This just in ... A new ACC member survey provides insight into just what the impacts of the cuts on practices will be. The practices surveyed said staff layoffs (42%), elimination of service lines (33%), limiting office hours (14%) or not accepting Medicare (13%) were options they were considering as a result of the cuts. Only one-quarter reported no action and those which will not change practice patterns tended to be in academia or work in hospitals. That being said, even academic institutions and hospitals are not untouched by the rule.

Patients seeing solo practitioners (100 patients seen on a weekly basis) will be hit the hardest with anticipated cuts across the board in staff, service lines, Medicare payment and office hours. Medicare patients will also be extremely inconvenienced as 13% of practices (17% of private practices) anticipate a need to reduce the number of Medicare patients or stop accepting Medicare payment. Cardiovascular practices report that about 50-60% of their patient volume is Medicare patients. Taking that into account, calculations reveal that at least 14% of the Medicare population receiving cardiovascular care (or 7% of all cardiovascular patients) would be directly impacted by the anticipated cuts.

The survey also shows a clear trend toward hospital migration. Almost one-in-five (18%) of active, practicing cardiologists in the U.S. have already migrated to another practice or hospital and 28% say that a practice merge is on the horizon. When you look at practice type, private practices which expect to be hit the hardest by the recent ruling are more likely to consider integration into a hospital system (39%).

I’m back in D.C. today after a whirlwind couple of days at AHA. It was an exciting trip, reminding me how much I look forward to ACC’s own scientific session in March (not to be missed!).

That said, there’s still one major item left to discuss from AHA’s meeting: the release of ACC Foundation/AHA/Society for Cardiovascular Angiography and Interventions focused updates on the management of patients with ST-elevation myocardial infarction (STEMI) and the management of patients undergoing percutaneous coronary intervention (PCI). It’s only fitting that the document was released during AHA – the update takes into account many of the major trials conducted recently for cardiology and released at AHA and ACC’s meetings. The update makes new recommendations to ensure patients reach lifesaving therapy for STEMI as quickly as possible. 

The update recommends that each community develop a STEMI system for triage and transfer of patients that complies with the standards set forth by Mission Lifeline. The system should include destination protocols to STEMI Receiving Centers and transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates and/or are fibrinolytic ineligible and/or in cardiogenic shock.

Another significant change recommended in the update is greater acceptance of PCI of the left main coronary artery. The update suggests it may be considered based on favorable anatomic condition and an increased risk of adverse surgical outcomes.

UPDATED: 11/19 with CVN video, as promised.

On Monday I attended a plenary about managing patient expectations in the face of the current cost-savings-focused environment. As doctors, we sometimes find that patients want the most expensive care or the most tests as part of their treatment because they view it as the “best” care they can receive. However, this usually isn’t true. The best care is the care that’s been validated by science – and high quality science at that. This can be difficult to come by, even in the field of cardiology, which compared to other specialties, has some of the best research available.

Why does cardiology have some of the best, most comprehensive research? Because cardiology has registries, and we use them to collect data in real-life, which we then turn into the research that informs the clinical documents that guide everyday practice. The ACC has a suite of six registries (NCDR) that together pull research from nearly 2,000 hospitals and 180 practices (yes, one of those registries is an ambulatory registry – the PINNACLE Registry -- formerly called the IC3 Program).

At AHA, research from the NCDR is making quite an appearance. There’s a total of 14 abstracts from the NCDR out at AHA, which hopefully you had the opportunity to check out: five abstracts from the CathPCI Registry; four from the ICD Registry, one from the CARE Registry, two from ACTION®-GWTG™ and two from the IC³ Program (now the PINNACLE Registry).

Of particular excitement are the two abstracts from ACC’s IC³ Program/PINNACLE Registry. The first is an oral presentation by Paul S. Chan, M.D., M.P.H., on “A Report of the First 10,000+ Patients.” The study found nearly three in five enrolled patients had coronary artery disease (CAD) and all the outpatient performance measures (PMs) could reliably be assessed. Adherence to the CAD PMs was often suboptimal, suggesting substantial opportunity for improving the quality of outpatient care.

The second (a poster presentation by ACC staff members Kristi Mitchell, M.P.H., and Sunil Gupte, Ph.D.) is “Electronic Medical Record Adoption in Cardiology Practices: A 2009 Snapshot.” This study found EMR adoption within PINNACLE Registry (then the IC³ Program) is slightly greater than that reported in the literature and may be due to the greater number of large practices enrolled. The PINNACLE Registry provides a foundation to analyze EMR adoption and implementation rates in U.S. cardiology practices and to observe trends associated with reducing some of the financial barriers due to the recent provision of federal funding. As such, the PINNACLE Registry will be positioned to determine the impact of EMR usage on clinical quality and patient outcomes.

The large number of abstracts presented at the meeting is a testament to the rich evidence coming from these groundbreaking registries. We need to keep moving forward with our efforts so that ALL clinical decisions can be made on the basis of the strongest level of evidence.

UPDATED: 11/19 with video.

I stopped by the Expo floor and couldn’t help but notice the decline in the number of industry exhibitors. We had similar declines in our exhibitors last year, which causes me to think this is representative of the new nature of our relationships with industry. Our relationships with industry are becoming increasingly sparse, which some would argue is how it should be. Or they would argue that the relationships shouldn’t exist at all.

That’s not the College’s view, though. We believe that although there must be firewall for relationships with industry, done correctly, they can be positive and constructive relationships. These relationships shouldn’t be seen as inherently bad, they just must be effectively and ethically managed, and breaches in ethics should NOT be tolerated.

The ACC handles our relationships by creating a firewall between the funding and the program it supports. The funding is solicited for specific new or ongoing programs/initiatives. The money is dedicated exclusively to an objective – but the industry supporter has no say in how the funds are used for the program/initiative. By using this process, the ACC can still get the valuable financial support it needs to continue to make available quality programming and education.

The College has taken a leadership role in this debate, building consensus on the issue among medical professional societies. (For more on ACC’s stance on relationships with industry, see a post from ACC.09.) We must continue to move toward responsible, transparent relationships that will allow us to maintain quality education and research in cardiovascular medicine.

What do you think?

Some good trials came out yesterday at AHA. Here's the wrap up.

One of today's posts comes to us from Jim Fasules, M.D., F.A.C.C., ACC's Senior Vice President of Advocacy. Prior to stepping up to the plate to lead the College's advocacy efforts during this tough practice environment, Jim was a pediatric interventional cardiologist at Arkansas Children's Hospital in Little Rock.

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At annual meetings like ACC.10 and AHA, cardiovascular professionals keep up with the newest and best science to make sure we’re providing patients with the right care. However, between the dwindling financial support from industry for these events and the even more dwindling reimbursement for CV services, maintaining this commitment to being knowledgeable about the most recent advances is becoming increasingly challenging.

The worst example of this is, of course, the Centers for Medicare and Medicaid Services’ final 2010 Physician Fee Schedule. Although many of the cuts included in the rule are phased in over a four year period (giving us time to fight their implementation), major cuts for 2010 include: 

• SPECT Myocardial Perfusion Imaging (78452): 36 percent cut
• Transthoracic echo with spectral and color flow Doppler (93306): 11 percent cut
• Coronary Stent (92980): 4 percent cut
• EKG (93000): 5 percent cut

ACC.org has a more detailed summary, but even this very brief overview highlights the grave situation cardiology is in right now. These cuts are deep enough over four years to threaten the survival of private practice cardiology. Indeed, many practices have already or are strongly considering selling their practice to hospitals. We are concerned this could have a major effect on access of rural and disadvantaged patients to timely cardiac care.

Our fight against these cuts has just begun. The ACC is working closely with cardiology practices through the Cardiology Advocacy Alliance (CAA) and with the cardiovascular subspecialty societies to mitigate the impact of the cuts. Though we obtained a four-year phase in, it is not enough. We’re continuing to fight on several fronts – regulatory, legislative and legal – to limit the effects of these cuts on you and your practice.

The road is steep though, and we’ll need your involvement more than ever. Visit www.acc.org/CAN to take action and to access the ACC resources available to help you survive these times. More tools will be coming in the next few months -- your feedback on the tools and resources you’d like to see is appreciated. Please email advocate@acc.org with your thoughts.

We’re doing all we can to help you and your practice get through these challenging times for cardiology, while we find a real solution to payment reform. We need to find a solution that reduces the cuts so we can focus on what we do best – providing high-quality cardiovascular care to patients.

-- Jim Fasules, M.D., F.A.C.C.

* Dr. Fasules' post is part of a monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!

*** Image from Flickr (Suviko). *** 

Here is Sunday's daily wrap up from CVN of LBCTs at AHA.

AHA kicked off its meeting with an opening session featuring AHA President and ACC member Clyde Yancy. Yancy helps lead the Coalition to Reduce Racial & Ethnic Disparities in CV Outcomes (CREDO), a joint society effort that stresses research (how accurately can we describe the present disparities?) and action (once identified, how can we target the areas to improve care?). Learn more about it from an interview I conducted with Clyde back in July.

Also speaking during the opening session was Thomas Frieden, M.D., M.P.H., director of the CDC. Dr. Frieden has been a friend to cardiology over the years through his efforts as commissioner of the New York City Health Department, where under his watch, the city cut smoking rates in teens and adults, eliminated trans-fats from restaurants, rigorously monitored the diabetes epidemic, and required certain restaurants to post calorie information prominently.

Another interesting bit on Frieden’s resume: As NYC commissioner, his department ran the largest community EHR project in the country, following a request from Mayor Bloomberg (another friend to cardiology). The project focused on getting EHRs into community health clinics to improve quality and now includes more than half of the doctors caring for patients in Harlem, the South Bronx and Bedford-Stuyvesant – low-income areas that would typically be the last to have access to such technology.

Dr. Frieden’s is an interesting approach – providing low-cost EHR and implementation support – to making sure that practice are able to implement technology. Outside of this program, you find that many offices, particularly those in small practices of one to three practitioners, face significant barriers to adopting technology. Even though the federal government is offering significant funds to help urge adoption, practices face high upfront implementation costs for health IT (we’re talking $124,000 over five years, with only $44,000 in incentives to offset the costs). That’s daunting – and many may not be enticed by the incentives knowing the cost of implementation.

However, our challenge is in reaching out to these docs to communicate the bigger picture: reduced costs and gained efficiencies—not to mention higher quality care for our patients. Getting engaged in health IT will provide the best chance of keeping smaller practices viable in the coming era of payment reform. (If you’re interested in health IT, you should come to ACC.10, where we’ll have a day-long spotlight session on the topic.) The ACC also has great resources online at www.acc.org/healthit.

***Image from Flickr (Prasan Naik)***

Today I’m traveling back again to Orlando (feels like ACC.09 was just yesterday!) for the American Heart Association’s Scientific Sessions2009. The event promises to be exciting ... more than 30 late-breaking clinicaltrials will be released and more than 4,000 presentations made. You’ve got tolove the suspense of wondering which LBCT is going to be the hot one of theconference. I have a jam-packed schedule while I’m here – I’ll be attendingseveral of the plenary and special sessions, and meeting with 10+cardiovascular societies.

Thesebig CV meetings are my opportunity to connect with the other societies andexplore ways we can work together. Given the drastic Medicare payments cuts facingcardiology over the next four years and the rapid pace of health care reform,working together is going to be key to our success.

Just like the European Society of Cardiology’s meeting in August, the ACC has heavy presence at AHA’s meeting. We have a booth down inthe exhibit hall (booth #2023) to give ACC members at the meeting the opportunityto mix and mingle with ACC colleagues and ACC staff (or become an ACC member ifyou’re not already). If you’ve got questions about what the ACC is up to thesedays, you can come down to the booth to find the answers directly from staff.We’ll also have our products available for purchase, along with registrationfor other cutting-edge CV educational programs.

If you’re looking for more coverage of the meeting, visit http://cardiosource.com or follow @Cardiosource on Twitter for up-to-the-minute summaries,presentation slides and videos from the meeting’s LBCTs. 

I'm heading down tomorrow to Orlando for AHA's 2009 Scientific Sessions. Are you joining?

Janet Wright, FACC, was recently asked to be a guest blogger on the Disruptive Women in Health Care blog for an ongoing series on medication adherence (soon to be an e-book!). She writes,

Over decades of practice in cardiology, I had a first-hand view of the challenges patients face in adherence – an inability to afford the prescription to an incomplete understanding of a med’s value or benefit to overestimating the risk to unclear directions or complex instructions on how and when to take the drugs. ... Successful medication adherence is not a failure on the part of the patient to take their medication, but rather a failure on the part of the health system – including patients, their providers, the reimbursement structure, the insurance companies, etc. – to make it easy and worthwhile for the patient to take his or her medicines. 

She concludes:

Successful patient medication adherence is not just about the patient taking his or her medication – it’s about the health system working together to allow the conditions to exist to enable the patient to take his or her medication.

Check out her full post on the Disruptive Women blog and leave your thoughts on Rx adherence below. 

*** Image from Flickr (DawnVGilmorePhotography). *** 

Last week former ACC President Jim Dove, MACC, led a fantastic meeting at Heart House, the Evolving Models of Cardiovascular Practice Symposium. The symposium was designed to help CV practices understand better their options for hospital employment or integration, versus creating independent/individual practice associations (IPA) or larger groups -- and/or trying to figure out how to survive business-wise in the changing marketplace. Physician and administrator representatives of 110 practices attended -- but over 200 were turned away!

The event was standing-room only, indicating just how relevant this topic is right now. According to a pre-event survey of attendees, 43 percent had integrated their practices with hospitals, or were seriously considering it, or were in the process of doing so. Dr. Dove rightly noted that it is disturbing to see the sense of hopelessness in cardiology today -- a specialty that has been at the summit of medicine for decades and has reduced morbidity and mortality from heart disease by 27 percent in the last decade alone. Regardless of the outcome of negotiations around the Rule, however, this symposium clearly hit a nerve with members. It’s just another example of the ACC providing the tools members will need in the coming months to ensure their continued ability to successfully practice cardiovascular medicine. ACC members Mike Valentine, Bo Walpole, George Rogers, Chuck McKay and others helped envision and organize this meeting with Dr. Dove. MedAxiom and the Cardiology Advocacy Alliance also participated in making it a successful program. We’re going to have to take it on the road. During the meeting, CVN recorded two great discussions about pratice viability with ACC leaders. Check out both segments: "Fighting for Patient Access: Part 1 and Part 2". 

From my own point of view -- one I expressed to the attendees -- the most important trend we’re NOT seeing, but need to promote is that of getting more exemplary physician leadership for group practices, IPAs, integrated system boards, and very importantly for hospital boards. As a profession, we have delegated and abrogated our former leadership of hospitals, insurers, and health systems. Such physician leadership is the best way to protect patient care and improve quality of care. If we’re going to be increasingly selling practices to hospitals, we also need to be populating the hospital boards to a much greater extent and impact. Good partnerships between administrators and dedicated physician leaders make the most successful practices -- but we need to help generate new generations of physician leaders for the best future for CV medicine and cardiology.

So, it’s an evolving profession (I know, some say devolving, but they’re wrong).

Congressman Gordon (D-Tenn.) has convinced House Energy and Commerce Chair Henry Waxman (D-Calif.) to allow his medical malpractice amendment in H.R. 3962. Gordon’s amendment would facilitate “certificate of merit” systems in states that achieve the reductions in premiums claimed in Ohio, Michigan and a few other states when such a program is designed and implemented properly. But the good Congressman has informed us he’s interested in a broader tort reform agenda, and we should help make it happen! During these tough and financially tight times, a reduction in med-mal premiums could be a godsend.

The other idea we are exploring is to provide a set of protections and/or safe harbors for those physicians who achieve the health IT-related “meaningful use.” I am working with a coalition (that we are helping to create) to explore this idea. The meaningful use process of the Office of the National Coordinator (ONC), David Blumenthal, MD, builds on allowing the federal stimulus benefit dollars to go to only those doctors who qualify as “meaningful users” of health IT. Basically, meaningful use will involve phased-in application of electronic health records, e-prescribing, clinical decision support systems, privacy and security protections, computerized physician order entry, and perhaps a few more elements of an e-office. If incorporating health IT could be accompanied by a significant reduction in medical malpractice costs (even if only for Medicare and Medicaid patients), it would be an additional big incentive to go electronic (not to mention being able to receive over $40,000 from the feds to help do it).

The PINNACLE Network™ concept is in fact the pathway to meaningful use for cardiologists and other physicians who care for cardiovascular patients. This is all happening rapidly, and we will talk to Congressman Gordon and others about expanding on his idea and giving the trial bar a run for their money before this reform process is completed.

And here’s an additional plus: This week, Chairman of our Working Group on Malpractice Insurance Bill Oetgen, M.D., F.A.C.C., and I met with the CEO and CMO of the nation’s largest physician-owned medical malpractice insurer, the Doctor’s Company. We discussed some exciting ideas that could reduce premiums for cardiologists at the same time reducing the risks of adverse events and patient safety-related incidents. This was a dynamite meeting.

Photo: http://www.flickr.com/photos/mindgutter/ / CC BY-NC-ND 2.0

Cardiovascular Business magazine yesterday came out with an interesting article on the rule: "CMS cuts could make hospitalists out of cardiologists." I was interviewed for the article, which says: "This lack of practice sustainability will lead cardiologists, according to Lewin, to become 'employees of hospitals, causing the closure of individual and group cardiology practices.'" What do you think?

Health system reform continues to march forward while we’re struggling with this aforementioned nightmare Medicare Rule. We once were fully engaged in reform -- until we were diverted. Nonetheless, we’re still keeping our voice at the table in the reform process. WE MUST. There’s more damage possible if we’re not engaged.

The first big item of importance relates to the SGR. The House has pulled the SGR 10-year fix provision out of their now unified bill to allow it to be merged eventually with a unified Senate bill. The SGR is in a parallel vehicle that can be potentially conferenced with the Senate bill (S 1776), which at this point lacks the 60 votes needed to move forward.

Both Chambers need to make sure the $245 billion SGR fix is not included in the cost of reform -- the President can’t sign that bill if it contributes to the deficit, which it would if it contained the SGR. However, Zeke Emanuel made clear that the White House does support the separate and parallel approach of fixing the SGR by adding the $245 billion to the $10 trillion national debt. That said, I think the SGR 10-year fix effort will nonetheless fail unless there is a way to get it approved by a simple majority in the U.S. Senate. That looks difficult. So, we might not want to tie our Medicare Rule fix to that wagon. One way or the other, however, the SGR 21% cut will not occur in January -- if the fix effort fails (which I predict it will), they will put a one- or two-year patch on as usual. 

Other Actions
In other reform actions, Sen. Reid made big news by insisting that a public option be in the Senate bill that merges the Finance and Health, Education, Labor and Pensions Committee proposals. The Majority Leader does not have 60 votes to support that decision, which he clearly made in defense of his own threatened Senate re-election race in Nevada. You see, he comes from a heavily union-dominated district, and he is facing stiff primary opposition supported by labor. So he needed to do this, even though he knows it can’t pass as crafted. Sen. Snowe could always bring back her trigger mechanism in the final bill in the Senate if need be, but I don’t see this version of a public option in what they ultimately produce.

The House will have a public option, but even Speaker Pelosi is having to accommodate the Democratic moderates and Blue Dogs in the provisions she ultimately will include. Only the Senate thus far is committed to an Independent Medicare Advisory Commission (IMAC) to replace MedPAC, but the all-important details of the IMAC -- if it proceeds -- will relate to who is on it, how they get appointed and how broad the powers of cost containment will be. 

One of the big controversies looming relates to the extent to which young healthy people should have to subsidize the costs of care for older and sicker people in reform. AARP of course wants to see a ratio of not greater than 2:1 between insurance costs for young, healthy people as compared with premium costs for older people in federal coverage programs. The insurance industry (and those concerned that young people won’t buy into mandated insurance if they’re up-front premiums are too high) want to see a 4:1 ratio between premium costs of seniors and the young-immortals.

And finally, we’re still stuck between a rock and a hard place in the House and Senate regarding whether we will tax the rich to pay for reform (the House choice), or we will tax Cadillac insurance coverage (the Senate choice) to pay. 

The House has completed their bill and the president has praised them for getting a proposal ready to go to the floor soon, but their bill is really far from done. There will still be a lot of debate, attempts at amendment and horse trading behind the scenes with the Senate before we get to a House and Senate conference committee to produce one unified bill. It will be a busy and politically crazy November and December.

*** Image from Flickr (Cedric). ***