COMMENTARY

Pivoting to Prevention and Population Health Will Not Be an Easy Pill to Swallow

John Mandrola, MD

Disclosures

April 03, 2016

In the plenary session at the American College of Cardiology (ACC) 2016 Scientific Sessions, Dr Kim Allan Williams (Rush University, Chicago, IL) made it clear that the ACC is pivoting toward prevention.

It makes sense. Heart disease remains a top killer, and cardiology is good at fixing problems; we are less good at preventing them. "It is time we shut off the faucet rather than mop up the floor," Williams said.

This change in focus puts cardiology into the tricky area of population health.

What I learned from population-health expert Dr David Nash (Thomas Jefferson University, Philadelphia, PA), who gave the Simon Dack opening lecture, was that achieving population health will mean enduring some tough diagnoses and treatments.

Can you feel concern in a lecture hall? I think I felt it when Nash spoke.

Here are three of his areas of alarm:

One person's income stream is somebody else's waste; one person's waste is somebody else's income stream. This truth, known to all but rarely spoken of, is the main reason the US ranks 17th among nations in health outcome measures. How else would spending 19% of our GDP on healthcare deliver 17th place? Nash estimated that wasted healthcare spending amounts to a trillion dollars. "That single inappropriate echo may not seem like much at the individual level, but it turns into a massive problem at the national level," he said.

Zip code is the most important biomarker of health. Forget cholesterol numbers, blood pressure, and HbA1c; where one lives is their health destiny. Nash showed a map of Pennsylvania counties color-coded by health outcomes. Philadelphia County, the home of five major medical centers, ranked dead last.

Access to medical care plays a small role in determining health outcomes. Read that one again. Nash said the key determinant of a population's health is not gleaming new medical centers, but individual behavior. He cited the recent study[1] showing only 3% of Americans live a healthy lifestyle (being sufficiently active, eating a healthy diet, being a nonsmoker, and having a recommended body-fat percentage).

Nash said population-health leaders will demand numerous things going forward:

  • Complete transparency: "I want to see cardiac catheterization results, every patient interaction, patient satisfaction scores; I want to see every medication error; I want to see all of that online, publicly available, 24/7. It's the only way we will achieve true professionalism." (Gulp.)

  • Total accountability: For who we are, what we do, and how we spend the nation's healthcare dollars. His four-word summary: No outcomes, no income.

  • Reducing practice variation: There cannot be 15 ways to treat the same patient in heart failure. We have to agree on best practices and standards.

  • Reducing slavish adherence to professional autonomy: "My waiting room is crowded; I know I am good." Nash says that idea must go. He counters: "In God we trust, but everyone else, bring your outcomes data."

  • Engaging with patients with regard to changing their individual behavior: Nash recommended that medical education focus more on behavioral economics, counseling, and nutrition.

  • EHR surveillance: Imagine if we could track doctors online, using EHR, to assess how well they were following the tenets of Choosing Wisely. Nash said there are companies working on that goal right now. Once we get to this point, someone will call you up and ask: "Doctor, tell me, I am curious, why are you ordering so many more echocardiograms than your colleague?"

  • Mandatory bundled payments are coming: Friday was the debut of bundled payments for orthopedics. Is the ACC ready when bundled payments come for heart failure? Nash asked.

My Comments

Being mad about this is like being mad when it rains. We may not like Dr Nash's message, but I think the ACC did the right thing in forcing us to take this medicine.

Some of these new realities are welcome change:

Bundled payments will surely improve the care of patients with atrial fibrillation, who, in my opinion, incur as much risk from overtreatment as they do their disease. The fee-for-service system needs to go—tomorrow.

Practice variation and our tolerance of it are black marks on our profession. There is no way some individuals and hospitals should be doing manyfold greater numbers of procedures on the same population.

I loved Nash's comment on access to care being a small determinant of health outcomes. Of course it is. Healthcare in the US too often fails to deliver health. The answer to population health is not more hospitals and MRI imaging centers; it's more parks, walkable neighborhoods, and social-support systems. (Do doctors deliver these things?)

It is time we shut off the faucet rather than mop up the floor.

I have three worries about the ACC's pivot to prevention. First is how it influences the doctor-patient relationship. I am a vigorous advocate for lifestyle measures as therapy, but doctors are not their patients' mothers. We live in a free country. Yes, I can counsel my patient on healthy behaviors, but ultimately, it's up to people to choose what's best for them.

Another worry is the medicalizing of life. In people without complaints, I rarely order tests and monitors. The human body didn't get to be so brilliant because of smartphone sensors. Lots of harmful things can happen in the name of preventing things that may or may not happen in the future. Exhibit A: preop testing.

Finally, my biggest concern is that doctors make the mistake of substituting drugs for prevention when walking, eating less, and common sense would suffice. The results of HOPE-3 presented here gives a nod to drugs for prevention. The glaring problem with that trial was its lack of a compactor arm for risk-factor modification through lifestyle intervention.

JMM

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