Traditional UM Programs Can't Move the Needle in Cardiology Care. Here's What Does.

Denial-heavy approaches do not just create friction with providers. They undermine the ultimate goal of driving sustainable, quality-driven behavior change. 

Cardiology should be a tempting target for health plans seeking to manage spend and improve members' care. After all, cardiovascular disease and stroke account for 14% of all health expenditures in the U.S.—more than any other specialty. That figure is driven not only by the prevalence of these diseases, but by overuse, misuse and underuse of cardiovascular services. Studies have found that 30% or more of cardiology spend may be clinically inappropriate. Among elective percutaneous coronary interventions, for example, 32% to 57% are considered rarely appropriate or potentially inappropriate

Yet, cardiology is loosely managed within many health plans. Unlike some other specialties, such as oncology, cardiology doesn't see a pipeline of extremely expensive drugs. Traditional UM approaches, with their focus on denials of a small scope of imaging and high-cost procedures, are ill-suited to effectively manage a specialty that sees a large scope of noninvasive testing and high-cost procedures. Simply put, plans cannot selectively deny their way to better overall performance in cardiology. 

True management of cardiology and cardiovascular subspecialties requires working with providers to improve practice patterns. Having practiced interventional cardiology for 30 years before joining New Century Health (NCH) in 2008, to guide its cardiovascular quality management program, I have learned what is required to bring about enduring, sustainable improvement in the field. Plans need to demonstrate that they have the clinical credibility to partner with cardiac, vascular and thoracic surgical specialists, a genuine focus on quality of care, and insights on how to improve care.    

These guiding principles have allowed us to routinely save 10% to 15% on cardiology spend by the second year of working with a new health plan partner, while ensuring that more cardiology practices follow the evidence.  

Cardiologists' decisions are guided by the collective wisdom of their peers. 

There is a reflexive (and often justified) skepticism among physicians when a health plan takes an interest in their clinical decision-making. Many have been subjected to brute-force prior authorization policies that wear down providers with paperwork and delays. 

Because of these experiences, they need to believe that a health plan truly puts quality first. What better way to make that case than by building a quality management program around the wisdom of their peers? At NCH, our clinical policies are based on appropriate use criteria (AUC) that are designed by experts from the American College of Cardiology and other professionally recognized societies. These criteria have been translated into high-value clinical pathways by our expert staff, following guidance from our Cardiology Scientific Advisory Board that consists of practicing academic cardiologists.

As a result, when physicians enter details of a patient case into our pathways tool, the guidance they receive is the product of their peers' wisdom across a comprehensive range of services for cardiac imaging, vascular medicine, Interventional cardiology, interventional radiology, electrophysiology, vascular surgery, cardiac surgery and thoracic surgery. They can see, on a scale of 1-9, whether a use of a service is rarely appropriate care (1-3), may be appropriate care (4-6) or appropriate care (7-9). The “appropriate” care requests are automatically authorized, while those scored rarely or may be appropriate care are flagged for further review and discussion.

Medical reviews are conducted as true peer-to-peer discussions. 

One of cardiologists' biggest frustrations about traditional prior authorization is having to justify the rationale behind their patient care decisions to medical reviewers from other disciplines. While their requests are typically authorized after a brief conversation (even if the request is not the most appropriate course of action), the extra hoop-jumping frustrates physicians, their practice staff and, often, their patients. 

_q_tweetable:Simply put, plans cannot selectively deny their way to better overall performance in cardiology. True management of cardiology and cardiovascular subspecialties requires working with providers to improve practice patterns._q_

In a well-managed program, these clinical conversations are led by health plan physicians with deep expertise and experience in cardiology and its subspecialties. At NCH, board-certified cardiologists treat these discussions not only as an opportunity to ensure that a given patient receives the most appropriate services, but also as a chance to engage providers, ensure they are on top of the clinical evidence and, hopefully, influence decision making to avoid unnecessary peer-to-peer discussions in the future.

What is particularly exciting for us to see is how these conversations, in combination with pathways, help prompt long-term behavior change. The requests submitted steadily become more appropriate—increasing about 0.5 AUC points after about a year—requiring fewer reviews and hence fewer peer-to-peer discussions. In addition, rates of denials are minuscule—about 0.33%—because we treat them as a last resort. In most reviews, requests are voluntarily withdrawn or modified by the physician.



A comprehensive scope of services drives direct and indirect savings.

Cardiology utilization or benefit management programs can be rather unspecialized, focusing on 15 to 20 services out of hundreds that exist. Some programs have resigned themselves to the idea that, while many services are overused or misused, the ROI does not exist to justify managing them. Our experience with clinical pathways covering more than 100 cardiovascular services points to a different conclusion: Effectively managing certain lower-cost services can also have a ripple effect across a cardiology program, producing direct and indirect cost savings.

Consider nuclear stress tests, echocardiograms and noninvasive vascular testing. These tests, when managed inappropriately, can set off a cascade of follow-up studies and other interventions that may also be unwarranted. Such “downstream” tests and procedures should therefore be included in the scope of a cardiology management program. According to an analysis by our medical economics team, a nuclear stress test that costs about $800 is a gateway for a series of subsequent cardiovascular services that total about $4,300 on average.

As another example, a patient with hypertension and a mildly abnormal electrocardiogram (EKG), but no chest pain, would typically not warrant an imaging stress test, per AUC guidelines. But if that test is performed, there is a 10% or greater chance that the test will return a false positive result for ischemia, leading to an unnecessary cardiac catheterization, which in turn may result in additional unnecessary interventions.

In many markets, NCH has helped plans to increase the percentage of stress tests and echocardiograms that are considered highly appropriate by 25% or more. 



Clinical pathways guide physicians to the optimal service—not just a decision on the service requested.

Traditional cardiology UM programs do not typically guide the clinician to a more appropriate service or therapy that the patient should receive than what has been requested. In many cases, the evidence calls for a different approach. 

Guideline-directed medical therapy (GDMT) is a prime example. GDMT has been demonstrated to prevent hospitalizations, ED visits and cardiac events while improving quality of life and reducing mortality for certain cardiovascular conditions. Yet, physicians sometimes skip or underuse GDMT before requesting more aggressive or unnecessary services. For heart failure with reduced function, a defibrillator implant would generally be considered misuse unless the patient has already been on GDMT at target doses for three months without improvement. That is because GDMT for this condition can often delay or avoid the need for a defibrillator and the complications that can follow. At NCH we have identified 22 services across eight conditions in which GDMT should be reviewed before an authorization is issued, and we are updating our clinical policies and pathways to reflect such guidance.

Similar examples occur where, for a given scenario, one service (AUC 6) is requested yet another service (AUC 8) is more appropriate or “preferred” independent of cost.

The risks of underuse are taken seriously. 

Underuse of evidence-based cardiovascular surveillance testing can be harmful to patients and costly to plans in the long run. For example, frequency guidelines call for an echocardiogram every 6 to 12 months in an asymptomatic patient with severe valvular heart disease. Patients in this category who are not monitored in heart valve clinics and/or do not undergo surveillance echocardiograms, have a two-year mortality of 46%. On the other hand, when echocardiograms are performed as per frequency guidelines, and disease progression demonstrates the need for elective valve surgery, the post-procedure mortality rate is less than 1%.   

Other examples of underused value-based services are noninvasive testing to screen patients at high risk for cardiovascular conditions, cardiac rehabilitation, and palliative care.

Traditional UM solutions are ill-equipped to tackle underuse because it occurs outside of the prospective prior authorization setting. Nudging providers to follow guidelines is not in their playbook or business model. 

Tackling underuse—which NCH will be targeting late this year—requires a more holistic approach. Our decision support tool can encourage physicians to deliver appropriate care based on frequency guidelines for underused services. In addition, we can regularly audit and analyze clinical data to see which physicians are underutilizing high-value services, then provide feedback and education to them. 

Cardiovascular specialists, like other physicians, tend to be high achievers and highly competitive. They've also been trained to value good data. Plans need to tap into those intrinsic motivations by providing regular performance feedback, so providers can benchmark themselves against one another along quality, utilization, cost, and outcome metrics. 

There is a huge opportunity for plans to improve cardiovascular care while avoiding unnecessary costs. However, they will not make a significant dent by denying requests, one service at a time, day in and day out. Capturing the opportunity requires investing the time today to improve providers' practice patterns tomorrow.

About the Author

Fernando Villacian, MD, FACC

Dr. Fernando Villacian is Senior Medical Director, Cardiovascular at New Century Health. As an interventional cardiologist and managed health care executive, he is responsible for the advancement of technology-based cardiology solutions that enhance quality of care delivery and reduce variation in treatment. Dr. Villacian has four decades of health care experience and has been with NCH since 2008.

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