Spreading the Quality Creed Through Affiliations and Alliances

Few physicians understand the complexities of today’s changing healthcare environment better than Jeffrey Rich, MD. Fewer still have as much experience in quality improvement and cost containment. That’s why Cleveland Clinic appointed Dr. Rich as Chairman of Operations and Strategy for its Miller Family Heart & Vascular Institute a few months ago.

Prior to the appointment, Dr. Rich held a variety of high-profile positions focused on quality improvement and payment reform. Among these, he ran Medicare’s fee-for-service program in the George W. Bush administration, held leadership positions with the National Quality Forum and testified before Congress on payment models that reward quality performance over volume.

While practicing cardiac surgery at Sentara Heart Hospital in Virginia, he launched a quality initiative along with other surgeons for sharing data and outcomes among all Virginia hospitals with cardiovascular programs. The program, called the Virginia Cardiac Services Quality Initiative, used a unique clinical financial tool to develop evidence-based protocols to reduce complications and costs, saving the hospitals hundreds of millions of dollars.

With this background, Dr. Rich was ideally suited to spearhead Cleveland Clinic’s growing network of cardiovascular and cardiac surgery affiliate and alliance relationships. While that represents a major component of his new job, Dr. Rich is also charged with promoting quality initiatives, developing innovative payment models and engaging in strategic growth planning for the institute. In the Q&A below we asked Dr. Rich to explain the value of these efforts in a volatile healthcare environment.

Q: How does Cleveland Clinic’s Heart & Vascular Institute work with its affiliate and alliance provider organizations?

A: We provide clinical direction, quality assurance and access to cutting-edge technologies and techniques for cardiology and cardiac surgery groups within hospitals [see figure below].

The relationships with our affiliate and alliance partners are rooted in our healthcare advisory services. Cleveland Clinic’s consulting team of 15 dedicated cardiovascular specialists thoroughly evaluates the processes and outcomes of each hospital or health system that enlists our advisory services, conducting comprehensive interviews with physicians, nurses, administrators and other staff involved in the institution’s care delivery pathway. We also assess the short- and long-term strategy of the organization’s cardiovascular service line. We then make recommendations for how they can improve quality using defined end points.

Our Heart & Vascular Institute develops affiliation and alliance relationships with like-minded organizations that have demonstrated high quality and a culture open to change. Each partner institution has specific reasons for pursuing a relationship with Cleveland Clinic, but most are interested in quality improvement, innovation, increasing efficiency and reducing costs.

We currently have 23 affiliate hospitals and seven alliance hospitals, all of which meet rigorous quality requirements. Alliance hospitals undergo an additional vetting process and are eligible for a recently developed program that’s cultivating direct-to-employer contracting relationships throughout the country. This program’s goal is to provide high-quality cardiovascular care that is also cost-effective to individuals who work for participating employers (and their covered family members) all across the country. Under the program, employees are eligible to access top cardiovascular surgeons and cardiologists who’ve been identified by Cleveland Clinic as cardiovascular providers with superior quality in their area.

Q: Are there similar networks in the U.S.?

A: No, we have a unique program dedicated to ongoing quality assessment and institution of best practices. A few centers offer different types of affiliation. These programs have varying goals and do not perform in-depth analyses of heart programs. We take a deep dive into each institution and look at every aspect of care to identify strengths and weaknesses.

One of Cleveland Clinic’s strengths is a commitment to learning every single day and to embracing change. We actively engage the affiliates and alliance hospitals in the same journey of transformation through many venues. Examples include regular quality, continuous improvement and administrative calls, as well as shared educational forums, on-site visits by Cleveland Clinic consultants to the affiliate and alliance hospitals, and affiliate and alliance member visits to Cleveland Clinic.

Q: What are some specific benefits for affiliates and alliance members?

A: Drs. Toby Cosgrove and Lars Svensson started our advisory services program 15 years ago when hospitals began asking Cleveland Clinic to help them improve their outcomes. Quality improvement and optimization of patient outcomes continue to be the core benefits. Commitment to quality initiatives drives significant improvements and helps reduce complications. Since complications add to the cost of care, this often lowers costs.

For surgeons and cardiologists, we provide a second-opinion program. Affiliates and alliance programs can call us about challenging cases. A Cleveland Clinic physician will then review the case and work with the affiliate/alliance physician to make a joint decision about how best to proceed.

Affiliate and alliance programs also can send individuals and teams on visits to Cleveland Clinic during which team members explore their specific interest areas — for example, observing surgeries and procedures or speaking with clinical subject matter experts about new techniques and procedures. We also provide access to Cleveland Clinic protocols and procedures. Affiliate and alliance programs can choose the protocols or procedures they are interested in, and we help them with implementation.

Q: How are these relationships evolving?

A: Historically we’ve been involved in cardiovascular surgery and medicine consulting, as well as cardiovascular affiliation/alliance relationships. We have now expanded our services to also do focused consulting assessments in hospitals. Examples include TAVR assessments and surgical and procedural process improvement consulting to help hospitals improve their efficiency and decrease costs.

Q: What do you, as a veteran in the health quality realm, think heart programs most need to recognize in order to thrive?

A: Medicare’s sustainable growth rate formula, which has been used for many years, has been replaced by merit-based incentive programs and alternative payment models. These reforms will cause great stress on hospitals and physicians, who need to build in efficiencies of care to succeed.

The majority of cardiologists, and a near-majority of cardiac surgeons, are now employed by hospitals. CMS is moving toward bundled payments for the management of specific diseases. When bundling arrives, physicians will no longer be paid separately. CABG, for example, will be reimbursed in a bundled payment that includes all Medicare Part A and Part B services, some services before the index hospitalization and selected services after discharge related to the procedure. The preop and postop windows will be determined and may range from 30 days preop to 90 days postop. Success under bundled payments will require close collaboration among providers to deliver efficient care, eliminate duplicate testing and lower resource utilization.

Cleveland Clinic is preparing hospitals for current and future healthcare reform by helping them create better, more efficient care pathways. If they don’t identify where they have inefficiencies, there will be financial risk — both for management of bundles and through potential penalties for failure to meet CMS quality standards for readmissions and other measures.

There will be challenges along the road to healthcare reform unless hospitals, physicians and other providers make changes to improve quality and increase efficiencies in care delivery. But it’s important to keep in mind that patients will benefit through improved care pathways. Cleveland Clinic has committed itself to helping hospitals across the country achieve these goals.