Q&A: Cardiologist Karen Joynt Maddox on why new healthcare policies are not improving outcomes
Cardiologist Karen E. Joynt Maddox, MD, MPH, specializes in evaluating how different healthcare regulations and policies can influence short- and long-term cardiovascular outcomes. In addition to seeing patients at Barnes-Jewish Hospital in St. Louis, she is a professor at Washington University in St. Louis, where she serves as co-director of the school’s Center for Advancing Health Services, Policy & Economics Research.
“There aren’t that many cardiologists who work in healthcare policy,” she explained. “In that way, I’m a little bit unique in the cardiovascular community.”
Joynt Maddox has been tracking the U.S. government’s ongoing shift toward quality-based care for years now. In fact, she delivered a keynote presentation on the topic—“Why Quality Increasingly Matters”—at ACC.24, the annual meeting of the American College of Cardiology. During her presentation, she examined just how much work there is to do if government programs want to help Americans live longer, healthier lives.
Cardiovascular Business spoke with Joynt Maddox after ACC.24 to discuss her presentation and much more. Read the full conversation below:
Cardiovascular Business: One of my biggest takeaways from your talk at ACC.24 was that quality reporting in healthcare has not necessarily improved patient outcomes. Do I have that right? Can you explain?
Karen Joynt Maddox, MD: Well, I should qualify that. I would say that government programs specifically designed to measure and pay for quality have not improved outcomes. In contrast, there have been some clinician-led programs that have actually made a big difference on outcomes. If you look at cardiovascular mortality over the last 50 years, for example, it has actually dropped quite a bit, and this is largely due to things like faster door-to-balloon times, new medical devices and new medications.
There have been an enormous amount of things that have happened over the years to improve cardiovascular care. Those things were mostly driven by clinicians who saw a clinical problem and then worked to solve it, and they really did improve quality.
However, the external sort of imposition of giving doctors a test, for example, has not improved quality—instead, it has created an entire industry of people who are just working on taking the test. That side of things has not actually helped patients.
So it is not that quality does not matter—it’s that the government’s value-based payment approach does not work. If you’re at a hospital and the government puts 2% or 4% of your revenue at risk because of a certain statistic, that means they think you are doing a bad job. They think you are going to start working harder and things will suddenly get better. But that is not really how it works.
Can you provide an example of what you mean?
Think about readmission rates. If a hospital’s readmission rate for something is 20%, the government will think that’s because the hospital is doing a bad job and the doctors should be threatened with losing compensation. But in reality, readmission may be 20% because of things like patients not having adequate access to care or patients not being able to afford their medications. The government being involved and potentially punishing the hospital or its doctors does not address the actual reasons its patients are unhealthy.
Now, of course there are ways that health systems can change what they are doing do improve outcomes—but taking their money away is not the answer. The answer is much more fundamental than that. Patients need coverage. We need to work on things like better patient relationships and improving patient access.
I’m not an apologist for poor outcomes—but the government is largely pushing things in the wrong direction and setting up this massive shell game instead of actually trying to meet patients where they are and help them feel better.
Does this suggest healthcare’s recent shift to quality over quantity has been a bust?
No, it’s still correct that we need quality over quantity. The problem is that our quality measures are not much better than when we were focused on quantity. We still build these massive hospitals and have patients just show up to see us every six or 12 months, and we haven’t actually changed care at all in any fundamental way. We’re just measuring things better without actually shifting healthcare.
I was on the phone for a few hours the other day with someone in charge of outreach nursing at their hospital; that is the type of person who knows what healthcare is about. They’re asking the right questions—can patients afford their medicines? How can they keep insulin cold if they don’t own a refrigerator? It’s not that we lack the medical knowledge to keep people safe—it’s just an issue how our entire health system is set up. Nobody blinks an eye if we need to pay $50,000 for a heart procedure, but we can’t get $200 to buy a patient a mini fridge to keep their insulin cold.
Karen Joynt Maddox, MD, MPH
You mention the fact that healthcare has not changed in a fundamental way—what about what happened during the COVID-19 pandemic? At the time, it felt like patient care was evolving with more health systems embracing things like at-home care and telehealth.
Well, we went from basically nobody using telehealth but the VA, to almost everyone using it as a result of the pandemic. But then telehealth went way down again and now it’s used for something like 5% of outpatient visits. That’s much different than it was before, but I don’t know if we actually changed the way we are practicing medicine in any meaningful way. It’s the same appointments we were having before, we’re just having them on screens.
What can hospitals and health systems do to truly change the way they deliver care and achieve better outcomes?
One of the big catchphrases of the moment—for me, at least—is population health. Individual health is pretty straightforward, right? There is a patient in front of me having a heart attack, I know what I need to do, and the system is set up to help me do it. Rural and other under-resourced areas aside, we have nearly optimized individual care for acute cardiovascular illness in this country.
The population health side of things, however, has not been done. If you’re an outpatient cardiologist, should you be seeing whoever happens to be on your schedule that day just because it’s been six months since you last saw them? I think it might make more sense to have a panel of patients who are all being monitored, and then the cardiologists can see who is sick and who may need care. Maybe someone needs to be brought in for a follow-up appointment based on their heart rate or blood pressure data. Maybe someone just hasn’t refilled their medications—we can detect that and help take care of it. And if someone calls in about concerning symptoms, we can bring them in that afternoon instead of asking them to wait. You’re managing a whole population that way as opposed to individual patients.
I do not want to take away from the amazing things we are already doing with pacemakers and ventricular assist devices and other technologies —but there is a lot more we can be doing when we monitor patients that can help keep them healthy. We have not put the time or effort into innovating in that space. And if we actually consider ourselves to be in the business of keeping people healthy and helping them be happy, we need to start focusing on those things.
One of your specialties is health equity in the United States. Based on what you have learned, what can cardiologists and their heart teams do to improve care in the more rural parts of the country?
I think we need more intentional partnerships. With telehealth, for example, you do see rural hospitals working with urban centers through telestroke programs, but we need more of that. We should be more intentional about getting our larger hospitals that have all of these capabilities to support our more rural hospitals. That’s one big thing.
Prevention is also so important. Rural areas tend to be places where public health has been disproportionately disinvested over the years—and it’s largely for political reasons. The rural-urban gap in healthcare just keeps growing, and that’s a gap that didn’t even used to exist. Years ago, when it didn’t exist at all and public health was pretty universal, there was not this big difference between care in urban and rural areas. But then economic opportunities in rural areas started to go down, public health measures went down, the social safety net was disproportionately eroded—it all led to people who are really struggling. To fix that, we need to reprioritize public health.
You mentioned that some of the biggest changes in healthcare policy seem to be political in nature. This reminds me of when Michelle Obama tried to make school lunches healthier when she was the first lady. There were a lot of really negative reactions to that—and it’s something that you still hear some people talk about with anger even to this day. How can policies be changed without leading to so much hostility?
Yes, that’s exactly the problem. People do not like being told what to do, especially these days. We have politicized stuff that does not need to be political. It didn’t used to be that way, and it hurts people in those areas. It’s very unfortunate.
I do hope that we can at least start to make some progress in more rural areas by focusing on the economic argument. We have had some luck with that more recently—if you can show states that insurance coverage can have an economic benefit and the state will be better off, maybe you can get more people on board. The best way to keep people healthy is to make sure they have access to preventive care.
Private equity investments are starting to become more and more common in cardiology and cardiovascular care. What do you think the long-term impact of this trend will be on patient care and patient outcomes?
I think private equity will ultimately have a negative impact, because I worry about the profit motives behind it. However, I think we can learn about what needs to change by paying attention to where these groups see opportunities to move in with their extra capital. For example, a lot of private equity groups are focused on staffing differently. That tells me we need more nurses, more social workers, more care coordinators. We need flexible payment models, we need more remote monitoring, we need more population health. We need all of those things.
I do worry about what happens when the patient incentive and financial incentive are no longer aligned. As long as places can make money by keeping people healthy, there should be opportunities to innovate. When that stops being the case, however, I think we’re in big trouble.
So I don’t think private equity’s influence in healthcare is a good thing, but since it is happening anyway, I’d say we should a least learn from what they are seeing and what they are doing.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.