Impact
The Health Care Policy section is devoted to understanding how health care policies can be effectively used to improve cardiovascular care quality and health. Our work has led to significant changes in cardiovascular research and care, including how health policies are developed, implemented, and evaluated, how federal programs assess and incentivize improvements in quality and outcomes, and how both can be effectively used to advance cardiovascular health. Having been cited in Congressional testimonies and reports, as well as in national guidelines and lay media outlets, work in the Health Care Policy Section is regularly discussed in national policy debates about cardiovascular health policy. Dr. Wadhera has served as a health policy advisor for the US Department of Health and Human Services, where he provided evidence-based guidance on federal policies that directly impacted cardiovascular care delivery. He has also served on the National Committee for Quality Assurance Utilization Measurement Advisory Panel, which provides advice on the quality measure development and testing process for health systems and payors. Additionally, he has served on the Medicare Technical Expert Panels on cardiovascular quality measures, and currently servs on the Institute for Clinical and Economic Review Advisory Panel, which votes on the strength of the evidence on the effectiveness and value of new drugs, devices, and delivery innovations.
National Value-Based Policies
Early work in this section showed the Hospital Readmissions Reduction Program (HRRP), which is a national value-based program that financially penalizes US hospitals based on 30-day readmission rates for heart failure, myocardial infarction, and other conditions, was associated with a concerning increase in heart failure deaths (JAMA, BMJ, Annals of Internal Medicine). This work gained national attention, with two articles in the NYT, and Dr. Wadhera presented his suggestions on how to improve the HRRP to the Centers for Medicare and Medicaid Services (CMS), leading to the creation of a group to re-evaluate this national policy. Similar work evaluating other national policies, such as the Value-Based Purchasing Program, Hospital Acquired Condition Reduction Program, and the Merit Incentive-Based Payment System, have also been carried out by his research group. As a result of these evaluations, Dr. Wadhera wrote a perspective piece titled "Toward Precision Policy: The Case of Cardiovascular Care" (NEJM) calling for a more rigorous and empirical approach to health policy development, implementation, and evaluation. Recommendations from this work has been adopted by CMS and under the 21st Century Cures Act, CMS changed the HRRP so that it only compares hospitals caring for similar proportions of low-income adults and also announced modifications to the Value-Based Purchasing Program to include an equity adjustment that benefits hospitals providing high quality care to more low-income patients.
Quality Assessment and Improvement
In a series of works published in JAMA, JAMA Cardiology, and JACC, our research team revealed that state-led initiatives to publicly report percutaneous coronary intervention (PCI) outcomes led to risk aversive behavior that impeded access to care for high-risk patients. This ultimately resulted in Massachusetts ending its PCI public reporting program.
In addition, our work has demonstrated that national registry data from the AHA and ACC identifies high quality cardiovascular care more reliably than federal quality reporting programs, and that health system performance is often misclassified by the latter (JAMA Cardiology 2020 & 2021). Additionally, we have found that national clinician-led quality improvement programs - like AHA Get With The Guidelines - reliably assess and meaningfully improve quality, while also narrowing racial disparities in the delivery of guideline-directed cardiovascular care. At the same time, our research has also highlighted the significant and rising number of quality measures and programs that clinicians and health systems have to navigate across payors (JAMA), which can impose significant administrative burden. Dr. Wadhera has presented this evidence directly to policymakers at the US Department of Health and Human Services, highlighting the need for Medicare programs to shift towards fewer, more meaningful, and valid quality measures. Due in part to this body of work, the Centers for Medicare & Medicaid Services implemented Meaning Measures 2.0 and announced the “Universal Foundation” initiative, which will reduce the burden of quality measures, enhance alignment across payors, and promote use of more meaningful measures.
Our research is at the forefront of health care policy in the United States, and our research team publishes timely and relevant work at the intersection of policy and cardiology, contributing to major debates within Congress and between key national policymakers.
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"...Lower education and income levels were associated with lower prescribing of GDMT, as well as outcomes post-MI..." (Association of outpatient practice-level socioeconomic disadvantage with quality of care and outcomes among older adults with coronary artery disease: implications for value-based payment. Circ Cardiovasc Qual Outcomes.)
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"...However, the current strategy of attaching quality metrics to fee-for-service payments has added to the administrative burden and worsened physician burnout. CMS has 2,266 quality metrics in its inventory..."(Quality Measure Development and Associated Spending by the Centers for Medicare & Medicaid Services. JAMA 2020.)
"...The Hospital Readmission Reduction Program is associated with decreased readmissions, as expected, but also with increased 30-day post-discharge mortality after hospitalization for heart failure..." (Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia. JAMA 2018.)
"...Quality metrics also disproportionately penalize safety net hospitals and hospitals which care for minority patients...." (Association Between the Proportion of Black Patients Cared for at Hospitals and Financial Penalties Under Value-Based Payment Programs. JAMA 2021; Medicare's Value-Based Purchasing And 30-Day Mortality At Hospitals Caring For High Proportions Of Black Adults. Health Affairs 2024.)
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"...People of color are more likely to delay care or forgo treatment..." (Racial/Ethnic Disparities in Delaying or Not Receiving Medical Care During the COVID-19 Pandemic. Journal of General Internal Medicine 2022.)
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"...Because of these vulnerabilities, dual-eligible patients are much more likely to require hospital care, nursing home care, long-term care, and home-based care, and are unfortunately at increased risk for experiencing poor health outcomes..." (Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017. JAMA 2020.)
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"...These disparities combined had a deadly effect in the pandemic. Black and Latinx residents were more likely to contract, be hospitalized for, and die from COVID-19 in Massachusetts..." (Community-Level Factors Associated With Racial And Ethnic Disparities In COVID-19 Rates In Massachusetts. Health Affairs 2020.)
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"...Study after study documents that facilities without sufficient nursing staff have both more cases of COVID-19 and more deaths from the virus..." (Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases. JAMA 2020.)
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"...In addition, during the COVID–19 pandemic in the United States, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths caused by heart disease and cerebrovascular disease..."(Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID–19 Pandemic in the United States. Circulation 2021.)
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"...Patients with DES experience significant disparities are also likely to be more medically complex and remain one of the most vulnerable populations..." (Mortality and Hospitalizations for Dually Enrolled and Nondually Enrolled Medicare Beneficiaries Aged 65 Years or Older, 2004 to 2017. JAMA 2020)
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"For example, studies have found that the number of primary care physicians and PAs per capita tends to be lower in low-income counties compared with higher-income counties; in contrast, NPs are more evenly distributed across counties or even slightly more prevalent in counties with lower incomes" (Primary care physician supply by county-level characteristics, 2010–2019. JAMA 2022.).
"Limited evidence suggests that MA plans do not provide greater access to services overall relative to FFS (Comparison of Medicare Advantage vs. traditional Medicare for health care access, affordability, and use of preventive services among adults with low income. JAMA Network Open 2022.)"
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"While increased access to services once beneficiaries are enrolled in MA could dampen some of the effects of favorable selection, limited evidence suggests that MA plans are not providing greater access to services overall relative to FFS." (Comparison of Medicare Advantage vs. Traditional Medicare for health care access, affordability, and use of preventive services among adults with low income. JAMA Network Open 2022.)
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"...Dual-eligible beneficiaries also have higher mortality rates, so their providers can have worse results on the discharge to community measure..." (Mortality and hospitalizations for dually enrolled and nondually enrolled Medicare beneficiaries aged 65 years or older, 2004 to 2017. JAMA 2020)
