Population Health Takes Center Stage to Open ACC

Sometimes it’s good to be first, but Kim Allan Williams, MD, president of the American College of Cardiology, made it clear Saturday that he’s ready to give up the title.

The president of the American College of Cardiology (ACC) opened the 65th Scientific Session in Chicago with a rousing call to his colleagues, saying that unless they are ready to commit to population health, cardiovascular disease will continue to be the number one killer in the United States.

“We must turn off the faucet instead of just mopping up the floor,” said Williams, who is chief of cardiology and the James B. Herrick professor of Rush University Medical Center in Chicago. “We must shift the paradigm from treatment to prevention.”

This year’s ACC meeting centers on prevention and population health, and Williams himself would take part in half-day “intensive” on lifestyle change later in the day. Some in attendance remarked that having the ACC President sit on a panel about improving dietary habits sent a loud message that the organization’s 52,000 members are ready to move to value-based care.

First Lady Michelle Obama delivered a video message to cardiologists gathered in her hometown, and thanked them for embracing a prevention agenda that aligns with her “Let’s Move” effort against childhood obesity.

“We all know that preventing conditions like cardiovascular disease starts early, with the habits we instill in our kids; from the food we serve them, to the physical activity they do, or don’t do, every day,” she said. “And healthcare providers like all of you are absolutely critical in these efforts. Because people look to you for the information they need about their health and their family’s health.”

Williams then introduced David B. Nash, MD, MBA, dean of the School of Population Health at Thomas Jefferson School of Population Health in Philadelphia. Nash, who gave the Simon Dack Lecture, "Population Health: Is It the Secret Sauce?" noted that he isn’t a cardiologist—although several family members are—but that his field of quality measurement and primary prevention is nonetheless tied to what happens among doctors who treat heart disease.

While Williams might lament that cardiovascular disease is listed as the leading cause of death, Nash worries that 40% of deaths are tied to 4 underlying causes: smoking, alcohol use, lack of exercise, and unhealthy diets. Ongoing poor health among Americans cannot be sustained, Nash said; he repeated a well-known study that despite massive spending on healthcare, the United States ranked 17th—dead last—on a survey of health quality among developed nations.

“I don’t know about you, but I’m a pretty competitive guy,” Nash said. “I don’t want to be number 17 based on spending 19% of the world’s largest economic engine (on healthcare).”

The shift from treatment—with expensive drugs, devices, and procedures—to prevention is essential in cardiology to reduce healthcare spending, and so is the move toward evidence-based care, with a reduction in clinical variation, Nash said. If physicians don’t take control of this process, he warned, they won’t like the alternative.

The Medicare Access and CHIP Reauthorization Act (MACRA), which is the legislation that got rid of the Sustainable Growth Rate, brought with it a whole new set of rules to force a shift away from fee-for-service, he said. Some changes will be painful.

“So you and I are responsible,” Nash said. “If you and I don’t take responsibility for quality measures, then our elected representatives will take over for us.”

Right now, he said, only about 20% of medicine at bedside is evidence-based, and “We ought to do better.” Steps like reducing unnecessary tests will be hard, not only because this will require difficult conversations with patients, but also because what is “waste” for a health plan may still be revenue for some physicians.

Besides clinical variation, too much of a patient’s health status is shaped by geography and socioeconomic status. “Your ZIP code is your healthcare destiny,” he said.

So what is Nash’s prescription? Transparency, accountability, and a focus on outcomes. Change will require constant measurement and availability of the data so that progress is continually monitored.

“We must reduce the slavish adherence to individual autonomy,” he said. “We’ve got to practice based on evidence. … We’ve got to engage patients with regard to their individual behavior.”

“No outcome, no income,” he said. “That’s what MACRA is all about.”