5 healthcare models that would facilitate co-management of primary care, cardiology

Five newly proposed care and payment models could ease Americans’ worries about affordability and quality care in their health system, according to a review published in JAMA Cardiology this month.

The U.S. approach to healthcare is no stranger to debate—costs, inconsistent results and decreased patient access all contribute to an ever-changing business model, first author Steven A. Farmer, MD, PhD, and colleagues wrote in their paper. Health reform is less of an option and more of a necessity to these physicians, who repeatedly stressed the importance of health reforms to improve healthcare quality and affordability—especially when it comes to comanagement of primary and specialized care.

Costs attributable to cardiovascular disease (CVD) care account for 17 percent of national health expenditures, Farmer and co-authors wrote, but few care models specifically address managing primary care with long-term heart health and chronic CVD.

“Primary care medical homes and accountable care organizations come closest, but both emphasize primary care, and cardiologists have often not been well engaged,” they wrote.

The group of 10 worked to outline five combined care plans—three for episodic care and two for chronic care—they believed would serve U.S. patients well. These are the bullet points:

Clinician-to-clinician consultation: all levels of cardiac risk

• Clinician-to-clinician consultations (CTCCs) are intended for primary care physicians (PCPs) who are unsure of diagnoses, test results or abnormalities and would like the expert opinion of another clinician.
• Despite the outsider’s contributions or suggestions, the PCP remains responsible for their patient’s quality of care, results and treatment.
• CTCCs are designed to be efficient—these meetings are brief, cost-effective, flexible and allow for simple testing. CTCCs can be in-person or over the phone, which allows increased care to high-risk patients in systems with a shortage of cardiologists.
• Could be appropriate for a PCP unsure of the significant of an abnormal ECG reading or test result, but who doesn’t need a full consultation.

Clinician-to-patient consultation: all levels of cardiac risk

• A one-time speciality consultation allows patients with limited or undefined cardiac issues to seek expert advice without needing ongoing speciality monitoring.
• This traditional model cuts costs since cardiac follow-up is limited. While the PCP manages the patient’s general care, the cardiologist is responsible for ensuring appropriate CVD testing and procedures.
• Could be appropriate for: a patient with hyperlipidemia and a possible statin-related adverse effect.

Procedural model: all levels of cardiac risk

• This option allows a PCP or cardiologist to refer a patient for a specific cardiac procedure.
• The performing clinician is responsible for the procedure’s results while the principal clinician—either a PCP or cardiologist—is responsible for the patient’s overall quality of care.
• The efficiency of this plan slashes prices with the reduction of follow-up. Ongoing cardiac care is often unnecessary in these cases.
• Could be appropriate for: cardiac stress testing, cardiac imaging or diagnostic left-sided heart catheterization

PCP as primary manager: low or intermediate cardiac risk

• In this plan, the PCP is responsible for managing a patient’s long-term care, including any chronic conditions. The cardiologist is scheduled for ongoing consults, and both doctors are responsible for ongoing planned and unplanned care.
• Could be appropriate for: patients with severe hypertension requiring 3 or more medications, stable coronary artery disease or valvular heart disease.

Cardiologist as primary manager: intermediate or high cardiac risk

• As its name suggests, this model puts the cardiologist in the management position. The cardiologist is the primary manager of the patient’s cardiac care; the PCP is the primary manager of the patient’s noncardiac care.
• Both doctors are available for ongoing planned and unplanned care.
• Could be appropriate for: patients with complex symptomatic coronary artery disease, complex arrhythmias or severe heart failure.

“The models described in this review aim to improve the care of patients with cardiac disease,” Farmer et al. wrote in the paper. “They emerged from discussions between PCPs and cardiology clinicians, are grounded in real-world clinical practice and are patient-centered. They offer an opportunity to create more satisfying approaches to patient care while improving value.”