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Despite its status as a world leader in treatment innovation and medical education, a quality chasm exists in American health care. Care fragmentation and poor coordination contribute to expensive care with highly variable quality in the United States. The rising costs of health care since 1990 have had a huge impact on individuals, families, businesses, the federal and state governments, and the national budget deficit. The passage of the Affordable Care Act represents a large shift in how health care is financed and delivered in the United States. The objective of this review is to describe some of the economic and social forces driving health care reform, provide an overview of the Patient Protection and Affordable Care Act (ACA), and review model cardiovascular quality improvement programs underway in the state of Michigan. As health care reorganization occurs at the federal level, local and regional efforts can serve as models to accelerate improvement toward achieving better population health and better care at lower cost. Model programs in Michigan have achieved this goal in cardiovascular care through the systematic application of evidence-based care, the utilization of regional quality improvement collaboratives, community-based childhood wellness promotion, and medical device-based competitive bidding strategies. These efforts are examples of the direction cardiovascular care delivery will need to move in this era of the Affordable Care Act.

Nowadays people know the price of everything and the value of nothing." -Oscar Wilde, The Picture of Dorian Gray (1) T he United States spends too much on health care and gets too little in return. Major public policy efforts, such as the Medicare shared savings and value-based purchasing programs, have been launched in recent years with this recognition (2). Private initiatives like the Choosing Wisely campaign similarly seek to reduce unnecessary spending through a pursuit of higher value care (3).Nonetheless, basic issues related to measuring and quantifying value in health care, defined as quality for a given level of cost, remain unresolved (4,5). This is due, in large part, to limitations in the evidence base and measurement systems for implementing a value-based care strategy. For many procedures and treatment regimens, best practices are not well defined and data for the cost and outcomes needed to assess value are often unreliable.It is in this context that the paper by Ho et al. (6), in this issue of the Journal, makes a significant contribution. The study evaluates cost variation and quality of care among patients receiving a percutaneous coronary intervention (PCI) in 60 U.S. Department of Veterans Affairs (VA) hospitals. One year after PCI, the authors found relatively little variation in mortality but large variations in PCI-associated costs (ranging from 55% below median standardized costs to 209% above median standardized cost). Not surprisingly, given these global findings, the authors also found that PCI costs had no correlation with mortality.In many ways, PCI, a common and costly procedure, was an excellent procedure on which to focus their investigation. Despite the unparalleled development of clinical effectiveness evidence in cardiology, there remains significant uncertainty about the value of many cardiac treatments. The American College of Cardiology/American Heart Association only recently produced the official Statement on Cost/ Value Methodology in Clinical Practice Guidelines and Performance Measures (7). This statement recognizes the historical reluctance to include explicit considerations of cost in practice guidelines, although the authors acknowledge costs have long been implicitly considered. This statement proposes a series of "level of value" categories; the primary barrier it cites for proper application of these categories is the lack of high-quality data for the cost and value of interventions and procedures used in practice. More is known about PCI than many other therapies, allowing for good investigations of value, like that of Ho et al. (6). Evidence suggests that in the appropriate context (e.g., ST-segment elevation myocardial infarction [STEMI]), PCI saves lives and is cost effective (8-10).On the other hand, other data indicate PCI (and coronary revascularization in general) is over-provided in the United States and is not related to improved outcomes in many patients (11).