Since the Affordable Care Act became law in 2010, cardiologists have been mired in a fog of uncertainty, leading to delays in making important practice management decisions.

“When I get together with colleagues at national meetings, I get the sense that nobody really understands the future,” said Cam Patterson, MD, MBA, chief of the division of cardiology at the University of North Carolina at Chapel Hill.

That uncertainty “throws a wrench into the planning process,” including recruitment and benchmark setting, he told MedPage Today.

“It’s a major sea change,” added Thomas Tu, MD, director of the cardiac catheterization lab for the Louisville Cardiology Group in Louisville, Ky., who notes that physicians are “struggling” to find ways they can be influential in the new environment.

Patterson noted the plight of young cardiologists seeking jobs in a healthcare market unsure of how or when to make its next move.

“It’s challenging to hire new recruits when budgetary and human resources decisions are essentially on hold until there is a better understanding of what the ACA will bring,” he commented.

Regarding setting benchmarks, Patterson said the days of merely imagining your quality is as good as the next practice or hospital are gone.

Cold, hard data are the new norm, but which data and how best to collect and analyze them, as well as apply the results in a robust and meaningful way, are being worked out slowly.

“As with everyone else, we are scrambling to get a grip on what our quality measures are,” Patterson said.

Education and Prevention Will Be Key

Hospitalists, as well as advanced nurse practitioners and physician assistants, can help ease the workload due to the shortage of primary care providers, a shortage that is particularly acute in California, according to C. Noel Bairey Merz, MD, director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles.

“If the reform happens the way it is intended, we should have an integrated healthcare system where primary prevention - management of hypertension, dyslipidemia, diabetes, smoking cessation counseling, and therapeutic lifestyle changes - is handled at the primary care level,” she said.

The truth of the matter, however, is that it takes twice as long to train the average general physician as it does an average nurse practitioner, and four times as long as the average physician assistant.

“It’s a lot to expect of physician extenders to practice primary care medicine,” Merz told MedPage Today.

“A better system is the medical home model, with physician team leaders and physician extenders who work on protocols. The physician extenders would be licensed and would be able to work autonomously within a protocol,” she said.

Five years ago, the cardiology department at Geisinger Health Center in Danville, Pa., employed four nurse practitioners or clinical nurse specialists. Today, there are 12 and the department is seeking three more, according to James Blankenship, MD, vice president of the Society for Cardiovascular Angiography and Interventions, as well as an interventional cardiologist at Geisinger.

Blankenship also said that acknowledging the need for more primary care providers is to miss half of the equation. “We will need more specialists, as well.”

Given the newly insured patients coming into the system, as well as the aging Medicare population, cardiologists will be stretched pretty thin. But the field of cardiology has been instrumental in advocating teamwork among the different specialties for years, he said. “That’s a train that’s already on the tracks.”

Merz noted an expectation to see more cardiovascular care teams in response to the ACA. Such teams typically consist of a physician leader, nurse practitioners, pharmacists, behavioral experts, rehab professionals, and others.

These teams are vital for the care of high-risk patients such as survivors of angioplasty, bypass surgery, and heart failure, she said, especially since there aren’t enough cardiologists to do it all.

Echoing Blankenship, Merz said that cardiologists will probably be busier than ever as heart disease remains the leading killer among men and women as the population ages. She noted a decline in the most severe type of heart attack—ST-segment elevation MI, or STEMI - in the Medicare population, a decline that is likely multifactorial, but two reasons stand out as attributable to the decline—the use of low-dose aspirin and statin therapy for primary and secondary prevention, she said.

“At whatever level these medications are prescribed and managed—primary care physician, nurse practitioner, cardiologist—one thing is clear: they work and they should continue to be utilized at the front line of heart disease management,” Merz said.

Patients with chronic diseases already consume a great deal of healthcare resources. The other side of that coin is prevention, noted Kathy Berra, MSN, ANP, president of the Preventive Cardiovascular Nurses Association and a nurse at Stanford Prevention Research Center in Stanford, Calif.

“Prevention is a family affair. It’s been shown that when women take care of themselves, the health of the family improves.”

Emerging as one of the more important gatekeepers for women’s health—including cardiovascular health—are ob/gyns, Berra said.

Gynecologists have increased their efforts to quiz women about heart disease risk factors such as hypertension, High cholesterol, and diabetes. If red flags are apparent, patients can be referred to primary care providers, internal medicine physicians, or cardiologists.

“Ob/gyns are on the front line of women’s health. Perhaps under the ACA model, these specialists will have a closer relationship with cardiologists,” Berra told MedPage Today.

Regarding nurses and other care providers in hospitals, they need to be able to educate patients about how to take care of themselves post-discharge, how to understand the importance of their medications, and how to best re-connect with their nonhospital environment.