recognition of the need to evaluate to evaluate imaging value more rigorously

• CMS Draft NCD for CCTA in 2007 under CED program

• NHLBI Workshop: Is an outcomes paradigm feasible for imaging research?

• PROMISE trial: RCT of functional vs anatomic testing in 10,000 pts with suspected CAD

– Clinical primary endpoint; Cost, QOL, Radiation secondary

– Results: Spring 2015

Douglas JACC Img 2009 2:897

Sample CQI Programs: Plan, Do, Study, Act

– Appropriate use - FOCUS

– Reproducibility of measurements and findings

• Formal testing; Review prior studies; Group reads

– Accuracy by comparison with other modalities

– Timeliness: performance, interpretation, reporting

– Radiation safety

– Patient and referring MD satisfaction

Who is Interested in Imaging Quality?

• Imaging and other professional societies

• Lab accreditation and provider credentialing

• Referring MDs: Choosing Wisely

• Payers including CMS

• NQF; PQRS; MedPAC

• Patient advocacy organizations

• Prediction: Increasing attention on professionalism and enahnced accountability

Imaging health care reform focus areas

•Quality

•Access

•Cost

•Value

• Leadership

JACC Imaging 2013; 6:385

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Health Care Reform: Access - 1

• Timely and efficient

• Customer service: Pt centeredness, pt satisfaction

• Enhanced availability

– Inpatient and ER: 24/7; ?new staffing models

– Outpatient: Convenience (location, hours), easy (parking)

• Integrate HIT into the lab workflow

– Computer Order Entry, Reporting, Image viewing/transmittal

• Collaborate on new technologies and novel uses

– Hand held ultrasound

– Chest pain unit CCTA

Health Care Reform: Access - 2 • Increasingly complex exams and new technology

– Intraprocedural support; Dysynchrony exams, etc

– Imager time and reimbursement

• Informed Consent

– Active patient involvement in decisions

– Individualized testing options, risks and safety

– Educational tools needed?

• New models of care: ACO / PCMH /Episode of care

– Financial incentives to reduce costs of care

– New care pathways scrutinizing test use

– Reductions in overall numbers of tests

Imaging health care reform focus areas

•Quality

•Access

•Cost

•Value

• Leadership

JACC Imaging 2013; 6:385

Ambulatory Care: Rarely Appropriate Imaging Stress Tests In Pts w/o CAD

National Ambulatory Medical Care Survey data (1993-2010)

P-value for trend (unadj) P-value for trend (adj)

Primary care 0.12 0.67

Cardiologist 0.02 0.04

Health Care Reform: Cost

• First, some questions

– Cost to perform to next study vs cost to equip and staff a lab ( fixed cost) vs reimbursement?

– Cost to whom?

• Traditionally: Payer

• Future: Patient? PCP? ACO? PCMH?

• Assumptions change when imaging becomes a cost center instead of a revenue generator

– Outpt revenue offset DRG flat rates…but no longer

• Prediction: Reimbursement, volume are not going up

Health Care Reform: Cost

• Minimize lab operating expenses w/o quality

– Reduced medication and supply costs

– Purchasing networks

• Imaging protocols to minimize time, preserve info

– Increase throughput w contrast, 3D?

• Lower costs providers may ‘win’ regardless of quality

– At risk PCPs and ACOs

– Patients may chose labs based on copay (Aetna online)

• Maximize revenue in P4P reimbursement

– Now both MD and hospitals

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Health Care Reform: Cost

• Participate in care re-design initiatives

– Ensure that imaging is utilized appropriately

– Correct modality at the time intervals

– Diagnosis by diagnosis basis

• Justify imaging by quality, availability, value, efficiency, downstream costs, improved outcomes

• Document commitment to appropriate use

• Prospective inclusion is better than complaning later

Imaging health care reform focus areas

•Quality

•Access

•Cost

•Value

• Leadership

JACC Imaging 2013; 6:385

Health Care Reform: Value

• Work towards the appropriate inclusion of imaging in care pathways and new health care delivery models

• Example: Use of stress imaging studies <2 y after PCI

– Highly important in dx restenosis

– Does early, surveillance testing w/o sx add value? Or costs?

– Rarely appropriate (Inappropriate) w/o symptoms

• NCDR Cath-PCI Procedure registry linked to Medicare A and B claims for long term follow up

• 15 mo post PCI test use: 250K pts, 656 sites

JACC 2013 62:439

Does the Intensity of Use of Early Post PCI Imaging Vary by Institution?

• NCDR Cath-PCI Procedure registry linked to Medicare A and B claims for long term follow up

• 15 mo post PCI test use: 250K pts, 656 sites

• Findings by patient and institution:

– 32% pts had stress testing (Hospital range 9-66%)

– 8% had dx cath (Hospital range 0-20%)

– 60% no testing (Hospital range 29-84%)

• Evaluation: Hospital quartiles of intensity of use of testing/cath stable over time and outcomes

JACC 2013 62:439

Frequency Early Post PCI Imaging May Reflect Different Strategies

• Intensity of use of post PCI stress testing/cath

• Stable over time and outcome

• Divided into quartiles for analysis

Surveillance driven? Symptom

driven?

Stress Testing Post PCI by Use Frequency: Relationship to Time From PCI

JACC 2013 62:436

Highest

Lowest use

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Outcomes by Intensity of Site Use of Post PCI Stress Testing

JACC 2013 62:436

Imaging health care reform focus areas

•Quality

•Access

•Cost

•Value

• Leadership

JACC Imaging 2013; 6:385

Health Care Reform: Leadership

• Leaders find opportunity in the midst of change

• Learn leadership and management skills

– Communications, finance, negotiation, governance, etc

– Strategic planning

– Effective advocacy

• Build strong, collaborative teams

• Think broadly and inclusively: lab, the practice, the heart center and across the institution

• Preserve innovation and education

Imaging health care reform focus areas

•Quality

•Access

•Cost

•Value

• Leadership

JACC Imaging 2013; 6:385