Reforming Cardiovascular Care in the United States towards High-Quality Care at Lower Cost with Examples from Model Programs in the State of Michigan

摘要

Despite its status as a world leader in treatment innovation and medical education, a quality chasm exists in American health care. Care fragmentation and poor coordination contribute to expensive care with highly variable quality in the United States. The rising costs of health care since 1990 have had a huge impact on individuals, families, businesses, the federal and state governments, and the national budget deficit. The passage of the Affordable Care Act represents a large shift in how health care is financed and delivered in the United States. The objective of this review is to describe some of the economic and social forces driving health care reform, provide an overview of the Patient Protection and Affordable Care Act (ACA), and review model cardiovascular quality improvement programs underway in the state of Michigan. As health care reorganization occurs at the federal level, local and regional efforts can serve as models to accelerate improvement toward achieving better population health and better care at lower cost. Model programs in Michigan have achieved this goal in cardiovascular care through the systematic application of evidence-based care, the utilization of regional quality improvement collaboratives, community-based childhood wellness promotion, and medical device-based competitive bidding strategies. These efforts are examples of the direction cardiovascular care delivery will need to move in this era of the Affordable Care Act.Keywords: Affordable Care Act, cardiovascular medicine, health care costs, health care reform, quality improvementINTRODUCTIONAdvanced technology and infrastructure, a superbly trained work force, and excellent academic institutions characterize the US health care system. Many believe it is the world leader in science, medical education, and health innovation as evidenced by the fact that immigrant physicians account for 27% of trainees in the United States and a quarter of the physician work force in the United States.1 It is estimated that approximately 84% of Americans have public or private health insurance.2 Unfortunately, the remaining 16% of Americans are either underinsured or uninsured. A quality chasm exists in American health care. Care fragmentation and poor coordination contribute to expensive care with highly variable quality in the United States. It is estimated that in 2011 the United States spent $2.7 trillion dollars on health care. If health care spending is not curbed, it is estimated that by 2020 spending may be as much as $4.6 trillion dollars.3The passage of the Patient Protection and Affordable Care Act (ACA) in 2010 represents a large shift in how health care is financed and delivered in the United States. The objective of this review is to describe some of the economic and social forces driving health care reform, provide an overview of the ACA, and review specific programs underway in the state of Michigan aimed at improving the quality and reducing the cost of cardiovascular care.THE US HEALTH CARE LANDSCAPEIn 2014, the US economy is facing many political challenges as it continues to emerge from recession. One of these challenges is the expiration of a portion of the Bush era tax cuts that have increased income taxes on the highest earners in the United States. Other challenges are the need to re-raise the national debt ceiling and the potential cuts in physician reimbursement associated with the sustainable growth rate. All of these pressures are compounded by a health care system that is spending out of control and growing faster than the national gross domestic product.4There are a number of opportunities to reduce health care spending in the United States. Excess care is thought to be responsible for $750 billion, medical errors account for $50 billion, and defensive medicine accounts for approximately $50 billion.5 The annual rate of malpractice litigation affects an estimated 8% of cardiologists and as many as 20% of cardiovascular surgeons.6High