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ACC Plans to Focus More on Cardiology's Business Management Issues

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03/17/2023
cardiovascularbusiness.com

Biga said ACC wants to "walk the walk" when is comes to dealing with the non-clinical business impacts of managing a cardiovascular department. The organization also hopes to take on more of the big challenges related to paying for cardiac care, moving beyond its traditional focus on clinical science, outcomes and quality. 

"As our physicians leaders and CV team leaders continue to evolve, it is imperative that it is not just a clinical track, but that they also understand that business side of cardiology. Because it does impact out patients and does impact us with our compensation models, so it is really important," Biga explained. 

What keeps cardiology administrators up late at night

Biga said staffing issues are the primary concern across healthcare right now amid the period of the "great resignation."

"This is really, really important because it does impact the finances. I explain to people that when we can't find our nurses, our advanced practice providers (APPs), techs, our OR teams, across the country we are closing ORs and cath labs because we just cannot get staff. It impacts all of us from a patient access prospective, but also from a compensation and a reimbursement prospective," she explained. 

While to drive to leave healthcare jobs was partly fueled by burnout during the pandemic and an amplification of pre-COVID issues, the decreasing amounts seen in reimbursements are also impacting the ability for healthcare systems to retain staff. Clinical workflows and efforts to get paid for the care provided to patients have increasingly become full of bureaucracy and obstacles, which have increased clinician burnout.

Prior authorizations have become a major burden in cardiac care

Increasing requirements to obtain prior authorizations are another contributor to both lower amounts of revenue and the increased staff burden to obtain them if physicians and hospitals want to be paid. She said this requires healthcare organizations to hire more staff to track down prior authorizations, which drives up overhead healthcare costs. 

This gets more complicated and involves more staff time that is unpaid when payers require a peer-to-peer reviews of why tests or procedures are needed and the physicians have to justify their decisions to insurance companies. 

"Sometimes this is also harmful to our patients because because their access to care gets decreased," Biga said. "And this is why the whole healthcare system of the United States is under scrutiny."

The American healthcare system is the most expensive, but fails to meet better outcomes of other nations, she said. She said the cost versus benefit evaluation of American healthcare shows a growing imbalance. While the U.S. spends more money per-capita on healthcare than any other country in the world, outcomes and life expectancy actually started decreasing among Americans prior to the pandemic. This lower-than-expected performance compared to costs was echoed by cardiologist and FDA Commissioner Robert Califf, MD, who presented these same statistics facing the U.S. healthcare system at the Transcatheter Cardiovascular Therapeutics (TCT) and the American Heart Association (AHA) meetings in 2022.

"Why is it that our quality or care and patient outcomes are not matching the dollar amounts that we are spending?" Biga asked. "This is a huge issue, because the fee-for-service basis that we are in uses a risk based model where we take baby steps, but we really need to be taking bigger steps to achieve something."

Biga said part of the problem is the American consumer expectation of immediate access to healthcare for everything. But she said immediate care does not mean quality care, and that is a concept the public needs to understand and accept. She said patients in some countries with socialized medicine might have to wait two months for an imaging test, but overall, the healthcare outcomes in those countries are better than in the United States.  

Movement toward risk-based models in healthcare

Biga said there is a movement in Washington to pushed the healthcare system to risk-based payment models. She said the health system is already moving in that direction. 

As the available funds for Medicare continue to decrease as more patients are added to the system, many patients are moving to Medicare Advantage plans.

"Call them anything you want, but Medicare Advantage are basically a risk-based model. And when you enter into a Medicare Advantage plan on our side in the office, it adds a lot more requirements," Biga said. 

These additional requirements include the need for appropriate use documentation, pre-authorization, your network gets more narrow so patients may not be able to go where they want to go. She said in many places this change is subtle, but in other places it is more pronounced.

"In Chicago, our percentage Medicare Advantage to traditional Medicare patients continues to escalate and I think we are going to be seeing more of that," Biga said. 

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Schedule24 Jun 2024