Interventional Cardiology in Transition

Aging baby boomers, new clinical therapies, and evolving regulations are increasing the work load of interventional cardiologists. Do these three factors represent a Perfect Storm for cardiology?

If so, let’s hope that cardiology weathers their storm better than the crew of the Andrea Gail fishing trawler did in the “perfect storm” of 1991 as depicted in the 2000 movie. Instead of a combination of meteorological conditions, cardiology’s brewing storm results from changing demographics, added clinical applications, and evolving regulatory requirements.

As the baby boomers age into retirement they are also entering the peak of cardiovascular disease. Cardiologists are also entering retirement resulting in a shortage of specialists to deal with the increased influx of patients.

The last ten years have seen major advances of less invasive treatments for major types of cardiac disease. Most notably heart valve replacements and ablation therapy for atrial fibrillation are now routinely treated by interventional cardiologists. The new therapies are further increasing the demand on interventional cardiologists and on cardiac catheterization laboratories.

As if the increase in demand driven by the aging population and new interventional therapies was not enough, the healthcare system is in a major sea change. The payment system is starting to shift from fee-per-service to value-based care in 2017. This change will occur over the next few years.

The rules for the new payment systems are evolving resulting in increased demands on providers for additional documentation of clinical decisions and procedures. Providers performing better than average will receive increased Medicare reimbursements and those providers performing below average will see decreased Medicare reimbursements.

Interventional cardiologists are just starting to deal with a larger patient base, more of whom will be treated in the catheterization laboratory, and will be working with an evolving payment system requiring more documentation.
Population Increase
Changing Population Demographics
The baby boomers are not only moving into their retirement years but are also moving into their peak cardiac disease years. The US Census Bureau projects that the 65 and older population is projected to grow from 43.1 million in 2012 to 72.8 million in 2030 – a growth of 70%.
AHA CV Disease
The 2015 American Heart Association’s “Heart Disease and Stroke Disease” statistics shows a remarkable increase in cardiovascular disease in the over 60 population in the US.

The changing demographics of the population is reflected in the interventional cardiologist population as well. The 2014 MedAxiom Survey showed 34% of the interventional cardiology workforce to be over 59 years old with a median age of 54.

Estimates of the shortages of interventional cardiologists vary but the rate of retiring cardiologists has not been balanced by a growth in fellowship positions. Reasons for the projected shortages vary as well. In addition to the changing demographics, other factors listed include the increased demand and the lack of growth in fellowship positions.

All estimates agree that there will be insufficient interventional cardiologists to meet the meet in ten years.

Cardiovascular disease is increasingly being treated in cardiac catheterization laboratories. Minimally invasive techniques have been developed and proven for disease once treated surgically if at all.

Clinical Therapy
For various types of heart disease, the preferred treatment has moved from open heart surgery to minimally invasive techniques, either minimally invasive surgery or delivered via a catheter (transcatheter) similar to angioplasty or stent placements. In come cases, a combined minimally invasive surgical approach and transcatheter therapy provide the best results.

For example for multi-vessel coronary, a minimally invasive surgically technique is most effective on a particular artery (left anterior descending coronary) while stents in other vessels inserted with a catheter by an interventional cardiologist are more effective in the other vessels. Both procedures are performed in a “hybrid” lab, a combination surgical and cardiac catheterization suite.

Similarly ablation therapy used to treat atrial fibrillation may be a combined surgical and catheter based procedure. Each procedure is more effective to access different areas of the heart.

More recently, heart valve replacement surgery is being replaced with a transcatheter procedure by an interventional cardiologist. This started with pulmonary valve replacement for pediatric patients, followed by aortic valve replacement, and now mitral valve replacements for adults. All of these new therapies creat an increased demand on interventional cardiologists.

As the types of interventional procedures have increased so have the reporting requirements. For example the FDA all transcatheter valve procedures be documented and submitted to a CMS (Centers for Medicare & Medicaid Services) approved registry which tracks procedures and outcomes.

The Transcatheter Valve Therapy(TVT) registry is joint collaboration between the American College of Cardiology (STS) and the Society of Thoracic Surgeons. It is the only registry approved by CMS for transcather valve replacment reporting.

In addition to the TVT registry, the ACC maintains nine additional registries for various types of cardiovascular transcatheter interventions. These registries include the CMS mandated ICD Registry for implantable cardioverter defibrillator(ICD) patients and the CMS mandated LAAO Registry for left atria appendage occlusion procedures.

Most facilities elect to participate in the non-mandated transcather registries as well as those mandated by CMS. The other registries are employed for quality control and provide outcomes data to insurance companies.

Regulatory
The healthcare system is moving from the fee-for-service to value-based payment models. Much of this change is driven by the Medicare Access and CHIP Reauthorization Act (MACRA) going into effect starting in 2017.

MACRA’s Quality Payment Program implements two payment options: the MIPS and the APM. The Merit-Based Incentive Payment Systems (MIPS) is a complex pay-for-performance system combining previous programs: the PQRS (Physician Quality Reporting Program), the VBPM (Value Based Payment Modifier, and the MU (Meaningful Use EHR Incentive Program). MIPS also adds an additional measure: Clinical Practice Improvement Activities. Medicare reimbursement gets adjusted based a weighted average of these four components.

The Alternative Payment Models will encompass a variety of shared risk programs such as Accountable Care Organizations (ACOs) and Medical Homes. These models are few to start with and more models are under development.

Most physicians will fall under the MIPS payment plan initially. However, the program plan is to move everyone to a APM in the future.

Payments under MACRA start in 2019 based on data submitted in 2017 and 2018. Supposedly there is more flexibility in the program in 2017 when data submission starts than in the following year. All of the measures under both payment plans must be carefully documented and reported.

Some of the documentation is taken care of by participation in the Clinical Registries, most notably the ACC’s NCDR (National Clinical Data Registry) suite of cardiovascular registries. However, some of the measures require additional documention and reporting.

One of these measures is the Appropriate Use Criteria (AUC) for imaging exams and associated therapies. ACU includes criteria for transcatheter procedures by interventional cardiologists. A deliberate assessment is difficult to make when a patient is coming from the emergency room with a serious cardiac event where “time is muscle” and every minute countsm The ACC AUC definitions are careful to state that a score of “rarely appropriate care” for a angioplasty and stent does not mean that it should not be undertaken in specific cases. However, “exceptions should have documentation of the clinical reasons” for proceeding.

Additional complicating factors are bundled payments where the hospital is paid for an episode of care which includes not just the inpatient stay and associated interventional procedures for a cardiac event but also any related services for 90 days after discharge. The rationale being that higher quality of care and results in fewer post procedure complications.

As most cardiologists are now hospital employees, hospital administration will be watching these events very closely. All of these changes result in increased responsibilities for the interventional cardiologist and a measure of uncertainty as the policies evolve. This environment may also lead to earlier retirement of older cardiologists.

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