Independent Health Plan
Buffalo, NY

Cardiovascular disease, including heart disease and stroke, is the leading cause of death in the U.S., responsible for nearly 800,000 deaths each year. The Centers for Disease Control and Prevention estimates that cardiovascular disease costs the U.S. nearly one billion dollars a day in medical costs and lost productivity.1

Cardiology services are among the health care system’s highest specialty care costs, and diseases of the heart and circulatory system are leading drivers of growth in medical spending.2 The nation’s aging population suggests that these conditions will continue to grow in volume.

In 2012, Independent Health began tracking clinical episodes of care from beginning to end including total cost of care for inpatient and outpatient visits, pharmacy and lab costs, and professional fees. The risk-adjusted data revealed significant variation in the cost and quality of care provided by the cardiologists to whom primary care providers were referring.

Primary Connection primary care providers were referring patients to as many as 30 different cardiology practices in the region, and variation in cost and quality was significant. Total cost of care data from the cardiology practices showed costs ranging from 40 percent higher than the peer average to 25 percent lower. Quality metrics were spread over a similar range. And costs associated with cardiology care were increasing about 10 percent each year.

In late 2012, Independent Health invited six cardiology groups to participate in a multi-year effort to reduce variation in cardiology services and move toward greater consistency in evidence-based interventions.

Collaborating with Cardiologists

Collaboration between primary care physicians and cardiologists was critical to changing practice behaviors and reducing variations in care.

In studying practice patterns to understand variations in cardiology care, health plan leaders identified issues such as excessive use of diagnostic testing and use of brand-name drugs instead of generics. Plan leaders worked to help cardiologists understand the cost implications of these decisions and others to help guide practice habits.

The effort to reduce variation also included educating cardiologists to accept broader responsibility for patients’ overall health. Standard measures of cardiology care include metrics such as whether patients have been prescribed a daily aspirin and a beta blocker after a cardiac event. Independent Health evaluates episodes of cardiology care that include additional quality metrics for care of patients with diabetes – including determining if A1c levels and blood pressure are in an appropriate range and whether or not patients are getting lipid tests on a recommended schedule.

Some cardiologists felt that diabetes-related measures and care should not be used to determine the quality of overall care provided. Independent Health leaders worked closely with the cardiologists and, after much discussion about diabetes as a risk factor for cardiac conditions, it was agreed that additional measures are appropriate to apply to cardiology. Effective collaboration between primary care providers and cardiologists constitutes good patient care, and evaluating cardiologists on measures related to diabetes care emphasizes this expectation.

“Some health plans look at variation across specialties and create a narrow network, but that doesn’t necessarily deliver excellence, because the outliers are still the outliers. No one is learning or improving. Our way is more time consuming, but involved meaningful communication and produced meaningful improvement.”

Tom Foels, MD, Chief Medical Officer, Independent Health

Cardiologists in the network also took the opportunity to educate primary care physicians by creating first-line treatment guidelines to help primary care physicians effectively evaluate patients’ cardiac needs. Cardiologists also provide continuing medical education presentations to the primary care physicians.

Supporting Efficiency

The Primary Connection’s value-based payment system incentivizes attention to quality and to reducing unnecessary costs. Primary care physicians are especially focused on collaborating with cardiologists to improve efficiency and care. High-performing cardiologists help to lower the total cost of care.

The improved working relationship between doctors also helps to increase efficiency in both practices. By being more readily available for phone consults, cardiologists help assess which patients are appropriate for referral and which patients can be safely treated in primary care. This shrinks the number of referrals — reducing administrative burdens on both practices — and decreases the cardiologists’ reliance on mid-level clinicians to see low-acuity patients. Moreover, it improves the match between patients’ needs and providers’ expertise, enabling cardiologists to see more of the challenging patients they were trained to treat.

Sharing Comparative Data

At the project’s outset, the health plan shared blinded, practice-specific data and quality measures so each cardiology practice could better understand how its performance stacked up against its peers.

Beginning in 2014, the participating cardiologists agreed to share their data with their peer cardiologists as well as with the Primary Connection physicians. Armed with this comparative data, Independent Health representatives met with cardiology groups to highlight opportunities for improvement. The plan was to share data quarterly to track improvement — or lack thereof — among cardiology groups. The message was clear: Primary Connection primary care physicians would refer only to high-performing cardiology practices going forward.


Performance reports from 2013 to 2015 showed:

  • A significant reduction in the variation of care and closer adherence to evidence-based medicine
  • A 3.5 percent aggregate cost decrease over the two-year period (compared to previous annual trend increases of 12 to 22 percent prior to the engagement)
  • Improved patient satisfaction

Performance reports for 2016 and 2017 show a continued reduction in the variation of care, increased adherence to evidence-based medicine and lower costs.

The success of this effort inspired its spread to other specialties. Independent Health has used this same process to reduce variation and improve efficiency and quality in other areas of specialty care, including gastroenterology, neurology, allergy, dermatology and pulmonology.


1. Centers for Disease Control and Prevention Foundation. 2015. Heart Disease and Stroke Cost America Nearly $1 Billion A Day In Medical Costs and Lost Productivity. Retrieved from

2. Kaiser Family Foundation. 2017. What Do We Know About Cardiovascular Disease Spending and Outcomes in the United States? Retrieved from


CASE STUDY: Reduce Variation in Cardiology Care

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