Saving 1 Million Lives
By Amy Lynn Sorrel Texas Medicine June 2015

Million Hearts Initiative Targets Quality Improvement, Public Health

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Quality Feature — June 2015 

Tex Med. 2015;111(6):39-44.

By Amy Lynn Sorrel
Associate Editor

Quality improvement and public health goals meet in the Million Hearts initiative, and Texas physicians say the package deal could be just the right combination to fight the No. 1 and No. 4 causes of death in the Lone Star State and in the country: heart disease and stroke. 

Co-led by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services (CMS), the national campaign aims to get physicians, health systems, patients, and public and private partners on board to prevent 1 million heart attacks and strokes by 2017 and to curb the $300 billion in annual costs associated with heart disease. In Texas, inpatient hospitalizations for cardiovascular disease and stroke cost roughly $21.5 billion in 2012, according to statistics from the Texas Department of State Health Services (DSHS). 

For physicians, the task means focusing on the "ABCS" — quality measures targeting aspirin therapy, blood pressure control, cholesterol management, and smoking cessation. The measures also coincide with a slew of other requirements doctors are subject to under public and commercial insurers' performance programs, and Texas physicians can get help sorting through the barrage from TMF Health Quality Institute. The statewide quality improvement organization is a Million Hearts partner. 

For the state, the fight involves a large-scale prevention effort spearheaded by DSHS, with a possible boost from the Texas Legislature. Texas was one of four states chosen to receive extra technical assistance from the National Association of Chronic Disease Directors to promote Million Hearts. The Texas Medical Association serves on the DSHS-led workgroup.

"We all know physicians' time is limited, and when they are looking at participating in different quality initiatives, they can more or less find a cross-pollination in Million Hearts," said Robert B. Morrow, MD, a member of the TMA Council on Health Care Quality and TMF Board of Trustees. "I tell my patients the most clinically and financially effective way to manage an illness is not to get one, and I know that's what my physician colleagues are working towards. So this is really a win-win-win for the physician, the patient, and, quite frankly, the community as a whole." 

The Texas Council on Cardiovascular Disease and Stroke (TCCVDS) shared those sentiments in its recommendations that the 2015 Texas Legislature fund additional support for Million Hearts as a statewide initiative. 

"Prevention is the most long-term, cost-effective way to decrease heart disease and stroke," said TCCVDS Chair J. Neal Rutledge, MD. The Austin neurointerventional surgeon says the public health goals tied to the Million Hearts initiative are contingent not only on physician quality improvement efforts, but also on expanding awareness of the broader implications of heart disease. 

"The bottom line is, we want everyone to be healthy, but we need all stakeholders to be involved, and the first place to do that is education," Dr. Rutledge said. "There are many, many things that help improve people's health. But some do it more than others, and Million Hearts is a nice package to prioritize that and help inform other partners, like the state legislature, of potential cost savings." 

Measures Alignment

Million Hearts targets clinical and public health interventions in its objectives to reduce the risk of cardiovascular disease. Like Choosing Wisely, the campaign has garnered support from professional medical societies like the American College of Cardiology and the American Medical Association. 

A major tenet of Million Hearts — in line with TMA's goals — is to help physicians and health care systems focus on a core set of high-impact clinical quality measures that align across various public and private quality reporting programs, says TMA Director for Clinical Advocacy Angelica Ybarra. On that front, she says the initiative has made significant progress, and there's no additional cost for physicians to participate. (See "When the Measures Align.")

Major Medicare quality reporting initiatives like the Physician Quality Reporting System (PQRS) and the meaningful use of electronic health records (EHRs) program, have embedded the ABCS measures in their requirements. The scores physicians receive on the metrics also feed into the value-based payment modifier — which adjusts physician payments based on quality and cost performance — and the Physician Compare website — where Medicare publicly displays physician quality ratings. (See "Your Guide to Medicare Value-Based Care," April 2015 Texas Medicine, pages 26-34) 

The ABCS are also part of the National Quality Forum's repertoire of evidence-based quality measures (see "Measure of Success," April 2013 Texas Medicine, pages 59-63) and the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) that Medicaid, employers, and other purchasers use to evaluate public and private health plan performance. 

On the commercial side, the ABCS also cross over with cardiac measures under Bridges to Excellence (BTE), a national performance improvement program that Blue Cross and Blue Shield of Texas (BCBSTX) has adopted, says Dr. Morrow, a BCBSTX medical director. The health plan's parent company, Health Care Service Corporation, is a Million Hearts Partner. While BTE is not directly tied to the initiative, the Texas Blues financially reward physicians who achieve BTE recognition for similar measures in cardiac care, as well as in diabetes and asthma care. 

"As we begin to move from a fee-for-service-dominated environment to a value-based environment, everybody is looking for ways to demonstrate value," including health plans and physicians, Dr. Morrow said. "The nice thing about Million Hearts is, it's not reinventing the wheel. The metrics are pretty straightforward, and they've already been vetted."

Outcomes That Matter 

The initiative not only reduces the reporting burden on physicians, but also helps doctors focus on outcomes that matter across patient populations, across specialties, and across the state, Dr. Rutledge adds. 

Hypertension, for example, is a key focus and affects multiple diseases. But the burden of heart disease weighs heavy on Texas, he says. "I see stroke patients on a daily basis. But I'm not seeing people before they have a stroke. I'm seeing them after the fact to prevent second strokes."

About one in 17 Texans has heart disease, according to the Texas Council on Cardiovascular Disease and Stroke report to the 2015 legislature. Of the $21.5 billion Texas spent on heart disease and stroke-related hospitalizations in 2012, $1 billion came from Medicaid charges.

The council conducted the first gap analysis of care to show exactly where the state most needs to marshal resources, like transportation and hospital resources for stroke and heart attack patients. 

Million Hearts also offers a Clinical Quality Measures Dashboard, which displays regional, state, and national data performance on the widely-adopted ABCS to show progress and gaps. 

The TCCVDS report asks the legislature for more money to build on past efforts lawmakers funded to improve transportation and trauma services in underserved areas; collect better data on heart attack and stroke incidents; and increase research and public education, for example. At press time, budget discussions were still under way. The House had approved a rider in its draft giving additional funds out of the DSHS budget to the council. 

Meanwhile, the DSHS workgroup continues to strategize ways to expand the role of community health workers in hypertension control and clinical quality improvement, specifically through the use of health information technology. 

Dr. Rutledge says Million Hearts dovetails with the council's overarching recommendations to improve prevention of heart disease and stroke, and the report asks for money to develop a comprehensive messaging campaign for patients and clinicians. "This program offers an efficient method for physicians and the community to focus on key elements needed to reduce the morbidity and costs of heart disease and stroke."

A Plan of Attack

At Kelsey-Seybold Clinic, a 300-physician, multispecialty clinic in the Houston area, the key focus has been a large swath of patients with out-of-control blood pressure. The clinic won recognition last year from Million Hearts for incorporating the hypertension measures in its quality improvement initiatives and raising control rates to 70 percent or more. 

To do that, Kelsey-Seybold formed a task force to understand what the quality metrics required and to create a plan to accurately measure and track the data using the clinic-wide EHR system, says Olethia Chisolm, MD. 

"We made sure everyone is on board," the internist and hypertension specialist at the Meyerland Kelsey-Seybold Clinic in Houston said. "In terms of prioritizing blood pressure, we felt that patients often get information on smoking cessation and cholesterol from the community or wellness initiatives. But high blood pressure, because it's more of a silent condition, is often neglected. And if you look in terms of outcomes — for stroke, chronic kidney disease, diabetes — it plays a big role." 

Kelsey-Seybold also participates in Medicare's PQRS and EHR quality reporting programs and BTE, and the task force helped coordinate their Million Hearts objectives with the various reporting requirements. 

"We knew if we hit targets for one program, we would hit targets for others that tend to be similar," Dr. Chisolm said. "Anytime we can make improvements, we are going to impact our patients' health and hit our quality goals, as well. And the cumulative effect of tackling these particular measures is substantial improvements in health." 

For practices without extensive resources, Dr. Morrow reminds physicians that TMF is available to help guide and support them in adopting quality improvement initiatives like Million Hearts. 

CMS added the program to TMF's most recent contract as the state's quality improvement organization, placing a stronger emphasis on improving cardiac health nationwide, says Tracy Swoboda. She oversees the contract as TMF project director for cardiac health, meaningful use, and value-based payment initiatives. 

So far, TMF has helped more than 60 physician practices put Million Hearts into action. Through consultants and educational networks, TMF provides no-cost technical assistance in evaluating the ABCS metrics, drilling down into areas of improvement, and putting workflow, documentation, and EHR systems in place to help practices reach their target populations and improvement goals. 

Because the measures tie into various public and private quality reporting programs, TMF helps practices evaluate and maximize the mechanisms they have for reporting — whether through EHRs or registries, for example — to make sure they get credit for their efforts, Ms. Swoboda says. 

At the same time, "there's only so much providers can do if they don't have the engagement and support of their patients," she said. 

In that regard, Million Hearts offers educational tools and resources to get patients involved in their treatment, Ms. Swoboda says. The initiative also aligns with the Affordable Care Act National Quality Strategy to increase the effectiveness of care for high-risk conditions like heart disease and to promote patient and family engagement in that care, she adds. 

There's not much downside to participating in Million Hearts, according to Dr. Chisolm. Other than the time physicians already spend on quality reporting, there's no cost to participate, "so it's not taking additional time away from patient care." 

Nor are practices required to tackle all of the ABCS. Rather, she recommends choosing metrics most impactful for their patients, like Kelsey Seybold did. 

"The biggest benefit is partnering across the nation to make a substantial difference," Dr. Chisolm said. "Whatever improvements we can make are going to benefit everybody: individual physician practices and patients' quality of life." 

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

June 2015 Texas Medicine Contents
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April 19, 2018

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