Driving down heart disease costs: Tips for plans, providers

Cardiovascular disease encompasses numerous conditions such as heart attack, stroke, heart valve problems, and arrhythmia. Nearly 800,000 Americans die each year from heart-related diseases, accounting for one in every three deaths. Heart disease and stroke cost the United States an estimated $320 billion in healthcare costs and lost productivity in 2011, according to Centers for Disease Control and Prevention (CDC).

The good news is that there is some progress being made in the fight against this disease, and in curbing costs associated with it. Here’s a look at some common heart diseases, including their frequency and costs, noteworthy treatment developments, and suggestions for what plans and providers should be doing to drive higher-value care in these areas.

Heart attack: New treatments help cut costs

About 750,000 people have heart attacks each year; about 116,000 individuals do not survive, according to the American Heart Association (AHA). Direct and indirect costs of heart disease total more than $207.3 billion annually.

GarrattKirk Garratt, MD, associate director, Center for Heart and Vascular Health at Christiana Care Health System, Wilmington, Delaware, says the high cost of care is related to advanced treatments for heart attack patients, such as angioplasty (surgical repair or unblocking a blood vessel) and stenting (inserting a metal-mesh tube to expand inside the carotid artery to increase blood flow). “Because these measures are often life-saving, they have become the standard of care and their costs have become accepted,” he says. “However, the interventions very quickly pay for themselves by getting people back to productive activities, and reducing the need for frequent medical attention.”

In recent years, some measures have been taken to control costs. Among these are determining whether a patient definitely will or will not benefit from a high-cost, high-tech treatment. Balloon angioplasty and stent placement are great examples. “A few years ago, stents would be used in patients who would most likely benefit from them,” Garratt says. “But as a result of clinical research, healthcare providers can now identify whether a patient will or will not benefit.”

Other noteworthy developments that have led to cost savings include:

Clinical research regarding more effective treatment:  “We now know that treating all serious blockages at the same time is safer and more cost effective than just treating the blockage responsible for the heart attack and having the patient return later for more treatment,” says Garratt, who notes that many years ago the latter was the standard procedure. “Again, we have clinical research to thank for this improvement in care.”

A move toward population-based healthcare rather than acute care-based. This involves healthcare providers broadening their focus when a heart attack patient needs hospital treatment. Traditionally, hospital-based care teams would only focus on a patient’s care in the hospital, with a hand-off of care to office-based providers when the patient was discharged. “Today, we’re exploring how to engage acute care doctors and nurses who work in hospitals in care plans after patients go home,” Garratt says. “These providers are responsible for longer-term outcomes than just survival after hospitalization, and are rewarded when patients do well in the weeks and months after a heart attack. This is due in part to a shift by insurance organizations toward paying hospitals and doctors for the quality of their work, rather than the volume of their work.”

An increased emphasis on patient safety. “Much of the high cost of healthcare can be attributed to the costs associated with taking care of patients who receive the wrong medicine or treatment, or those who suffer injuries while hospitalized,” Garratt says. “Working hard to eliminate these events is certainly the right thing to do, and it also helps reduce medical expenditures.”

Along these lines, Garth Graham, MD, MPH, FACC, president, Aetna Foundation, Hartford, Connecticut, says it’s important to ensure that both diagnostic approaches and procedures are used effectively and properly for each patient. Currently, there is a national dialogue around the appropriate use and deployment of available tools.

Next: Other ways plans and providers can curb heart-attack associated costs

There are additional steps plans and providers can take to control heart attack-associated costs while improving quality, say experts. Garratt points to the Center for Medicare and Medicaid Services (CMS), which has (and is) consulting with internal experts, external experts, and stakeholders to identify useful changes in healthcare delivery that should drive higher value care. To take this a step further, CMS provides financial incentives to hospitals and healthcare providers to embrace the suggested changes. In time, the incentives end, and shortly thereafter, those who don’t embrace the changes receive penalties. To ensure that an institution is not unfairly penalized, CMS considers feedback from hospitals and healthcare providers, he says.  

As healthcare systems make changes to achieve CMS targets, all patients with heart attack patients, regardless of insurance type, benefit, says Garratt. “This approach has helped to soften the financial blow of implementing badly needed system changes by forward-thinking hospital systems that benefit heart attack patients and everyone else.”  Private health plans should support healthcare delivery systems in a similar manner, he says.  

Other ways to get more involved include:

• Providing incentives. Rewarding hospitals that comply with guideline-recommended therapies for heart attack patients is a reasonable step, as is partnering with clinical research groups and practice groups to determine which patients are best qualified for advanced, expensive, highly-effective newer therapies, such as the PCSK9 class of cholesterol-controlling drugs, says Garratt.

• Streamlining authorizations. Payers should also pursue faster and less onerous methods of authorization for recommended procedures or medications (and, importantly, more streamlined appeals processes for managing denials), especially when fast approval is needed to prevent possible harm, he says. 

• Providing prevention services. Mark A. Creager, MD, president, AHA, and director, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, says that by providing primary and secondary prevention services addressing heart disease, as well as rehabilitation services for heart attack and stroke survivors, payers can better control costs. He also recommends supporting workplace wellness to promote increased physical activity and providing adequate coverage or reimbursement for prescription drugs to prevent heart attacks and strokes.

GrahamTo truly control costs while improving quality of care related to heart disease, Graham says the industry needs to focus more on eliminating health disparities-which cost the United States up to $3 billion per year. One way for health plans to do this is to harness the power of technology.

According to Pew Research, 84% of low-income adults have access to a mobile phone and one in three mobile phone owners have used their phone to research health information. While underserved communities are disproportionately impacted by chronic disease, technology serves as a powerful equalizer.

Next: Stroke - New prevention tools reduce frequency

Stroke: New prevention tools reduce frequency

According to the CDC, every year more than 795,000 people in the United States have a stroke. Stroke kills almost 130,000 Americans annually, and is also a leading cause of serious long-term disability. Strokes cost the United States an estimated $34 billion each year, according to the CDC. This total includes the cost of healthcare services, medications to treat stroke, and missed days of work.

PatchenWithin the last five years, some minimally invasive procedures for stroke prevention became available, including Boston Scientific’s Watchman Left Atrial Appendage Closure Device, approved by FDA in 2015. Neuro-coiling and stenting are new and evolving endovascular approaches to treating aneurysms and narrowing of blood vessels in the brain that were previously only able to be treated via neurosurgery or not at all, says Paul E. Patchen, RN, MBA, FACHE, vice president, Cardiovascular, Service Line, Sharp HealthCare, San Diego, California. These procedures should eventually help control costs as device prices deflate; and have already led to decreased lengths of hospital stays.

KimRobert Kim, MD, cardiologist, New York-Presbyterian/Weill Cornell, New York, New York, believes providers can improve their patients’ heart health by encouraging active participation in their care. “A physician needs to figure out each patient’s personality type in order to effectively help them change their behavior, because everyone has a different perspective on what is important to them and what motivates them to change,” he says.

Some individuals prefer a numerical approach, and for them risk calculators and estimates of their risk are effective. Others prefer to visualize goals (e.g., being alive for their daughter’s wedding day) and will work to achieve long-term health for those reasons. Still others prefer a more authoritative approach and simply want to be told what they can do to minimize their risk.

Next: Other ways to improve outcomes among stroke patients

Other ways to increase patient engagement (and therefore improve outcomes) include:

• Encouraging physical activity. Kim has found that the easiest way to start patients down the path of healthy behavior is to help them find a way to incorporate more activity into their day. Whether this involves getting off one stop earlier on their commute to work, going for a walk at lunch, or taking the stairs as much as possible, anything that can be easily achieved on a regular basis is a good first step.

• Setting healthy goals. Adherence to treatment guidelines is important, but healthcare providers must realize that guidelines are the start of a discussion, not the end. “Looking beyond a patient’s numbers is important in assessing their overall health status,” Kim says. “For example, someone who is overweight but exercises regularly and follows a healthy diet is doing a great job. Putting too much emphasis on their being above their target weight could risk discouraging them and losing some of those healthy behaviors.”

• Paying close attention to medication quantities. Regarding medications, Kim reviews them at every visit and determines which ones are still necessary and whether any can be reduced or eliminated. “Often, this can be done if the patient has engaged in healthier behaviors that have brought down their weight, blood pressure, sugar level, or cholesterol level,” he says. Because the more frequently a patient has to take a medication, the less likely someone will comply with it, Kim prefers those that only need to be taken once daily whenever possible.

• Promoting realistic behaviors. Finally, because draconian dietary restrictions can be challenging to maintain, Kim typically advises simpler measures such as skipping dessert; avoiding fried foods and deli meats (which are high in sodium); and reducing red meat intake as good first steps. “Weight loss can be achieved through a variety of measures, the most important of which is simply becoming aware of the number of calories you consume and reducing them in a thoughtful and consistent manner,” he says. “Just like exercise habits, changes in diet have to be something you can achieve and maintain in the long run to be effective.”

FerdinandKeith C. Ferdinand, MD, FACC, FAHA, FASH, FNLA, professor of medicine (cardiology), Tulane University School of Medicine, New Orleans, Louisiana, says costs can be controlled by addressing risk factors for stroke early on.

“Hypertension is perhaps the most powerful determinant of risk for both ischemic stroke and intracranial hemorrhage,” he says, citing a Circulation report stating that approximately 77% of individuals have a blood pressure that exceeds 140/90 mmHg when they have their first stroke.

Next: Heart valve problems - Treatment advances contain costs

Heart valve problems: Treatment advances contain costs

According to the AHA, about 5 million Americans are diagnosed with heart valve disease each year. “This is one of the most expensive diseases in the healthcare system to treat,” says Robert Kipperman, MD, interventional cardiologist, Heart Valve Program at Morristown Medical Center, Morristown, New Jersey. For patients without health insurance, valve replacement surgery has an average cost of $164,238, according to the AHA, not including a typical surgeon fee of $5,000.

Recent treatment advances include:

• Percutaneous valves. Steven Nissen, MD, MACC, chairman, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, points to several recent treatment advances for heart valve problems, which will help to contain costs. One is the use of percutaneous valves that are inserted through a catheter rather than opening the chest and performing open-heart surgery. “This approach is growing by leaps and bounds; the patient can go home in a day or two,” he says. “Costs to perform this procedure will decrease as more medical facilities offer the procedure.”

• Mitral valve repairs. Another advancement is using robotics to perform minimally invasive repairs of the mitral valve. Instead of opening the patient’s chest, the surgeon makes three small half-inch incisions in the chest, inserts the instrument, and manipulates tiny instruments in the chest to repair the valve. “Recovery is quick, so hospital stays are short,” Nissen says. “As a result, the cost of post-surgical care is less, and the number of lost days of work are reduced.”

In addition, Abbott Vascular’s MitraClip Percutaneous Mitral Valve Repair System reduces regurgitation without any surgical procedure. “Although relatively new, it is increasing in use and has significant potential to help some patients-who can oftentimes avoid surgery as a result of using it,” Nissen says.

One of the best ways to contain costs and make treatment of heart valve problems less expensive is educating physicians about early interventions recommended in heart association guidelines, Kipperman says. Treating and managing patients with a multi-disciplinary heart failure team is also critical to ongoing, proper care. “This allows for conversation about different ways to treat the patient based on each healthcare provider’s specialty and ensures a collective path forward that is in the best interest of the patient,” he says. Educating doctors about when to refer patients to doctors for surgical or transcatheter valve intervention can also help contain costs.

Next: Arrhythmia - Tailored treatments produce results

Arrhythmia: Tailored treatments produce results

More than 4 million Americans have recurrent arrhythmia (an irregular heart rhythm), according to the AHA. The most common type of arrhythmia is atrial fibrillation (AFib), which causes an irregular and fast heartbeat. More than 750,000 Americans are hospitalized each year for AFib, the CDC reports. The condition contributes to an estimated 130,000 deaths annually. AFib costs the United States about $6 billion each year.

Non-valvular AFib is a leading cause of stroke. The AHA estimates that 2.7 million Americans have AFib. As the U.S. population ages, this number is expected to increase. Treatment modalities for AFib include ablation (using a catheter to correct structural problems) and anti-coagulation therapy (blood thinners that prevent clots from forming), Patchen says.

Over the years, treatment has evolved from controlling rhythms with blood-thinning medications to exploring what form of device therapy is best suited for each patient.

In order to control costs while improving quality, Graham advises engaging patients early on regarding behavioral changes. “By educating patients, you empower them to make the best decisions for themselves,” he says.

Again, taking a team approach leads to the best outcome for the patient through patient education, engagement, and empowerment.”

Ultimately, Patchen says early diagnosis and treatment of patients with all of the above conditions greatly improves their chances of positive outcomes and survival. In addition, more aggressive monitoring and education for patients who are discharged from the hospital can help prevent readmissions and decompensation or exacerbation of these conditions. He also suggests that payers offer low-cost wellness visits along with early intervention once a diagnosis has been made.

Next: Heart disease infographic

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.