Health care in general is gravitating towards value-based payment models. About 1 in 6 health care dollars are spent on cardiovascular conditions and there are already various incentives, penalties in place to improve quality and reduce costs of cardiovascular care. Some examples of such payment reforms are:

1. The Hospital Readmissions Reduction Program, which has a penalty for higher-than-average readmissions for acute myocardial infarction, heart failure, and coronary artery bypass graft surgery.
2. The Hospital Value-Based Purchasing Program, which ties Medicare payments to performance on a variety of quality metrics like risk standardized mortality rates for acute myocardial infarction and heart failure.
3. The Bundled Payments for Care Improvement initiative, which pays hospitals a fixed amount for delivering quality care over a fixed period after a qualifying event.

Due to the inherent structure and design of most cardiovascular fellowship training programs, FITs do not get follow a patient longitudinally over the disease course. This trains them well in the traditional fee for service mindset of episodic care, but in value-based care settings, cardiologists must think two steps ahead. This involves being proactive about thinking what could go wrong in the future course of a patient and addressing those issues skillfully, rather than being good at reactive thinking. 

Knowing the latest updates in guideline-directed medical therapy for heart failure is important, but ensuring patients are adherent to the therapy, coordinating care with primary care providers, and addressing social determinants of health require a different skillset and emotional intelligence. Unfortunately, these skills cannot be practiced at a CME course, but they can be developed by working in a well-structured organization where all incentives are aligned to improve quality and outcomes.

The future compensation of cardiologists is not going to be tied to wRVU’s, but to quality and outcomes. Early career cardiologists and FITs should start investing in learning and developing this mindset.

One of the key elements here is mastering the art of behavior change. As we know, medical therapy impacts only about 30% of patient’s outcomes. The other 70% is determined by patient’s lifestyle changes which, in turn, is determined by various social determinants of health. In value-based care settings, physicians must learn to have impactful conversations which lead to sustainable behavior change in patients. Cardiologists must also think holistically about patient health and be comfortable discussing goals of care and advanced care directives, instead of relying solely on primary care providers for these discussions.

Cardiologists must also learn to look at the cost effectiveness research of any intervention. Most interventions are approved based on trials, so the real-world cost-effectiveness data takes few more years after the drug or intervention has been in market. Cardiologists should be comfortable having cost discussions with their patients. One of the top reasons for medication non-adherence is high cost. Often, it is wise to prescribe a generic medicine than a newly approved, slightly superior but significantly expensive brand medicine, which leads to higher non-adherence, thereby worse outcomes.

Health care costs are rising, cardiovascular costs are a significant portion of the total health care costs. The Centers for Medicare & Medicaid Services is committed to improving quality of care at lower costs, thereby the transition to value-based care is imminent.

I will end with a famous Wayne Gretzky quote: “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.”

This article was authored by Kunal Uttam Gurav, MD, MBA, FACC, medical director of cardiology at ChenMed.

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