COMMENTARY

Home Monitoring for Heart Failure: About TIME

Melissa K. Walton-Shirley, MD; Ileana L. Piña, MD, MPH; Clyde W. Yancy, MD, MSc

Disclosures

October 15, 2013

In This Article

Impact on Daily Routine

Dr. Walton-Shirley: You know, if this trial is as good as it sounds, I have some concern about how it will impact the infrastructure of the daily office life. I do just 30-day telemetry monitoring. At the end of my day, I have a stack of monitors to go through, and then I have to adjust medications and locate the patients and --

Dr. Piña: And note it on the record.

Dr. Walton-Shirley: And note it on the record. I am not complaining about that, but can you speculate about how it would impact your daily office life dealing with all of this information, integrating it?

Dr. Yancy: The first thing I will tell you is that I remain quite circumspect that the veracity of a mortality benefit will be verified once we have an opportunity to see all of the information; however, for the sake of discussion, let's argue -- I think correctly -- that some integration of a value add to an implantable device will come forward as being important in the management of patients with heart failure. Hopefully that will concomitantly come forward with some sort of passive information technology that is a very easy data capture, whether it is by smartphones or uploads to an electronic health record -- something that will in and of itself facilitate the data management because if it is by hand, then you are correct. It is going to confuse and frustrate an already stressed healthcare environment. There has to come with this process of care additional strategies in healthcare delivery and personnel utilization. So we need to see --

Dr. Piña: [interposing] Or even stratification, Clyde, of the sicker patients who may require the more intense monitoring vs the ones who are doing well, and that is very difficult to do in a busy practice where clinicians have 8 minutes to see a patient in and out the door.

Dr. Yancy: But that is why having an IT platform as the connectivity between the device and the practitioner, preferably a nurse-directed management team, would be smart.

Pay-for-Performance

Dr. Walton-Shirley: I have a question about the pay-for-performance issue and how it has affected this sudden advent of a wonderful monitoring system that can actually reduce mortality. Is that what has driven us to this point? And is it going to result in perhaps a negative slant where we have patients who are implanted who maybe should not get a device? In our desperation to keep patients out of the hospital, are we going to implant these devices in patients who don't need them?

Dr. Yancy: Melissa, let me help you with that piece because many people listening to this program will make the same set of assertions and assumptions that you have made, and I can understand why. In truth, value-based purchasing, which is present with us right now, is in fact what pay-for-performance used to be, so it is already happening. Our healthcare systems are already at risk of losing up to 1% and greater in years to come of their total Centers for Medicare & Medicaid Services reimbursement.

Dr. Piña: [Interposing] Two percent this year already, Clyde.

Dr. Yancy: So it is already here for value-based purchasing, and that is in addition to the penalties for rehospitalization, so let's be very clear. Pay-for-performance and value-based purchasing are the same thing, and they are already here. Currently, value-based purchasing does not include any exposure based on the events, particularly rehospitalization, because it is in a separate space. But going forward, the equation will change so that heart failure mortality will then be incorporated in the value-based purchasing. So to be very clear, it is going to be quality measures, outcome measures -- which is something that is very contentious -- and then it will be patient satisfaction measures for the hospital.

Dr. Piña: [interposing] And risk models too.

Dr. Yancy: So it gives you a sense of where all of this is going to be. I think the first thing to say is that pay-for-performance, in the current iteration called something else, is here. Now the greater concept, though, and you are spot on with this desperation concept, is that as hospitals understand that these penalties are increasing each fiscal year and readmissions will not go away (they may be redefined, which would be a good thing, but they are not going away), everyone is looking for a strategy, something somewhere that will make a difference.

Dr. Piña: The next models that are coming, already in demonstration projects, are "at-risk" models that include a period of time after a hospitalization. A lot of hospitals -- for example, ours -- put in for that and got it. My concern is that hospitals looking for strategies in those 90 days to try to cut costs and to try to cut those readmissions may be investing money upfront with lots of systems of care that are not totally proven, and so that excess use, as you had said, concerns me.

Dr. Walton-Shirley: Sure.

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