SMARTCare is designed to give better, more appropriate care at lower cost to patients experiencing chest pain due to heart disease. Today, many patients experiencing periodic chest pain receive tests and procedures that are unnecessary, expensive, and can actually be harmful to them. SMARTCare will give primary care physicians, cardiologists, and patients ready access to the latest scientific evidence about what tests and treatments are the most appropriate for their heart problems in an easy-to-use, electronic format, enabling them to make the best choices about tests and treatments. SMARTCare also will change the payment system for cardiac evaluation, testing, and treatment in order to deliver better outcomes at lower cost for Medicare, private purchasers, and patients, while also maintaining the financial viability of high-quality cardiac care in physician practices and hospitals.
When a patient is experiencing occasional chest pain and comes to a primary care physician or cardiologist for an evaluation, the physician would first determine whether the patient is at immediate risk for heart attack and needs to be hospitalized, and if not, the physician would attempt to rule out obvious causes unrelated to heart disease, such as gastrointestinal reflux disease or muscle strain, and also rule out heart problems other than stable ischemic heart disease.
If it appears the patient is likely experiencing the symptoms of stable ischemic heart disease, the physician would use an electronic decision-support tool called FOCUS to help determine what the most appropriate next steps should be based on the patient's history and symptoms. The FOCUS tool is based on the appropriate use criteria developed by the American College of Cardiology, and it incorporates the latest evidence regarding the benefits and complications associated with different tests and treatments for ischemic heart disease. The FOCUS tool would inform and support decision making by the physician and patient about the most appropriate care, but it would not dictate a particular approach. In general, it would indicate which tests and treatments are usually appropriate for someone with the patient's characteristics and symptoms, which other tests and treatments may be appropriate in certain circumstances, and what tests and treatments are rarely appropriate. The physician and patient would then decide what is best for the patient, informed by those guidelines.
In some cases, the physician would send the patient for a non-invasive stress test to evaluate the extent of their heart disease. In other cases, the physician would first prescribe medications for the patient to determine if that would control their symptoms and their disease. If it is determined the patient needs a stress test, the FOCUS tool would help the physician and patient determine which type of stress test is the most appropriate. There are many different types of stress tests; some have much greater ability to determine exactly how severe someone's heart disease is, but they involve greater risks to the patient, they are more expensive, and when used for patients with mild symptoms or low risk factors, they have the disadvantage of also having a higher "false positive" rate, i.e., they can indicate that heart disease is present in someone who really doesn't have serious disease. Consequently, using these tests is undesirable if they are not necessary or used in patients with a low chance of having heart disease.
If the stress test indicates that the patient does have more than a minimal level of heart disease, the physician and patient would then discuss what to do next. It might be appropriate to do an additional, more sensitive stress test, or it might be appropriate to do an angiogram in a cardiac catheterization laboratory. While an angiogram provides the clearest information on the severity of any artery blockage a patient may have, it is an invasive procedure and has greater risks to the patient. One of the goals of SMARTCare is to reduce unnecessary use of invasive imaging that could be more harmful than helpful to patients. Moreover, it is important for the patient to determine what action they will take based on the results of the angiogram - would they do best with a stent or cardiac bypass surgery if the test shows significant blockage, or would they prefer to simply manage their disease with medications.
There is often no "right" answer to this decision. Under SMARTCare, the FOCUS tool would help the physician and patient make the best decision about additional testing; in addition, the physician and patient would use the ePRISM tool to help determine the most appropriate decision about whether to use a stent, what type of stent would be appropriate, and how best to minimize the chance of any unwanted complications from the stent procedure. The patient would also have access to education materials and shared decision-making tools to help them make those choices in collaboration with their physician.
Regardless of what testing and interventions are used, it will be important for all patients to take appropriate action to reduce their risk of developing more severe heart disease that could lead to a heart attack as well as painful angina (chest pain). Under SMARTCare, physicians would be able to use the INDIGO tool to help patients better understand (a) the risk they currently face given their family history, habits such as diet, activity, tobacco use, and existing level of heart disease, and (b) the reductions in risk that could be achieved through changes in diet, changes in activity, use of different types of medications, and other interventions. INDIGO creates a customized personal risk profile for various combinations of medication and lifestyle interventions. In addition, the use of Cardio-Smart and patient education tools would maximize patient understanding of their risks and how to address them.
Although the SMARTCare tools will help physicians and patients make better decisions about care today, they will also help physicians and patients make even better decisions in the future. This is because the FOCUS and ePRISM tools are not merely static "guidelines," they are also data collection tools. The choices physicians make using the tools, and the outcomes their patients achieve, will be recorded and used in two important ways:
SMARTCare physicians would collect and report on a series of quality and performance metrics to assure patients and payers that patients were receiving truly better care and achieving better outcomes at lower cost. This would include measures of patient experience as well as clinical quality measures.
Today, due to misinformation about the nature of heart disease and about the benefits of different tests and treatments, many patients end up receiving unnecessary testing, unnecessarily expensive or invasive testing, and unnecessarily expensive and risky interventions. SMARTCare is designed to ensure that patients who really need tests and interventions receive the most appropriate ones, while sparing the others the risks and costs associated with unnecessary tests and treatments. SMARTCare is expected to reduce spending in the following ways:
While savings from fewer tests and procedures will be significant, it is important to recognize that the true savings will be less than the current amount that payers are paying for the avoided tests and procedures. There are fixed costs associated with a cardiology practice, a cardiac testing facility, and a cardiac catheterization laboratory which must still be covered even if fewer tests and procedures are performed. Consequently, changes in the payment system will be needed to allow cardiology practices and hospitals to reduce unnecessary spending without jeopardizing their ability to continue providing the appropriate tests and procedures to the smaller number of patients who do need them.
Today, many health plans have required that before the cardiac tests or procedures ordered by a physician can be performed, a health plan employee or a contract firm has to review the case and approve the order. Not only does this delay the delivery of appropriate care to the patient, it increases administrative expenses for the health plan and for the physician. Only the patient's own physician understands the facts and circumstances regarding the patient well enough to determine what is appropriate for them; SMARTCare will provide a mechanism so that physicians can do their own review of appropriateness, rather than having a health plan or other entity do so. This will reduce administrative costs for both health plans and physicians.
There is also a cost to SMARTCare, however. FOCUS, PRISM, and INDIGO all require money to install in a physician's practice and to maintain with the most current information available. Collecting the information, adding it to NCDR and PINNACLE, and providing performance feedback to physicians also involves costs. Although these costs should be more than offset by the savings from avoiding unnecessary tests and procedures and eliminating the costs of prior authorization systems, there is no direct way to cover these costs under current payment systems, so payment reform is needed to enable implementation of SMARTCare.
The ideal payment to support SMARTCare would be a single condition-based payment, paid to a SMARTCare provider for each patient requiring evaluation and treatment of new or significantly changed symptoms of stable ischemic heart disease. This payment would replace all current physician fees and facility-based payments for evaluation and management, testing, and PCI procedures for these patients during the six month period from the time they first seek care. The SMARTCare provider would have the flexibility to use the payment to redesign care while assuring payers such as employers, health plans, and Medicare that spending would be lower than it is today and that the quality of care would remain high. The amount of the payment would be determined as follows:
Only patients appropriate for the SMARTCare payment model would be included; for others, payments would continue to be made under the current fee-for-service payment system.
In order to facilitate the transition to the bundled payment model, it may be necessary to temporarily use an alternative payment model that provides some of the same flexibility and accountability as the bundled payment model. This transitional payment model would have the following components:
The pricing, risk adjustment, and inclusion/exclusion criteria would be defined similarly to what was described above for the bundled payment model.
Cardiologists in Wisconsin and Florida, working through the American College of Cardiology, have developed SMARTCare. The Center for Healthcare Quality and Payment Reform and the Partnership for Healthcare Payment Reform have been providing technical assistance.