There were some exciting late-breaking clinical trials presented here today and yesterday, and ACC leaders were widely quoted in the media on the implications of what was discussed. 

I took a little time out yesterday from the international scene to hold a panel with the American Heart Association to examine AHA and ACC’s vision for the future of U.S. health care. The panel featured me, Fred Bove, Clyde Yancy and Robert Califf.  Part of the purpose was to help cardiologists and CV professionals understand better the differences and areas of collaboration between AHA and ACC. We focused on the positives, which are numerous, rather than on areas on competition. As I’ve said before, the future of health care should be rewarding for continuous outcome improvement and providing patient-centered care.

The ACC has a health care reform campaign, called Quality First, which, like the name suggests, advocates for payment incentives for quality care, along with increasing the focus on patient value (which we define as transparent, high quality, cost-effective, continuous care), better coordination across sources and site of care and emphasizing professionalism to increase partnerships with patients. Reform would also provide universal coverage through an expansion of public and private programs. (You can read more about Quality First and specific examples of how to make it a reality in ACC’s “Blueprint for Reform.”)

Of course, making sure all of this is included in health care reform is quite a tall order, which is why the ACC is working with lawmakers and the White House to make sure that they know what we feel is best and how best to achieve it. We’ll know soon enough if we’ve left an impact.

The science so far at ESC 09 has been quite impressive. Check out Sunday's daily wrap-up video from CVN, featuring RE LY, PLATO and CURRENT OASIS 7.

¡Saludos de Barcelona! The theme of this year’s ESC Congress is “Prevention of Cardiovascular Disease from Cell to Man to Society.” From the ESC 2009 program:

“Cardiovascular disease remains the main cause of mortality and morbidity [and] we felt that major advances in prevention and risk factor identification should be our scientific highlight.”

According to the World Health Organization, an estimated 17 million people die of cardiovascular disease – in particular heart attack and stroke – each year. In the U.S., over 860,000 people died in 2005 from cardiovascular disease, accounting for 35.3 percent of all deaths in the country. This is a very important topic, and ESC plans to address it through nearly 80 sessions focused on how to reduce the CVD burden.

At the ACC, one way we address prevention is through our patient education Web site, CardioSmart. CardioSmart is a place for people diagnosed with cardiovascular disease to learn more about their condition and how to improve their health. We like to consider it a “safe space” for patients to come online and look for more information. Not only can they find more information, they can also participate in their health through the CardioSmart Blood Pressure Tool, which gives visitors a simple, secure and easily accessible way to enter their daily blood pressure readings and see their process. They can then take to their readings to their next doctor’s visit. The format of the site and the tools that it offers helps to make the patient a PARTNER with their physician, which in turn can help increase compliance and improve outcomes.

*** Image from Wikimedia Commons (Metamario). ***

Beginning tomorrow, I’m off for several days to the beautiful city of Barcelona for ESC (European Society of Cardiology) Congress 2009. I’ll be covering the event daily, so check back for updates. Also, follow the ACC on Twitter for more scientific coverage (@Cardiosource) and general news (@ACCinTouch) from the meeting.

Check out this preview video from Cardiosource:

Sherif F. Nagueh, F.A.C.C., our ACC representative to the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) reported recently that during ICAEL’s July meeting, members debated the idea of a two-tier accreditation system in which there would be minimum accreditation requirements, as well as a higher level that offered recognition that a lab meets a higher level of quality. One benefit for labs achieving the higher tier of accreditation might be a longer period between accreditations. The ICAEL board has not made any decisions yet, but Dr. Nagueh encouraged us to share our thoughts.

The ACC leadership had strong consensus that this is a bad plan and lowers the standard for quality under the first tier. Bill Zoghbi, F.A.C.C., said, the two-tier system:

"Adds complexity to the process with little added benefit. Importantly it does not address the current situation: Although overall good, criteria for accreditation are still sub-par in some areas and with low penetration. The minimum standards for accreditation should indeed be minimum standards for good quality.”

Former ACC President Doug Weaver, M.A.C.C., adds that recently he heard of a dentist and a neurosurgeon opening a medical imaging center together. “This is what is wrong in American health care, and we need to support even higher standards than what exist today,” Doug said.

The Obama administration's team held a conference call last night for interested physicians to help get us up-to-speed on all that is happening in health care reform. They agreed to try to answer questions by e-mail. While the call was a great idea -- to get us engaged and accurately informed on their policy recommendations to Congress -- it's tough to pull this kind of communication off well. The reforms proposed are overdue. IF, that is, Congress enacts them.

There really is a lot of BS (Blatant Scare-tactics) out there, but there is also a lot of concern over the deals that insurance, hospitals, and others have cut with the Administration to be supposedly immune to further injury: the deals are in favor of those industries and won't create the "bending the cost curve" savings needed to pay for expanded access (emperor's clothes are missing).

Doctors may be the only low-hanging fruit left to prune. The WH staff are not into that tactic, but are they boxed in if Congress moves in that direction? I think those who didn't e-mail in their questions in time last night were shouting those kinds of futile concerns on the call. Nobody heard them.

However, I think that many physicians -- such as our members, and oncologists, nephrologists and other specialists who got the short straws in the absurdly unscientific 2010 Physician Fee Schedule proposal -- are so focused on protecting their practice viability by opposing the proposed rule that there’s no time or energy left over to focus on the critically important issues of health reform. That's worrisome. 

Think of my wistful but sincere Kennedy tribute. We're going to get something in a health reform bill -- and it is needed. But what will we get?

The insurance industry will come out OK, I suspect. We're generally helping them by our expressing with them our misgivings about a public plan. But is insurance helping us? Duh (they're very busy right now).

The semi-tragic reality is the President and his Administration really DOES want to empower us. They sincerely acknowledge how important the contributions of physicians and other health care practitioners are to meaningful reform. I believe them on this. They see why that IS important to patients and the future. But I don't see it happening in what's in the bills so far. And the massive donations to Congress of the other constituencies (we tend to be loud but cheap) bother me in terms of what Congress will actually do. The call was a nice gesture. But we still have our work to do! The fall will pass quickly and then the winter approaches. It's almost pruning time.

I accepted a very arduous travel arrangement requiring that I take a quickie 3-day trip to Hawaii last weekend to speak at a physician conference, and also attended a meeting with the fledgling Hawaii Chapter of the ACC. Finally, we may be able to add some ALOHA to the ACC agenda!

The meeting with the Hawaii Chapter was promising. Hawaii, where everything is more expensive than the mainland, EXCEPT for health care, is one of the per capita lowest cost health care spending states, despite also having better population-based outcomes at lower costs. Hawaii has a lot to teach us. Stay tuned folks. We can be mentored by our colleagues there. 

Even though health care in Hawaii, where ALL employed people have health insurance, is far from perfect, it’s a lot more perfect than the rest of the US. Some surmise this is because Hawaii is more generous in its treatment of those at the lower end of the economic totem pole (not a Hawaiian metaphor) than the rest of America. Others theorize that Hawaii is so successful because it has a population that is genetically superior. We think that is the case in Washington DC too (!), but there is absolutely no evidence for it here or in Hawaii, according to CDC, which notes that Polynesians have some of the most high risk genetic factors of any subpopulation in the country. Another theory about Hawaii’s lower health spending and lower morbidity and preventable mortality relates to the alleged superior lifestyle benefits of Hawaii, where the thinking is that all citizens spend most of their time surfing (this is again certainly not the case, and in fact obesity and sedentary lifestyles are very common there). Then there is the mysterious “Island Factor” not yet discovered by Manhattan, Puerto Rico, Nantucket, or the Caymans that might explain things? 

Well, the reality of Hawaii’s relative success is not that complicated: Hawaii’s benefit comes from 20 years of universal coverage of all working families who have had better access to good primary and specialty care. The reason Hawaii has the highest incidence of breast cancer of all 50 states, for example, along with the LOWEST death rates for breast cancer, is that Hawaii citizens have access to primary care prevention and surveillance generally. Our CV colleagues there will nonetheless share that they are just as frustrated with Medicare spending and payment cuts, and the impending Medicare Rule for 2010 as everybody on the mainland. They are clear the health care there, while better in many ways, is in trouble in the future like everywhere else. And it won’t get fixed by having another Mai Tai. 

That said, the lesson of the benefits of great access to both primary and specialty outpatient care in reducing preventable morbidity has been discovered not just in the 50^th State, but in all other developed nations except ours. Hello-Ha.

UPDATED: Check out this piece from the Honolulu Advertiser about my trip.

The American Medical Association (AMA) has asked us to help disseminate a message from Jim Rohack FACC, President of AMA, about their support for HR 3200. As I told you last week, I think the AMA has been unfairly treated based on misinformation on their position on H.R. 3200. They are trying to eliminate the SGR. This message is aimed to clarify their reasoning. According to the AMA:

• The original bill contained a core set of high-priority provisions that the AMA has long supported;
• Bill sponsors were not likely to maintain the $230+ billion investment in Medicare physician spending if the AMA did not register support for the bill (hospitals, the home health sector, Medicare Advantage plans and pharmaceutical companies are all facing cuts in the tens and hundreds of billions of dollars); and
• As an early supporter, the AMA is well positioned to help shape revisions to this bill, as well as the final legislation that will ultimately be presented to the President.

The AMA message also points out that the organization is continuing to share its concerns with the White House and legislators about reform legislation and the pundits’ assertions that doctors are anything less than committed to doing what’s right for their patients. I think we can all get behind that message. AMA is getting beat up over it’s support of H.R. 3200. We didn’t take a full support position; but their push to get the SGR fix will be a big help to all docs if it succeeds.

The two economist titans, Uwe Reinhardt and Paul Ginsberg had an interesting point-and-counterpoint on payment reform last month that was published on the Health Affairs blog.  Reinhardt suggests shifting away from the present, price-discriminatory system of semi-arbitrary private sector pricing toward an all-payer system. He sees this as a transition to a future system based on bundled payments per episode of illness for acute care, and a new and better version of capitation for chronic care and prevention.

Ginsburg suggests that an all payer system might put pressure on doctors to contain costs in a "far less radical" manner than the public option proposed by many advocates of health reform. Ginsgurg praises the "success" of Maryland’s all-payer system. (Health Affairs will cover Maryland’s in detail in their Sept. 9 issue).

I am fond of both of these exceedingly thoughtful and smart gentlemen. But, I think both suggested methods could be scary for doctors and patients without a phase in or glidepath from where we are to any new model. As they sparred in a friendly fashion, I was reminded metaphorically of the old Godzilla and Mothra movies, where the altercations resulted in no damage to the fighters, but instead destruction of the infrastructure all around (and I supposed we would be the people running down the street screaming).

Uwe's proposal would be far simpler than competition around the present 20,000 or so itemized charges or list prices each hospital uses, or the more than 9000 list prices for doctors in the physician fee schedule. He also suggest associations (like ACC) might negotiate with insurers in a region (a state?) as is done in Germany, and make the results binding for both doctors and insurers. Doctors would then charge all insurers or patients the same price for identical procedures.  Medicare and Medicaid could be part of the arrangement he thinks. Pretty radical. Some major anti-trust relief would be needed, and there are clearly risks associated. But, hmmmm.

I asked this question back in March during ACC.09, and the winner was payment reform, closely followed by malpractice and access issues. Given everything going on now, let's see how it changes.

We’ve been hitting the media particularly hard with our messages about both reform and the outrageous proposed payment cuts in the parallel 2010 CMS-issued proposed Medicare Physician Payment Rule, noting our membership’s focus on reform has been completely diverted to trying to undo the impending payment rule. People need to be clear that “health reform” and the “Medicare Rule” are 2 different and almost unrelated topics. The Rule is just the annual CMS announcement about changes in payment they will institute (supposedly based on sound data and methodology -- NOT!).

On the rule: All the CV societies and the Cardiology Advocacy Alliance are working together with us (as is Oncology) on getting the word out about how unfair the proposed Rule would be if implemented. At this point, we have about 12 House members ready to sign on to the Gonzales-Roger letter to the Secretary, asking that the CV aspects of the Rule not be implemented. We think there are more willing to sign, but with them out on recess it’s hard to know yet. On the Senate side, Senator Lincoln sent a letter for American Society for Therapeutic Radiology and Oncology addressing the cuts in the Rule, and we have other letters pending. Our Board of Governers and Chapters have been cranking out the letters and visits to members in the Districts. This is great advocacy, and we are all soooo grateful here to those who are working so hard.

On reform: the ACC conducted a satellite media tour on the topic from the National Press Club, reaching 15 stations across the country. An ACC op-ed appeared in Roll Call online, making our point that “basing health care reforms on quality and driving down costs will allow us to provide more coverage and make available more resources for education, the environment and other critical societal needs.” On some of these stories we were able to get the flawed Medicare Rule in there also, as something that exemplifies what a mess the current CMS payment structure is, and how this issue is stealing the energy for reform as we fight to get the Rule reversed before it is issued.

Also on reform: With little notice (somebody important probably cancelled out), I was asked to depart early from the NY CEO meeting to rush over to FoxNews.com Live with Alan Colmes on a panel to discuss the push for health care reform. We debated tort reform (me positive), the single payer option (me skeptical), and the need for payment reform (me positive) in what was a very stimulating conversation — so stimulating in fact that my fellow hospital administrator panelist (CEO of Universal Hospitals) was so frustrated apparently about hospital cuts and ‘public options’ questions that he walked off the set. I wasn’t able to get the Rule issue raised in my few minutes there though, but asked Colmes if we could have another chance to get our leaders on to talk about it.

Other societies have been busy beating the health care reform drum, too. Our own J. James “Jim” Rohack, M.D., F.A.C.C., President of the American Medical Association, appeared on “Larry King Live” to discuss health care reform and give us some background on why the AMA endorsed HR 3200. Dr. Rohack carefully avoided throwing his full support behind the details of the bill, saying the AMA endorsed it “to move the process forward” in order to increase access. Former Sen. Bill Frist, another panelist on the show, strongly rebutted the AMA position, saying we need to “stay at the drawing board” and listen to senators who are working toward bipartisan legislation that will “bend the cost curve.” The AMA is getting beaten up based on a lot of misinformation, and I told Dr. Rohack we'd send around a letter he’s writing to get straight the facts about AMA’s positions on the controversial issues.

Dr. Rohack did make an important note that “the reason HR 3200 is very important is there is a fatally flawed formula (SGRrrr) … that will affect seniors’ access to Medicare.” He continues that “at least … the House bill … fixes this fatally flawed formula once and for all.” 

*** Image from Flickr (maliciousmonkey). ***

Today's post comes to us from Margo Minissian, ACNP-BC, MSN, CSN. Margo is heavily involved in ACC committees, as Chair of the CCA Chapter Liaison Working Group, Co-Chair of the Cardiovascular Team Council and "ex-officio" cardiac care associate member of the Board of Governors. When she's not involved in ACC committee work, or speaking on behalf of the College with her lawmakers, Margo is a cardiology nurse practitioner at Cedars Sinai Womens Heart Center.

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As a nurse practitioner, I work with patients to help them understand and manage their heart condition. I’ve seen patients across the spectrum – from those who have the means and the commitment to changing their health to those for whom every day is a struggle. I hear them when they talk about their day-to-day experiences managing heart disease and I do what I can to help.

Because I see the health care system from both the perspective of a health provider and from the experiences of my patients, I have a unique perspective to provide lawmakers and others in talks of reform. All health care professionals have this unique perspective. WE are the experts on health care and our lawmakers need us to get up-to-date on the different issues. One congressman put it this way: “We know a lot about a little, and rely on the professionals to get us up to speed.”

Proposed Physician Fee Schedule
One issue right now where that statement couldn’t be more true is the proposed 2010 Physician Fee Schedule, which, if enacted as proposed, would cut payments for cardiovascular services by as much as 30 percent. This is going to have a devastating effect on patients’ well-being.

I think there are a lot of issues at play here that led up to the cuts being so large – pressure to be budget-neutral and to give increases to primary care, and to use data from a flawed study, among many others. But also, I personally feel that there’s a stereotype present in lawmakers’ mind about cardiologists’ income. Lawmakers think: “Here is this group of well-appointed individuals, predominately physicians, who are concerned that if cuts are made, they might have to keep the office open Wednesday afternoon instead of going golfing.”

We all know this couldn’t be farther from the truth. Cardiovascular professionals work tirelessly in service of their patients. This means calls in the middle of the night, a workload that far exceeds 40 hours per week, a constant attention to medical journals to stay on top of the newest scientific evidence. Our primary concern is the patient.

Breaking the Stereotype
Knowing that the stereotype exists, what can we do to break it? My ACC Chapter, the California Chapter, has done a great job of this. First of all, we show up as a team. Doctors, nurses, and technicians with a unified voice to show all the different, and complicated, aspects to providing care.

Secondly, we bring patient examples. One great story to tell lawmakers is of appropriate use criteria at its best. This shows the lawmaker why it’s so important to have the right test for the right patient at the right time, while demonstrating that there are alternatives to blunt cuts to payments, like the one that CMS is proposing. In sum, if you want to make a difference, contemplate bringing staff from your office (after all, you’re likely not the only person at the clinic caring for patients) and make sure to be ready with patient examples to bring your points home.

Taking Action
The August recess is a critical time to contact your lawmakers about the proposed 2010 Physician Fee Schedule, especially because the comment period ends August 31. Let them know how the proposed fee schedule will affect your practice and your ability to provide patient care. Make sure that the other providers in your office contact their lawmakers as well. It’s up to us to tell Congress what we think the health care needs and how best to provide it. No one is going to do it for us – so take action now!

* Margo Minissian’s 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 (marie-II). *** 

Surya Mohapatra PhD, hyper-successful CEO of Quest Diagnostics, a $19.4 billion dominant force in medical laboratories nationally, sees new opportunities in cardiovascular care for his company and our members. He and I talked at the CEO forum I mentioned yesterday. While hospital labs still comprise about 60 percent of the inpatient and outpatient laboratory marketplace (physician offices are only 8 percent), Quest keeps expanding over the national environment and is the reference laboratory for many large hospital systems including Hopkins, Mayo, University of California, Geisinger, Sloan Kettering, Stanford, Yale, Walter Reed, Kaiser, the Brigham, etc. They employ over 800 pathologists and have 37 regional mega-labs and 150 rapid-response labs in addition to being sole provider in over 180 hospitals.

Quest directly connects the laboratory results to over 150,000 physicians, and they are now reaching out to a much larger group: patients. Their new patient portal is very impressive indeed, and it’s time that we start talking about possible collaboration and synergy. Mohapatra has approached us on this basis several times, and I’m going to make sure we talk in more depth soon.

*** Image from Flickr (Joriel "Joz" Jimenez). ***

At a CEO forum last week in New York, many of the industry leaders reported feeling mugged by Congress in the health care reform process. Certainly our members are frustrated and angry about the recent Medicare proposed rule -- that’s a real mugging. But, it seems everybody -- hospitals, insurers, pharma, device companies, nurses, businesses, consumers -- feels like somebody’s raining on their parade. Nobody seems happy with where we may be going yet. But I question the notion that there have been many muggings thus far:

Hospitals
Hospitals have agreed through the American Hospital Association to pony up $155 billion over 10 years as their collective commitment to the costs of reform. That’s only $15.5 billion a year, folks. Hospitals get more than $10 billion a year ($100 billion over 10 years) just from DSH (‘dish,’ or disproportionate share) funds for covering uninsured persons. Cutting that is logical. The additional $5 billion a year they need to make this up isn’t going to be a big deal, and they know it. That’s not a mugging. That’s a good deal.

Of course, bigger problems for hospitals might be related to reducing admissions and re-admissions if payment reform comes into place and if payment reform shifts toward capitation or global budgeting. Reductions in inpatient care (resulting from better outpatient care and prevention) could put real skids on hospitals’ ability to capitalize equipment and facilities in the future. Paul Levy, M.D., CEO of Beth Israel Deaconess, told me his board is worried about Massachusetts moving toward capitating private coverage again. He thinks doctors may do fairly well under a new version of global budgeting, but not hospitals in his state, and he fears that Partners (which Levy feels has a monopolistic market share) has the upper hand.

PhRMA
PhRMA seems to have successfully convinced the Obama Administration to put Medicare negotiation of drug rates on the back burner for now, using their pledge for $80 billion in savings over 10 years as the means of encouraging that. That’s no mugging either. Given that Obama is very committed to science and research, I think PhRMA and the device world are not in such a bad position going forward, unless the regulatory side of government in this administration and era becomes more aggressive. But PhRMA also pledged $150 million in pro-reform advertising to the administration last week also, and that sounds like they are pretty happy.

Insurers and AHIP
Insurers and AHIP see the certainty of more insurance regulation as survivable, assuming their dreaded public option doesn’t manifest -- but in many ways, the 'party's over' related to the heyday of 20 and 30 percent returns on investment, and they know it. That doesn’t mean they can’t do very well over the long term with more stable yet lower margins (as the investor owned life insurance industry has). Non-profit insurers like many of the smaller BC/BS and Kaiser plans may have a new advantage here.

But, I have believed all along that even if a public option is included in reform legislation at the behest of the liberal Democrats, private insurance will find a way to out-compete the government plan and to ensure that Congress won’t give a public option unreasonable financing advantages. In fact, the greater likelihood is that Congress could underfund a public option -- think Medicare and Medicaid reimbursements -- that would be my worry.  Regardless, the insurers haven’t been mugged either. They get cuts in the huge added incentives they secured in Medicare Advantage plans, yes -- but, they also get millions of new insureds to cover presumably.

Doctors and Patients
There will be an enormous amount of new money going into health care benefits for the millions of patients who are now uninsured or under-insured, and a significant part of that will end up in the pockets of physicians and other providers; but as all know, there will be winners and losers there too. The primary care incentives will so far not do much of anything -- and they shouldn’t be created by slashing specialty payments (the flawed CMS Medicare Payment Rule proves that nothing yet is being done rationally -- although the CMS Rule has nothing to do with health care reform bills; it’s just indicative of a broken system of flawed formulas and administrative and payment nightmares).

As I have stated earlier, the coming pandemic of CV disease and consumer respect for cardiology is certain to make cardiology an attractive and in-demand professional venue for decade to come. Prevention and earlier intervention to reduce what’s in the pipeline may be the only ways prevent a veritable burn-out of cardiovascular professionals due to the impending high-volume demand on the horizon. Patients are going to be holding hands with doctors as reform progresses, because our fates are likely to be linked. I think that bodes well for the profession.

*** Image from Flickr (dirac3000). ***

No vacations for the Senate ‘gang of six’ (Democratic Sens. Baucus, Bingaman and Conrad; and Republican Sens. Grassley, Enzi and Snowe). They are still meeting to try to craft a bipartisan solution, just not in DC. They must be hiding out from the very raucous ‘town hall circus events.’ Maybe they’re worried that the alleged death panels might be intended for them if they can’t come up with something tangible soon.

Baucus said on Thursday that he was reaching a bipartisan accord that would reduce spending over the House (H.R. 3200) and Senate Health, Education, Labor and Pensions bills. How he would do that is still not fully clear, but he would hit up Medicare Advantage plans, hospitals, and PhRMA as previously noted, and he would cut the $230 billion in H.R. 3200 to eliminate the SGRrrr back to a one year fix for $11 billion. He’s kicking the can down the road again. We’d have to lobby in 2010 to find $285 billion to prevent monumental cuts in 2011. Give me a break. The House bill (and AMA) is right here! Get ‘er done, folks. But what do you bet there will be no tort reform in there?

*** Image from Flickr (Dakotilla).***