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Taking the Payment Improvement Initiative to heart 

Cardiologist David Rutlen and UAMS team make changes in the best way to care for their patients.

click to enlarge UAMS Cardiologist David Rutlen image
  • Brian Chilson
  • UAMS Cardiologist David Rutlen

Dr. David Rutlen, 67, has been a cardiovascular researcher at Yale University, chief of cardiology at the Medical College of Georgia, and director of cardiovascular medicine at Froedtert and The Medical College of Wisconsin Cardiovascular Center in Milwaukee.

The director of cardiovascular medicine at the University of Arkansas for Medical Sciences for the past eight years and a clinician, Rutlen and "a cast of thousands" (as he likes to say) took on another challenge in 2012: revamping the way UAMS originates care for congestive heart failure patients as part of the state's Payment Improvement Initiative to control Medicaid spending.

For six months, attending physicians, fellows, residents, nursing students, pharmacists — the number was actually 40 — met to examine what UAMS was doing to treat its patients with chronic heart disease who come to UAMS for acute care. It looked at the heart failure order sheet of various procedures and asked, what should be here and what need not be here?

Who among us has not had a doctor ask us to get a test another doctor performed in recent months? Shouldn't that be determined before one is ordered? The medical center's order sheet — which drives doctors' decisions in testing — included cardiac ultrasounds, chest X-rays, full blood work. And Rutlen said the team said, "Let's just rethink this." What if the patient had had an ultrasound recently? Was the chest X-ray really needed? Why order full bloodwork when what you want to know is whether the patient's kidneys are functioning the way they ought or has their poor heart function loaded their lungs or legs with fluid? Isn't it critical to get a pharmacist and the nursing staff involved to see what medicines the patient has been taking (heart patients are sometimes on as many as 30 meds, Rutlen said)? Are we providing the best care? What if the patient was put on an intravenous diuretic instead of a bolus, and what if the patient was to be seen a week after his hospital visit to make any needed adjustments in medications? Should that be included in UAMS'protocol?

The approach was to see "what exactly do we need to know to take care of the patient?" Rutlen said. The result was a "sea change," impacting not just its Medicaid patients but all heart patients seen at the medical center.

UAMS expected that its average charge for 30-day episodes of congestive heart failure would be in the $4,700 to $6,500 range, Rutlen said. But the data came back better: UAMS' average charges to Medicaid for 20 episodes of congestive heart failure were $3,500. That's in the "commendable" range established by initiative, which means UAMS will get money back from the state Medicaid system.

Will the Payment Improvement Initiative make a real difference in containing Medicaid costs? Rutlen believes it will.

The Payment Improvement Initiative is only tangentially related to the Affordable Care Act, which expanded Medicaid eligibility and thus access to health care for hundreds of thousands of Arkansans. But the PII's creation of the medical home — the coordinated care of patients by cooperating providers — could help with outreach to persons who didn't have insurance or who simply didn't feel comfortable going to the doctor. Rutlen's wondering about his patient with congenital heart failure whom he's never been able to convince to have the surgery he needs. Maybe he will now.

"It's exciting," Rutlen said. "Medicine is moving so quickly. ... With the Affordable Care Act, you can look at it as a burden or as an opportunity."

Rutlen added, "My personal perspective would be for universal health care, but only Obama's plan would have passed" Congress.

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