Transforming Clinical Practice: A Case Study in Complexity

When discussing how to reduce the cost of care and transform clinical practice, the conversation often turns to groups consuming the most resources, or "super-utilizers." One example that often comes up is heart failure patients.

Heart failure costs the United States $32 billion annually, more than half of all hospitalization costs, according to the Centers for Disease Control and Prevention. In 2014, Medicare's Hospital Readmission Reduction Program fined 2,610 hospitals for high readmissions, cutting reimbursements to those facilities by up to 3 percent. While these fines apply to readmissions of all types, the statistics around heart failure show it's a prime target for cutting costs by reducing avoidable readmissions.

High readmission rates result from heart failure's association with other health conditions, as well as the fact that heart function often starts declining long before patients see outward symptoms like fluid retention or weight gain. This asymptomatic worsening of heart failure has been a major barrier in effectively treating the condition.

"When patients get sick and go to the hospital, patient management is more straightforward. But when they're outpatients, we tend to think they're stable," says Kunjan Bhatt, M.D., director of heart failure for Austin Heart, a physician group that partners with the Heart Hospital of Austin in Austin, Texas. "We're not actually sure if they are, because we're basing stability on symptoms."

By the time the patient shows up in the emergency room, the person's condition is often sufficiently advanced as to require hospitalization and complex interventions.

CardioMEMS, a breakthrough device recently introduced by St. Jude Medical, has the potential to change that. Indicated for stage 3 or stage 4 heart failure patients hospitalized in the past year, the device lets doctors remotely monitor pulmonary arterial pressure, a leading indicator of heart function.

"The thought is that perhaps we can help patients feel better before they have the chance to feel bad," Bhatt says. The device is roughly the size of a dime or large paper clip, implanted via a simple procedure. At home, the patient stands in front of a receptor that transmits arterial pressure data to the doctor's office.

The heart failure clinic at Austin Heart was the first in Texas to implant one of the devices. David Laird, CEO at the Heart Hospital of Austin, says the results have been impressive. "So far, there have been no heart failure readmissions for any of the patients who had a CardioMEMS device implanted," he says.

Steven Manoukian, M.D., vice president of HCA's cardiovascular service line, agrees that CardioMEMS is a potential game-changer that could dramatically improve clinical outcomes. He adds that a number of HCA facilities have started implanting the CardioMEMS device in heart failure patients.

"Data measured by a CardioMEMS device traditionally required an invasive procedure performed in the intensive care unit of a hospital," Manoukian says. "The ability to monitor that data in the outpatient space on a continuous basis holds huge promise for patients with heart failure."

Despite the potential benefits of advanced devices, Manoukian points out there's no silver bullet for reducing heart failure readmissions, citing differences across healthcare environments and patients themselves.

For instance, Manoukian highlights the importance of patient education in boosting compliance with medications, follow-up and dietary guidelines. As part of the National Forum for Heart Disease and Stroke Prevention's Stronger Hearts Partnership, he helped establish the Stronger Hearts Helpline, which provides 24-hour information to educate patients on heart failure and referrals to community resources.

The use of CardioMEMS is just one part of the Heart Hospital of Austin's strategy to prevent avoidable readmissions. Other strategies include mandatory cardiology referrals for all heart failure patients.

"Data show readmission rates are dramatically higher for patients who don't receive a cardiology consult," Laird says. The clinic's structured follow-up has also helped reduce overall readmissions to around 10 percent, significantly better than the 25 percent rate for heart failure patients nationally.

The $750 Billion Question 

Another crucial part of increasing healthcare value is reducing waste and unnecessary spending. In fact, a 2012 report by the Institute of Medicine says up to $750 billion in annual healthcare spending could be eliminated without negatively impacting the quality of care.

Major categories of waste include overutilization and variation in the way hospital procedures are performed. Experts disagree on whether variation results from clinical decision-making or simply because certain populations are sicker.

In addressing variation, Manoukian says HCA focuses on standardizing processes across the organization, which can improve outcomes by raising the level of care for all patients.

"What we're attempting to do is to ensure that all of our facilities have an overall process on how to best manage heart failure patients within their community," he says.

Manoukian explains that while some facilities offer comprehensive cardiovascular programs complete with board-certified heart failure and transplantation specialists, other hospitals with general cardiologists--or those without a cardiologist on staff at all--may not be as experienced in managing heart failure.

"It's really about educating practitioners who might see a heart failure patient," he says, pointing out that this also includes primary care providers and emergency department physicians. "They, too, need to understand what the continuum of care for heart failure looks like so they can make rational decisions that lead to superior clinical outcomes for these often high-risk and challenging patients."

Another source of wasteful spending experts frequently underscore is overutilization, including the use of more resources and more expensive services and prescriptions than necessary.

Amy Boutwell, M.D., MPP, founder of Massachusetts-based Collaborative Healthcare Strategies, says two tactics can help hospitals reduce avoidable overutilization. The first is to go beyond standard referrals or discharges to improve transitional care, an area Boutwell focuses on in her work with the CMS Center for Innovation and Partnership for Patients.

"That means high-touch, human-delivered transitional care directly into the next healthcare setting," she says, pointing out that traditional approaches don't go far enough. "The distinguishing feature is not yesterday's referral. It's not, 'I referred you to X, or I discharged you to the next setting of care.' It's that warm handover, which today looks more like co-management across the continuum."

The second strategy is to establish complex or integrated care teams that focus on the whole person rather than just the current health issue. It's especially important for at-risk patients caught in a cycle of multiple hospitalizations.

"The fact that these patients have high rates of admissions, readmissions and hospital utilization shows that the current healthcare delivery system is not working for them," she says.

Boutwell says real progress demands hospitals account for behavioral health and social complexity issues, disagreeing with the American Medical Association's efforts to water down readmission penalties for hospitals serving economically disadvantaged populations.

"What they're saying is that hospitals should be allowed to have higher readmission rates if they serve poor patrons," she says, noting that healthcare systems need to understand that social complexity is a huge driver of healthcare utilization.

Boutwell adds that while improving self-care is a worthy goal, the fact remains that some patients are unable to do a better job of taking care of themselves, and thus will always need a navigator or advocate. She points to patients struggling to pay for basics like rent and food, many of whom may not have jobs, vehicles or even enough money for bus fare.

"When people are operating on a survival level, talking to them about self-enhancement of their healthcare is, from a behavioral health and social theory perspective, patently inappropriate."

While implementing care transition programs and integrated care teams requires significant effort and resources, Boutwell says there are some areas where hospitals can improve without making sweeping practice changes.

One of those is high-cost imaging such as CT scans, which account for up to 40 percent of imaging ordered in emergency departments. Research shows some physicians order up to four times more scans than the lowest utilizers, driving up costs and unnecessarily exposing patients to radiation.

"An almost universal strategy we're seeing across highly competitive organizations is closer scrutiny of the imaging department," Boutwell says. "Externally, they're looking at decreasing their utilization of skilled nursing facilities."

According to Boutwell, skilled nursing facilities contribute the highest number of readmissions of all post-acute discharge settings. She says hospitals participating in an accountable care organization (ACO) or CMS' Bundled Payment for Care Improvement initiative have sharply reduced referrals to skilled nursing facilities. These hospitals are using home health nurses to provide wound care, IVs and physical therapy at lower costs.

Pressures Driving Change

Reducing overutilization is easier said than done, especially when consumer preference factors into treatment options. Paul Hughes-Cromwick, senior health economist with Altarum Institute's Center for Sustainable Health Spending, says it's a classic dilemma.

"If you're the patient, and there's even a very small chance that a diagnostic test would find something, then suddenly the calculus sounds different," he says.

Even so, says Ani Turner, economist and deputy director of Altarum Institute's Center for Sustainable Health Spending, cost-conscious consumers are now shopping around for coverage, leading many to forgo care with marginal value.

"If it's the insurance company saying no, then you might protest that. But if it's coming out of your own pocket, you're going to be more comfortable saying no," Turner says. "I think people are more willing to accept some restrictions in exchange for lower premiums."

Both economists say there have always been ways to improve consistency in clinical practices, such as requiring healthcare providers to use a certain knee replacement so the hospital can negotiate a better price.

"It's getting easier for hospitals to implement these efficiencies because there's [now greater] pressure coming from a variety of directions," Turner says, pointing to the rise of ACOs and strategies such as value-based purchasing and bundled payments.

Fortunately, hospitals have more information than ever before to leverage in the pursuit of progress--including mountains of health data to guide better clinical decisions.

"It's not just the technology; it's the way people use it," says Hughes-Cromwick, explaining how even small technology incentives can have big impacts down the road. "One day, lo and behold, you get the efficiencies technology has been promising."