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General CardiologyEditorial

ecent Initiatives in Cardiovascular Care Quality:he Future is “Pay for Quality” and Increasingransparencyim A. Eagle, Sharon Van Riper, Richard Prager, andauro Moscucci

ecent developments in health care reimbursement andeasurement are fueling increasing change in how the

ealth care community will view cardiovascular quality inhe future. Perhaps none of these will be as important ashose accompanying projected plans for Medicare. Re-ently, the US Senate and House of Representatives havegreed by conference committee to establish a 5-year dem-nstration program that encourages the delivery of im-roved patient care quality with emphasis on the following:) incentives to improve the safety of care provided toeneficiaries; 2) appropriate use of best practice guidelines;) reduction of scientific uncertainty through examinationf service variation and outcomes management; 4) encour-gement of shared decision making between providers andatients; 5) the provision of incentives to improve safety,uality and efficiency; 6) appropriate use of culturally andthnically sensitive care and 7) related financial effects as-ociated with these changes.

Health care groups that may participate in this earlyemonstration program include physician groups, inte-rated health care delivery systems and regional coalitions.hese health care groups may implement alternative pay-ent systems that encourage the delivery of high quality

are and streamline documentation and reporting require-ents. They may also offer benefit packages distinct from

hose that are currently available under Medicare Parts And B and under the Part C Medicare Advantage plan. Toualify for the demonstration, health care groups must meetepartment of Health and Human Services establisheduality standards; implement quality improvement mecha-isms that integrate community-based support, offer pri-ary care and referral care; and encourage patient partici-ation in decisions.

The Center for Medicare and Medicaid Services haslready launched a voluntary program for hospitals to re-ort, for public access, levels of quality indicators for vari-us in-hospital conditions including acute myocardial in-arction and heart failure. In addition, many other insurersave launched similar quality programs that require qualityeasurement for key cardiovascular conditions and nowrovide an adjusted reimbursement formula for evidence ofigh quality care. While these vary both by scope and

ntensity from region to region, it is notable that suchnitiatives are, in general, increasing throughout the US.

How are these changes likely to affect cardiovascular f

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are? First, both physician providers and hospitals will besked to demonstrate quality surrounding conditions suchs acute coronary syndromes, heart failure, atrial fibrillationnd stroke. Second, similar accountability for quality andppropriateness will surround procedures such as coronaryypass surgery, percutaneous coronary intervention, pe-ipheral artery intervention, ICD placement and arrhythmiablation. While the formulae for measuring quality in eachf these clinical areas are at best crude and often onlyocused on processes of care or volume of procedures, theres no indication that payors or the government are going toait for this clinical science to mature. In short, the care werovide patients will be measured, and it is likely thatemonstration of better quality, using whatever metric isvailable, will be recognized through enhanced reimburse-ent.To illustrate how quality assessment and reimbursement

re being played out, one need only look at the activitiesurrounding cardiovascular care delivery in the state withinhich we practice (Michigan). As a Blue Cross Blue Shieldf Michigan Cardiovascular Center of Excellence, our cen-er (University of Michigan Cardiovascular Center) agreeso abide by a number of quality bench marking activitiesncluding:

. Participate in a statewide health and safety strategy.

. Participate in a statewide Michigan Society of Tho-racic and Cardiovascular Surgeons regional STS dataregistry enrolling all open heart procedures.

. Participate in a statewide percutaneous coronary in-tervention quality improvement collaborative (BCBSof Michigan Cardiovascular Consortium), enrollingall coronary interventions and participating activelyin audits of both our own cath lab experience as wellas others.

. Agree to minimum operator and institutional volumetargets for heart procedures:

Institution’s MinimumVolumes

Individual OperatorMinimum Volumes

pen Heart Surgery(valve � CABG)

300 50

ercutaneous CoronaryIntervention

400 75

ardiac Catheterization 500 150

. Provide data regarding processes of care for manage-ment of acute coronary syndromes, in-hospital heartfailure and data stemming from the above procedureregistries in accord with Class I recommendationsfrom the ACC/AHA guidelines for each of theseprocedures.

To incent success in quality, Blue Cross Blue Shield ofichigan has been proactive in creating effective financial

ncentives. First, participation in the percutaneous coro-ary intervention collaborative has included a return of

unds to each Center of Excellence to be specifically used in

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he data collection and quality improvement efforts. Allospitals participating in the BMC2 and STS data registryrojects and related, collaborative quality improvement

nitiatives will be eligible to receive financial analysis sup-ort for data collection and comparative performance anal-sis. In addition, hospitals that achieve exemplary perfor-ance on a wide array of structure, process and outcomeeasures in cardiac care will receive a bonus payment as an

dd-on to established DRG payments. Second, BCBS ofichigan has used key quality indicators in heart failure,

cute myocardial infarction and pneumonia care as a basisor their Participating Hospital Agreement Incentive Pro-ram (2001–2003). For 2004, additional indicators haveeen added for Surgical Infection Prevention, which in-ludes cardiovascular surgery. This program offers partici-ating hospitals the opportunity to earn reimbursementased on several quality and patient safety efforts based on aool of dollars representing up to a potential 4% of allospital DRG payments that can be earned in addition toRG reimbursement.In the case of CMS, our center has voluntarily partici-

ated in a statewide demonstration project with the Mich-gan Hospital Association, contributing data surroundingey process of care measures for acute coronary syndromes,eart failure, pneumonia and other conditions. The nexttep for this activity will include providing these data toMS for public reporting and agreeing to participate in an

ncentive program that rewards success in achieving higherformance; CMS will reduce payment to hospitals notarticipating by 0.4%.

In our estimation, the overall effect of these and othertate and national initiatives has been favorable, both for theroviders, but more important, for patients. Our Center,long with others has seen steady improvement in keyuality indicators for acute coronary syndromes and heartailure. Our participation in the statewide percutaneousoronary intervention and cardiac surgery registry anduality improvement initiatives has facilitated more stream-

ined care accompanied by improving risk-adjusted out-omes. By agreeing to reach certain quality standards, ournstitution has invested in both human resources and data-asing efforts that have facilitated the creation of structure,rocess and outcomes tracking systems, which wereeeded for us to improve. And by demonstrating success,he institution has been financially rewarded in reimburse-ent for high quality as well as directed funding to support

he databasing effort.The nation’s public, employers, insurers and lawmakers

re increasingly interested in value-based health care. AsMS, Blue Cross Blue Shield and other major health care

nsurers incent quality through differential reimbursement,t is clear that cardiovascular specialists and hospitals will beewarded for achieving quality goals. These incentives,

long with an increasing emphasis on transparency of care

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uality, through publicly available data, are changing theandscape of cardiovascular care nationwide. This evolutions not without its problems especially as our specialitiesdopt appropriate new approaches and technology. Ourethods for measuring quality are both crude and chang-

ng. Our practices and hospitals are highly variable in theirbilities to seamlessly track data required for measurement,mprovement and reporting. Each metric creates the poten-ial for biased reporting or gaming, and the costs required toe successful in this new paradigm are substantial. Never-heless, the early signals from our own experience and thatf others are generally positive. Americans can receive bet-er care if we create the necessary metrics, systems andewards (or penalties) to improve. The movement for betteruality challenges us and the institutions within which weork to do a better job for our patients. Ultimately, the

egion and the nation deserve demonstrable quality inardiovascular care. By participating in the change process,ather than fighting it, we have the best chance of definingeaningful measures of quality, and palpable, rationalethods for rewarding it.

uggested Reading

edicare reform. www.CMS.hhs.gov/medicarereform.olan E, Van Riper S, Talsma AN, et al. Rapid cycle improvement

in quality of care for patients hospitalized with acute MI orheart failure: Moving from a culture of missed opportunity toa system of accountability. Am J Manag Care (In Press).

oscucci M, Share D, Kline-Rogers E, et al., on behalf of the BlueCross Blue Shield of Michigan Cardiovascular Consortium(BMC2). The Blue Cross Blue Shield of Michigan Cardiovas-cular Consortium (BMC2) Collaborative Quality Improve-ment Initiative in Percutaneous Coronary Interventions. J In-terven Cardiol 2002;15:381–6.

line-Rogers E, Share D, Bondie D, et al., on behalf of the BlueCross Blue Shield of Michigan Cardiovascular Consortium(BMC2). Development of a multi-center interventional cardi-ology database: The Blue Cross Blue Shield of Michigan Car-diovascular Consortium (BMC2) experience. J Interven Car-diol 2002;15:387–92.

ehta RH, Das S, Tsai T, Nolan EM, Kearly GE, Eagle KA. Qualityimprovement initiative and its impact on the management ofpatients acute myocardial infarction. Arch Int Med 2000;160:3057–62.

oscucci M, Kline-Rogers E, Share D, et al., for the Blue CrossBlue Shield of Michigan Cardiovascular Consortium. Simplebedside additive tool for prediction of in-hospital mortalityafter percutaneous transluminal coronary interventions. Cir-culation 2001;104:263–8.

reeman RV, O’Donnell M, Share D, et al., for the Blue Cross BlueShield of Michigan Cardiovascular Consortium (BMC2). Ne-phropathy requiring dialysis after percutaneous coronary in-tervention and the critical role of an adjusted contrast dose.Am J Cardiol 2002;90:1068–73.

oscucci M, Muller DW, Watts CM, et al. Reducing costs andimproving outcomes of percutaneous coronary interventions.

Am J Manag Care 2003;9:365–72.

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