Cardiovascular disease is the number one cause of death in America, and post-COVID pandemic, the percentage of fatalities due to heart disease is rising: in 2020 and 2021, heart attack deaths increased by up to 21% for those 45 to 64 and 17.9% for people 65 and older, according to a Cedars-Sinai Medical Center study.
With so many individuals requiring cardiovascular care, it is important for health plans to have a strategy that improves access to quality cardiovascular care while managing medical expense for this complex patient population.
Cohere’s clinical cardiology team manages the end-to-end review for delegated cardiovascular tests and procedures. In celebration of heart month, we caught up with Marie Parker and Russ Rotondo. Get to know these two influential leaders of Cohere’s cardiology program in this Q&A!
Dr. Russ Rotondo is the Medical Director of Clinical Strategy and Innovation, Cardiology, at Cohere Health, from Knoxville, TN.
What made you want to work in cardiology?
Athletics and cardiovascular physiology have always been interests of mine. As part of a medical school project to alter my own cardiovascular risk factor profile, I started participating in endurance running. It seemed like with these interests, it was a natural progression to pursue a career in cardiology.
What are some unique challenges facing prior authorization for cardiovascular care?
Prior authorization in cardiovascular care is used for both high-volume routine testing, like stress tests and echocardiograms, as well as complex surgeries and procedures like heart surgery to treat coronary artery disease and other cardiovascular conditions. Because the review process has to cover these two extremes, it can be difficult for health plans to manage decisioning of these requests in-house, especially if they rely primarily on manual review.
Additionally, because care frequently starts with a primary care physician (PCP) who may not feel comfortable prescribing conservative treatment plans for lower-risk patients, there’s an opportunity for prior authorization strategy to make a difference, by reducing unnecessary and often expensive testing and ensuring patients receive appropriate care.
What is one way that Cohere is helping to approve appropriate care for patients?
Our technology embeds a best practices approach into an AI-driven decisioning engine to enable consistent evidence-based decisions, with immediate response for about 88% of requests. By using specialty-specific guidelines in the automated decisioning process, Cohere can help to provide more certainty for primary care physicians in risk-stratifying their patients and affirming their use of conservative treatment where appropriate, while also dramatically shortening the review process.
An example for this process would be using the American College of Cardiology (ACC)/European Society of Cardiology (ESC) pre-test probability (PTP) of coronary artery disease table when a physician is considering ordering an MPI SPECT scan. The ACC and ESC recommend using the table to evaluate a patient’s likelihood of having coronary artery disease based on various factors. Primary physicians might be surprised to learn that many patients would actually score to a low risk–too low for the use of an advanced imaging test such as an MPI SPECT based on the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Therefore, based on a patient’s PTP rating, a provider requesting prior authorization for an MPI SPECT would be notified of the patient’s low risk. This extra clinical information may result in them feeling confident in adjusting their treatment plan and consider ordering a less advanced test, such as an EKG, a coronary calcium score, or a routine treadmill test. Helping to align care to evidence-based recommendations is a good start toward reducing care variation, and Cohere’s tech-based, evidence-backed approach is a persuasive and time-saving model for both primary care and specialty physicians.
Dr. Marie Parker is the Program Director of Cardiology at Cohere Health from Atlanta, GA.
Do you have a favorite cardiovascular statistic?
Yes. It is well-established that the majority, upwards of 70% in some studies, of all cardiovascular disease cases and deaths are attributable to modifiable risk factors. To me, this is a measure of hope and optimism: the trajectory of heart disease is not absolute and can be altered drastically through provider and patient behavior changes that align with evidence-based medicine and clinical practice guidelines.
What is a “care path,” and how is it changing the approach to cardiovascular care?
Traditional prior authorization is a dichotomous, transaction-focused decisioning process based on medical necessity criteria within a health plan’s clinical policy. Cohere has taken a different approach. Through our partnership with the ACC and collaboration with medical advisors, we have developed over 20 unique cardiovascular care paths that account for optimal sequencing and services along a patient’s care journey. This enables positive impact on care outcomes far beyond simply saying “yes” or “no” to a prior authorization request.
It is within the care paths that we leverage “moments of influence”—opportunities during the course of the service request where we can provide recommendations tailored to patient’s unique needs and aligned with the most up-to-date clinical best practices. The end result is higher value care that leads to better health outcomes for the patient. “Nudging” is an example of one such intervention.
What is nudging and how does it help improve cardiovascular care management?
Nudges are a commonly used mechanism that guides the end user to a desired decision. At Cohere, we strategically deploy nudges to make choosing the right decision easy for ordering providers. Nudges are useful to avoid unnecessary delays in care; for example, we use ‘administrative’ nudges as in-workflow pop-up messages to ensure that the required clinical documentation is attached. In this manner, all authorizations submitted are complete, increasing the likelihood of a real-time approval and decreasing the time spent waiting while the authorization is rejected and then sent back with the complete documentation.
Nudges are used during key moments of influence where, through aligning service requests within care paths and leveraging comprehensive data assets, we can make real-time recommendations that optimize health outcomes. In these instances, we deploy “adherence” nudges to alert providers to gaps in care and opportunities to better align care with clinical practice guidelines.
Interested in learning more about how Cohere Health is reducing care variation and improving cardiovascular care with our end-to-end outsourced utilization management solution, Cohere Complete™?
About the Authors:
Marie Parker, PharmD, PhD, BPCS, CPHQ Program Director, Cardiology
Marie Parker leads Cohere’s Cardiology Clinical Program, bringing over 15 years of experience in developing, implementing, and evaluating chronic disease programs to improve quality across various sectors of the healthcare ecosystem. In addition to board certification in pharmacotherapy and healthcare quality, she holds a doctor of pharmacy degree from the University of Georgia and both a master’s degree (Emory University) and a doctor of philosophy degree (Georgia State University) in public health. Read her blog post on streamlining cardiovascular care.
Russell Rotondo, MD, FACC Medical Director of Clinical Strategy and Innovation, Cardiology
Russell Rotondo has more than 25 years of experience as a general, invasive, and interventional cardiologist. He holds a bachelor’s degree and an MD degree from Brown University, received training in internal medicine at the University of Tennessee Medical Center and the Washington University Medical Center, and completed his cardiology fellowship at the Washington University Medical Center.
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