April 5, 2018 | Jesse Adams, MD, FACC; Andrew Miller, MD, FACC; and Cathie Biga, MSN, RN

We currently face a rapidly evolving environment that poses unique challenges to the provision of cardiovascular care. Resilience in this time of rapid change is necessary and requires a full spectrum of clinical, business, quality, operational and leadership knowledge, along with the requisite skills to achieve organizational excellence. The ACC Cardiovascular Summit – Contemporary Strategies for Quality Improvement, Operational Excellence, Finance and Leadership was held in Las Vegas, Feb. 22 – 24, 2018. The course director was Howard “Bo” Walpole MD, MBA, FACC, with course co-directors Cathleen Biga RN, MSN, and Pamela Douglas MD, MACC. The Cardiovascular Summit is one of the premier meetings that the ACC provides each year, with multiple sessions focused on best practices and state-of-the-art knowledge on the business of cardiology, leadership, operational excellence and quality improvement, and workforce wellness. This year marked the 10th annual Summit and there were approximately 400 attendees.

The two-and-a-half-day meeting consisted of a number of plenary sessions with topics of interest to all, coupled with small workshops centered around the four main topic areas: business of cardiology, leadership, operational excellence and quality improvement, and workforce wellness. Additionally, there were mini-intensive sessions where a critical topic was covered in great depth during a longer session, providing attendees actionable items to take back to their practices to implement. And the hallmark of the Summit was just that – what do I need to know and how do I make this work in my environment?

Many of the sessions not only provided great didactic information but also stressed action items for attendees to consider implementing. The sessions were geared for all members of the cardiovascular team – clinicians and administrators – with a focus on proven business and leadership skills that could be rapidly implemented. Indeed, many organizations brought dyad teams of their cardiologists and administrative counterparts to this meeting, and this proved very fruitful.  We also are seeing a “triad” leadership team evolving – physician leader, practice admin and cardiovascular service line leader.

While it is beyond the scope of this brief article to capture all the meritorious ideas that were shared during the Cardiovascular Summit, there are several that all cardiologists, practices and organizations could benefit from.

One major theme was the importance of knowing your risk score. It was recommended that you meet with your billing department and ensure you are billing correctly and capturing the complexity of your patient’s care accurately and completely. A “power-users” tip would be to run a report for each individual provider listing their top five diagnoses. There should not be any unspecified codes on the list and the primary diagnoses should always reflect the reason for the visit at it most complex level. It is important to be aware of the risk scores, both for your taxpayer identification number (TIN) and individual providers. Those providers with low-risk scores or frequent use of unspecified codes (they will usually be the same) should be a focus for education. It was suggested to look at your Quality Resource and Utilization Report (QRUR), supplemental QRUR (S-QRUR) and field tested episodes – all available by TIN on your Enterprise Identity Data Management website – to look at risk scoring. Check out the website with instructions on how to access all of your Centers for Medicare & Medicaid Services (CMS) reports.

A second key action item was to ensure that individual providers have the correct taxonomy codes as recorded by CMS. Many cardiologists at the meeting found that when they checked, they were listed as “Internal Medicine” or “Family Practice” rather than one of the four cardiology taxonomy codes (general cardiology, interventional cardiology, electrophysiology or heart failure). From a cost and quality perspective, a cardiologist who is incorrectly listed as an internist may be viewed unfavorably by CMS, especially related to cost as their peer group would not accurately reflect their specialty. It is easy to determine a taxonomy code; your billing staff can check the Medicare Provider Enrollment, Chain and Ownership System (PECOS) or you can complete a preliminary review and enter each provider’s National Provider Identifier number to see their taxonomy code displayed.

Thirdly, many sessions discussed the Quality Payment Program and the Medicare Access and CHIP Reauthorization Act with a special focus on understanding cost and quality metrics. Methods of using the QRUR report were discussed. In prior meetings, there were discussions of how to additionally use the S-QRUR report but the latter has been replaced by the new Field-Tested Reports, and information was provided on that subject. Proper documentation to accurately capture risk and the complexity of the individual patient was stressed. It is critical that specific codes (not unspecified diagnostic codes) are utilized and a complete documentation of the different Hierarchical Condition Categories such as chronic systolic congestive heart failure, diabetes mellitus with circulatory complication, morbid obesity, stage IV renal insufficiency, and aorta atherosclerosis are accurately captured. There were sessions that explained how to get your electronic health record (EHR) to help in diagnoses selection – a welcomed suggestion!

Finally, in typical Summit fashion, the burgeoning platforms (innovations, new alternative payment models (BPCI-A), strategic planning and quadruple aim) as well as the basics (physician comp, contract negotiations, service line development and governance) were discussed at length in interactive sessions. Engaging the Cardiovascular Team was a central theme in the sessions focused on palliative care, heart failure clinics and readmission strategies.

In summary, here are a few of the take-aways we brought home from the meeting:

1. Improve your risk scores by relooking at diagnosis codes; use more specific codes and choose the most complex as your primary diagnosis. Meet with your EHR vendor to help improve your ability to choose appropriate complex diagnosis and make them your favorites.
2. Make sure you are in your correctly designated specialties in PECOS and ensure you know your TIN structures.
3. Think about how to utilize Advanced Practice Provider (APP) colleagues in your practice. Use “incident to” and shared service billing appropriately. Schedule 48-hour discharge follow-up appointments and utilize pre-op risk assessments. A healthy practice ratio of APP to physicians is probably 1:2 and growing.
4. Think about how you can augment clinic access to new patients. Engage wholly in team-based care, set clinic minimums for new patients to at least four hours per physician, and open a 2 – 2:30 p.m. slot for urgent referrals or walk-ins on everyone’s schedules.
5. Finally, everyone might benefit from a “vital signs” dashboard for our practices. What are your vital signs? Here is one suggestion for top 10 metrics to populate a dashboard:

  1. Total new patients
  2. Patient panel size
  3. Imaging utilization
  4. Cath and PCI utilization
  5. ICD and ablation utilization
  6. PINNACLE tracking of our MIPS metrics
  7. STEMI times and Acute MI mortality
  8. CATHPCI tracking of less than 50 percent stenosis, stress test before intervention and   elective PCI appropriateness
  9. Clinical activity via wRVUs
  10. Finances via EBITDA

Given the pace of change, there will undoubtedly be many new items and refinements by this time next year. The next Cardiovascular Summit will be held in Orlando, FL, from Feb. 14 – 16, 2019, and you should consider attending with your entire care team. Each year, many of the Cardiovascular Summit attendees are repeat attendees, a testament to the demonstrated value.  This meeting is a necessity for the physician and administrative leaders in your practices to improve their nonclinical competencies and stay up-to-date on the business and operations of your clinical practice and cardiovascular service line.

This article was authored by Jesse Adams, MD, FACC; Andrew Miller, MD, FACC; and Cathie Biga, MSN, RN.