What cardiologists should expect as U.S. healthcare payment models evolve
Cardiologists are bracing for major changes in how Medicare is transitioning from traditional fee-for-service (FFS) reimbursement to value- and risk-based payment models. This shift is not a distant prospect, but a rapidly approaching reality, particularly under Medicare’s 10-year strategy aimed at placing all Medicare fee-for-service beneficiaries into accountable care organizations (ACOs) by 2030. The shift will require cardiologists to adapt both clinically and financially to these new payment environments.
“By 2030, we’re looking at a landscape where two-thirds or more of our patient population as cardiologists will be engaged in ACO relationships, either through privatized Medicare or traditional Medicare,” explained Dan Blumenthal, MD, MBA, chief quality officer at Cardiovascular Associates of America and a cardiologist at Massachusetts General Hospital. He presented on this topic in the business of cardiology sessions at Heart Rhythm 2024, the Heart Rhythm Society (HRS) annual meeting.
Blumenthal emphasized that while the changes ahead are daunting, they also present opportunities for cardiologists to take a more active role in driving care and collaborating with hospital leadership. He said cardiologists will be required to be more involved than in decades past in decisions that impact hospital and practice economics.
Blumenthal stressed clinical leaders will be required to explain what is needed to diagnose, manage and treat various patients with different levels of risk, disease severity and comorbidities so that hospitals are better prepared to take on more risk in the new payment models. Clinicians will be in the driver's seat when it comes to justifying new technologies to help them better assess risk, streamline operations and manage patients. They will also have to consider the use of AI tools that may not be reimbursed, but can help deliver improved outcomes.
“We know that the traditional fee-for-service system is not sustainable,” Blumenthal concluded. “This transition could allow us to make better decisions at the point-of-care, predict risk more accurately, and ultimately, take better care of patients at lower costs.”
As the U.S. healthcare system continues to evolve, he said cardiologists and electrophysiologists will need to adapt to these changes, ensuring that they are not only providing high-quality care, but also thriving financially in a value-based world. He said the next decade promises to be a period of significant transformation, with both challenges and opportunities on the horizon for the field of cardiology.
Impacts on electrophysiologists and procedural cardiologists
The transition to value-based care has raised concerns, particularly among electrophysiologists and procedural cardiologists who traditionally operate within an FFS model, where each service is billed separately. Many are apprehensive about how these new payment models will affect their practice, especially when dealing with expensive procedures that are currently billed individually and not rolled into a fee paid for the full continuum of care for that patient episode.
“There’s a lot of apprehension about how payment reform will impact those who spend much of their time in the EP suite or cath lab. The question is, where will the funds for necessary, costly procedures come from when payment models move toward a lump sum for managing a patient’s overall care?" Blumenthal said.
The role of business education in cardiology
These are questions cardiologists will be asked to help sort out with the rest of heart care teams and C-suite administrators in the coming years. The time to begin learning more about the economic side of care is right now, not in several years when serious decisions will need to be made.
For this reason, and due to ever shrinking margins due to drops in Medicare reimbursements, many cardiology societies, including HRS, the American College of Cardiology (ACC), Society of Cardiovascular Computed Tomography (SCCT), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC) and others, are now offering a series of business of cardiology sessions at their meetings to boost cardiologists' understanding of the economics.
Blumenthal acknowledged that many cardiologists have expressed frustration with the complexity of existing models like MIPS (Merit-based Incentive Payment System). However, he argued that population-level payment models, while different, could ultimately simplify care management. But, cardiologists need to understand the current payment system to understand how the next system will operate and the factors that need to be kept in mind.
“There’s growing recognition that understanding the macro policy landscape and how it influences payment is more important than ever,” Blumenthal said. “Specialty societies like HRS are responding to this need by offering more business education.”
Medicare’s strategy for engaging specialists
The Centers of Medicare and Medicaid Services (CMS) is actively developing strategies to engage specialists like cardiologists in value-based care. According to Blumenthal, this includes improving data accessibility to help specialists make more informed decisions and drive competition based on value. Additionally, Medicare is extending and piloting bundle payment models and creating benchmarks for specialty care within broader total cost-of-care models.
The private sector is also moving ahead with risk arrangements, particularly in cardiovascular care, where cardiologists are increasingly sharing financial and clinical outcome responsibilities with primary care physicians, he said.
Blumenthal has spent the past five years heavily immersed in Medicare payment policy and the CMS plan to change the reimbursement system. Hear more of his insights in the video interview at the top of the page.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com