Guest Post – “The Million Hearts Initiative: Game Changer or Heartbreaker?”

The Million Hearts Initiative:

Game Changer or Heartbreaker?

September 13^th 2011 marked a seminal moment in the healthcare policies of the United States. As an interventional cardiologist who treats atherosclerosis and intercedes during such events as acute myocardial infarctions the potential for change excites me; yet hope is always counterweighted by a healthy dose of reality and critical analysis.

Despite assertions that the US healthcare system is irrevocably broken, quite the opposite is true. In analyzing many different types of healthcare delivery from around the world the one commonality is that there is, as of yet, no perfect system. Each model has strengths and weaknesses and the US model is no exception. One of the strengths of our current system has also become a bit of an albatross; the focus on acuity of care. The current US healthcare delivery system evolved from the triage of battlefield medicine, particularly influenced by the Civil War. At that time a gunshot wound to the abdomen was treated with more expediency than an achy tummy. The focus was on the problem that could be readily identified and treated. This, even though disease like dysentery, typhoid and pneumonia killed more people, over 400,000 of the 620,000 people who died in the US civil war. Today that tradition continues, we are still better at treating a heart attack than preventing it.

Cardiovascular disease (CVD) is the leading cause of death in the US and by some accounts is responsible for approximately 17% of all health care expenditures. The costs continue to increase at a rate of approximately 6% annually over the last decade. This increase is expected to continue into the foreseeable future, with some estimates suggesting over 40% of the population with some form of CVD by 2030.

To address this growing threat, as part of the 2010 Patient Protection and Affordable Care Act (ACA), the government through its agencies in partnership with healthcare providers, professional organizations, industry and centers of education has launched the Million Hearts Initiative. The goal is that through a coordinated effort of all of those involved 1 million heart attacks and strokes can be prevented over the next 5 years. To achieve this, the plan calls for a shift of focus on preventive measure. A successful integration of preventive strategies to combat CVD would represent a well needed paradigm shift in how we identify those at risk, diagnose and treat CVD. That is the good (really great) intention and hope.

Unfortunately the reality, as noted by Saint Bernard of Clairvaux (1091-1153) is that, “Hell is full of good intentions or desires.” The Centers for Disease Control (CDC) play a prominent role in this campaign. A large portion of their effort is focused through the ABCS of heart disease and stroke prevention: Aspirin therapy, Blood pressure control, Cholesterol control and support for Smoking cessation. Let us briefly look at some of the key proposals of the initiative:

• Integration: The success of the initiative hinges on successful integration of many federal, state and local governmental agencies, not only among themselves but in a coordinated effort with the private sector. Many of specific initiatives derive from Title IV of the ACA: Prevention of Chronic Disease and Improving Public Health.
• Community Transformation Grants: As provided through the ACA, grants will be awarded to effect a reduction on the incidence and prevalence of chronic disease states. Strategies based on the ABCS principles include education and preventive services, tobacco-free living campaigns, increased low-sodium options in grocery stores and restaurants, and posting of nutritional information and calories contained in restaurant meals and vending machines.
• Physician Quality Reporting System: As part of the ACA healthcare providers must report certain data on Medicare patients or face punitive measures. The idea is to establish baseline measures of quality and maintain quality standards.
• Medicare Shared Savings Program: As part of new Medicare regulations, accountable care organizations (ACO), have been proposed. Through the ACA Medicare Shared Savings Program an ACO is eligible for a portion of any savings, based on the quality it delivers.
• Centers for Medicare and Medicaid Services 10^th Statement of Work for Quality Improvement Organizations: This publication establishes the measures for quality, effectiveness and efficiency that are enforced by quality improvement organizations. These organizations are contracted through the Centers for Medicare and Medicaid Services (CMMS).
• Coverage of Clinical Preventive Services: As required by the ACA Medicare and private insurance are required to cover evidence-based clinical preventive services without cost sharing. These include things like hypertension and cholesterol screening, obesity counseling and smoking cessation.
• Essential Health Benefit Package: The Department of Health and Human Services (HHS) is tasked by the ACA to define an essential health benefits package that must be offered by all health plans.

The list represents some daunting challenges. Coordinated integration of federal governmental services across multiple agencies, not to mention state and local agencies is fraught with logistical impediments. The track record is simply not good and the potential for waste is high. Preventive efforts like requiring restaurants to list nutritional and caloric information are notoriously ineffective, with a less than 15% impact rate on a recent follow up of a similar effort in New York City. Informing people of the dangers of cigarette consumption by labeling had no significant impact until additional taxes for consumption were levied. Being against quality measures of any form is like being against kittens and baby seals. Of course quality is important. The difficulty lies in defining quality and implementing meaningful measures. These are people with complex disease states, not grades of meat. The current status of ACOs is unclear, with governmental identification of exactly who or what constitutes an ACO lacking. Organizations contracted as governmental enforcers run the risk, especially if their compensation is tied to fines, collections or savings, of engendering gamesmanship of data instead of pursuit of quality care. Ultimately, decisions are based on a measure of value, not quality. Value must measure the quality (amount of positive improvement or effect) and quantity (number affected positively) against the cost, usually measured in dollars. This is the reality of the economics.

Preventive care must become an integrated arm of our healthcare delivery system, especially as we confront increasing burdens placed upon the system as the result of chronic disease states like diabetes and CVD. That goal is clear. However, the path we travel to reach that goal is not. Overarching initiatives can end up binding real efforts through regulation, waste and the law of unintended consequences. We must execute our hopeful visions grounded in reality. A grand experiment is under way.

Tomaselli, G. F., Harty, M.-B., Horton, K., & Schoeberl, M. (2011, October 8). The American Heart Association and the Million Hearts Initiative: A Presidential Advisory From the American Heart Association. Retrieved September 13, 2011, from The American Heart Association: http://newsroom.heart.org/pr/aha/document/Tomaselli–Million_Hearts-_Sept._2011.pdf

(Tomaselli, Harty, Horton, & Schoeberl, 2011)