The last post reviewed the systems that are needed to improve the management of chronic cardiometabolic conditions like diabetes. None of those systems are possible without an appropriate payment model and we must get that part of the puzzle right. “One of the strategic objectives of the Centers for Medicare & Medicaid Services (CMS) Innovation Center, which was authorized under the Affordable Care Act and tasked with designing, implementing, and testing new payment models, is to increase the number of Medicare beneficiaries in a “care relationship with accountability for quality and total cost of care.” The most common arrangement is Medicare Advantage.
The sickest people in the country are at the heart of the matter. Just 5% of the patients account for 57% of healthcare spending. Many of these patients have advanced cardiometabolic disease. They don’t have one condition. They have hypertension, high cholesterol, high triglycerides, diabetes, a history of a heart attack, congestive heart failure, and chronic kidney disease. The new systems and optimal medical therapy can delay progression into the 5% and pull patients out of the 5%.
“Because patients with high needs and high costs have more complex interactions with health care systems, persons who are seriously ill are the virtual “canaries in the coal mine” for quality of care—the stress test of MA plans or ACOs to deliver competent, coordinated, person- and family-centered care. In particular, there are 2 important concerns about current quality-of-care measures used for accountability.”
This post will address the first concern. “Quality-of-care measures publicly reported on the CMS Care Compare websites focus on payment silos, such as for acute care hospitalization, home health, nursing home care, or hospice. Measures such as hospital mortality and 30-day rehospitalizations, as well as perceptions of the quality of outpatient care in MA plans, hospital care, home health services, or hospice care provide important information about these payment silos, which are mostly organized by setting of care rather than patient populations or episodes of care. But Medicare beneficiaries experience care as a whole, not just by payment silos. For example, a seriously ill person might experience transitions from home to hospital to skilled nursing home—and then finally return to home with home health services.” We also have process quality measures that don’t matter. Did you measure the blood pressure, the cholesterol, and the hemoglobin A1c? These quality measures don’t help pull seriously ill patients out of the 5% or slow their progression into it. Success requires a comprehensive solution that brings all the elements together.
Here are the three factors that matter most for the complex cardiometabolic patient that I described above.
Care by a primary care cardiometabolic condition team using a protocol that enables nurses and pharmacists to change therapy without checking with a physician.
One specific quality measure: Did the patient above achieve optimal medical therapy (OMT) as defined below using best practice medications and life-style measures? (patient had a history of heart attack) In usual care, less aggressive goals are achieved concurrently in only about 20% of patients.
a. Blood pressure 130/80 or less.
b. LDL cholesterol of 70 or less on high-intensity statin.
c. Hemoglobin A1c of 7
d. Not smoking
e. On aspirin
These goals should be acheive with a protocol using carb and salt restriction, exercise, metformin and empagliflozin for type 2 diabetes; Lisinopril or losartan, hydrochlorothiazide, amlodipine, and spironolactone or eplerenone for hypertension; and a high-intensity statin like atorvastatin for cholesterol.
The systems, goals, and therapeutics protocol are equally important. When applied early, they can slow progression to the seriously ill category. They are less effective when the patient is already seriously ill, but still represent the most potent approach. The evidence is in. Let’s get started.
This is where Multifunction Computational Electrophysiology Technology Platform shines! We can help the team to early detect, monitor and protect those who are at the highest risks of heart failure! Bill. Please include us.