TCT: Goals of U.S. healthcare from 1927 will be the same in 2022

MIAMI—When tasked with predicting the cardiovascular healthcare landscape in 2022, David R. Holmes, MD, of Mayo Clinic in Rochester, Minn., reminded an audience at the 2012 Transcatheter Cardiovascular Therapeutics (TCT) conference on Oct. 23 that the specific goals set by healthcare leaders in 1927 mimic today’s agenda items, in spite of a different payment structure and more technological advances.

In attempting to look forward, he presented the historical view from the American Medical Association in 1927, which stated at the time: “The costs of healthcare are spiraling upwards. Ideas for reforming the healthcare systems are hotly debated. The promise of medicine has never been brighter. This future, however, has never been more uncertain.” Also, in 1927, the AMA listed as its highest priority agenda item "the inability of the people to pay for modern, scientific medicine.”

Currently, cardiovascular medicine is a “target for three main reasons,” said Holmes, who is past-president of the American College of Cardiology (ACC).

First, the sheer number of patients makes the specialty a target. Among Medicare patients, more than one in three has asymptomatic heart disease, more than one has in six has congestive heart failure and more than one in 10 has atrial fibrillation.

Second, cardiovascular treatments cost a lot of money to the healthcare system, according to Holmes. The top 1 percent of treated CV patients accounts for 20 percent of healthcare spending in the U.S., while the top 10 percent accounts for 60 percent of healthcare spending.

Third, cardiovascular practices vary widely across wide-ranging regions in the U.S. The median use of PCI in the five leading markets is between seven and 12 per 1,000 patients. There are nine other markets in the U.S., which have 50 percent higher rates. “That much variability makes people question,” Holmes noted.

Looking at the cardiovascular landscape, cardiovascular diseases (CVDs) are the No. 1 cause of death globally. An estimated 17.3 million people died from CVDs in 2008, representing 30 percent of all global deaths. There are approximately 1.5 million annual heart attacks in the U.S. “This number is likely to grow as we see more troponin infarcts,” Holmes said.

In terms of U.S. healthcare policy, he said that the Patient Protection and Affordable Care Act is “clearly moving ahead, and will have a huge impact on cardiovascular care through Medicare expansion and the locking down of quality performance measures.”

In 2013, Medicare reform will be on the table, according to Holmes, while sustainable growth rate and tort reform will continue to be “challenges.” He also predicted the medical societies, like ACC, will play an increasingly larger role in healthcare policy as advisers to Congress.

Moving toward 2022, he said that payment reform will take several steps, including:

• Measure to manage;
• Value more value, rather than volume;
• Measure to negotiate, including with payers;
• Shift toward population-based care; and
• Dramatic shift in cardiovascular employment away from private practice to the hospital setting.

To the last point, it is reported that there is not a single private practice in the state of New Hampshire. “These integrations are part of an iterative process,” said Holmes. “The first round of contracts looked pretty good, but the second round was not nearly as good because the hospitals had more negotiating power.”

Finally, there will be tremendous technological advancements in the coming years. “By 2022, there will continue to be major new medical innovations,” he said. “The speedometer on innovation continues to move upward at a very fast pace.”

He pointed to EHRs, mobile technologies and robotics as having a “tremendous” impact. Discovery in cell therapy, genetics and biotechnology will take place. Another aspect of change will be patient-focused care, including biomarkers and personalized medicine, especially with the goal of creating evidence-based prediction models. “There is a staggering statistic that 80 percent of tests are determined to be normal,” Holmes said. “We can’t continue this path. We need to do a better job identifying which tests should be ordered for which patients.”

Smarter supply chain management will be “terribly important as we continue to rein in costs and make our practices more efficient,” he said.

Finally, the wireless revolution will continue to accelerate the capabilities of medicine, especially through mobile applications that turn phones into medical devices. “Less expensive than full-sized machines, they will only get more affordable, and they will probably be used for billing as well,” Holmes said. “In the future, all cardiologists will need to be interconnected with the cloud of the hospital network.” Also, the devices themselves will be used to collect physiologic metrics, calorie counts, etc.

“MRI machines in 2022 may be as small as cellphones, but clinical judgment will still be at the center of appropriate CV care to make sure we do the right thing for the right patient at the right time,” Holmes stated.

To conclude, he returned to the charge of the AMA Committee’s on the Cost of Medical Care in 1927, which was: “To discover the best organization for healthcare delivery to offer the most efficient production of service.”

“That’s where we were in 1927, and that’s where we are in 2012, and that’s where we will continue to be in 2022,” he concluded.