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). *** 

Yesterday I arrived in San Francisco for the TCT (Transcatheter Cardiovascular Therapeutics) conference, a yearly interventional cardiology meeting. Meetings like TCT provide an opportunity for interventional cardiovascular professionals to stay up-to-date on the latest science, technology and procedures. When it comes to cardiovascular education, the traditional paradigm is under attack and a new -- and more relevant -- platform is emerging. Not only are there new tools linking education and quality, but CMS, Congress and others are increasingly focused on education linked to licensing, certification and credentialing.

The ACC is actively addressing these issues by providing an integrated approach to life long learning. This includes developing opportunities for cardiovascular professionals to measure, track, and improve their performance, and, thus the quality of care they provide to patients. We are planning to help members meet and excel in the face of these new requirements. I like to think we’re leading the revolution in cardiovascular life long learning.

Meanwhile, we’re leveraging ACC’s quality resources like our registries, guidelines, performance criteria and expert faculty to facilitate this revolution. A great example of a new tool is our IC3 Program – our pioneering registry focused on the ambulatory setting. IC3 allows participants to benchmark their clinical performance, compare with others, and make adjustments where necessary -- and to participate easily in various new payment incentive models. 

All this talk of education and measurement isn’t going away anytime soon. We’ve got to adjust and take steps to thrive in a changing environment -- by directing and leading the change.

That said, if the frustratingly ill-crafted proposed CMS 2010 Physician Payment Rule is not taken off the table for cardiology, we’ll be diverted away from leading in the health reform charge in order to deal with a vestigial example of what's very wrong with the current environment and payment system. The proposed Rule would reduce practice revenues in outpatient cardiology by 20-40 percent, essentially devastating community cardiology practice. This is occurring in parallel to an opportuntiy for real and positive system change. What tragic timing -- and what a painful example of the problems and archaic nature of the current HHS and CMS systems (see my last post for more of my views on this). 

*** Image from Flickr (Paraflyer). ***

Sunday night I attended a charity event for “European Heart for Children,” a humanitarian initiative launched on Saturday by Roberto Ferrari, current President of ESC with his wife and others. The program’s purpose is to improve treatment of pediatric congenital heart disease in third world and emerging economy countries where treatment of this condition is inadequate. The program will offer training to health care providers to help them improve the care they offer, as well as educate physicians and politicians on CHD. Says Ferrari:  

“To me it's completely shocking to see first-hand that in some countries...the only hope for a child born with congenital heart disease is to go to another country for an operation otherwise they'll die. We hope that our initiative will give some hope to the children of Europe.”

Other CHD Issues
Treatment of pediatric CHD is a serious problem, not only because of the inadequate treatment in some countries, but also because of the lack of research. As a recent Wall Street Journal article put it: “Hardly any of the myriad drugs and devices developed for ... cardiovascular disease are designed with kids in mind.” Because of this, when treating pediatric CHD, “physicians often must rely on instinct, back-of-the-envelope calculations and anecdotal case reports swapped at medical meetings, instead of the more rigorous clinical evidence.” I heard from various European pediatric cardiologists and physicians here engaged in CHD diagnosis and treatment that Eastern European and some European countries have challenges in the CHD and adult CHD that still need attention locally.

Clearly, this lack of knowledge about best evidence and therapeutics regarding CHD is unacceptable. This is why the ACC two years ago began laying the ground work for a registry to look at outcomes and treatment for pediatric and adult CHD. The registry, called IMPACT (For Improving Pediatric and Adult Congenital Treatment), is in pilot phase currently but will launch officially in 2010. It will be the first national registry to provide data relating to demographics, acute management and in-hospital outcomes for patients undergoing diagnostic catheterization or catheter-based interventions for congenital heart disease. Also, it will serve as the benchmark for comparing catheter-based interventions to the more traditional surgically-based interventions currently in place. Once it’s nationally rolled-out, the pilot is going to provide invaluable knowledge about what works in the treatment of CHD and what doesn’t.

*** European Heart for Children logo. From ESC's Web site. ***

Chair Herb Kohl and the Senate Special Committee on Aging held a hearing last week on industry funding of continuing medical education (CME). Predictably, most of the witnesses opposed industry funding, including ACC Past President Steve Nissen, M.D., M.A.C.C. Dr. Nissen and other witnesses called for a strong firewall between the sales and marketing divisions of organizations offering CME and the educational divisions that develop the CME.

Of course, this “firewall” is already reality at the ACC, where there is a firm separation between our corporate relations and fundraising teams and our education division. The College has been a vocal advocate of responsible, transparent relationships with industry.

But, the College leadership differs from our respected Past President in that we believe eliminating industry funding for CME could be a serious blow to medical education in this country -- and ultimately to quality care. Steve’s arguments are compelling however, in terms of how often breaches of ethics have occurred (to the consternation of ethical physicians and industry participants in the CME process). What is important from the College’s point of view is that conflicts can be effectively and ethically managed -- and that breaches in ethics need NOT be tolerated.

The College has taken a leadership role in this debate, building consensus on the issue among medical professional societies and drafting a straw man proposal on conducting responsible, ethical relations with industry. The ACC remains committed to working with members of the house of medicine to protect access to the very best continuing medical education and -- most importantly -- to defend the interests of cardiovascular patients.

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

A group of ACC leaders and staff met this week to develop a bold agenda for maximizing the appropriate use of cardiac imaging. This new initiative, called FOCUS (Formation of Optimal Cardiovascular Utilization Strategies), aims to minimize geographic variations in cardiovascular imaging and reduce unnecessary imaging by 15 percent through the development of educational programs and data collection and measurement tools that help put appropriate use criteria directly at the point of care.

While still in the development phase, this initiative is critical, particularly as the debate over health care reform continues and lawmakers and others look to imaging as an area to cut costs. The ACC strongly believes that the use of appropriate use criteria at the point of care is a viable alternative to unilateral cost cuts that don't take into account appropriate use of imaging.

But, given the entries that preceded this one, get the IRONY: Here we are diligently working on reducing unnecessary or inappropriate imaging, while Congress continues to apply blunt instrument price cuts that will not truly reduce costs, and will result in disparities by which lower income families will not have access to appropriate and needed images. This is nuts.

Much has been made last week of relationships with industry. During ACC.09, reporters and other stakeholders took note that the ACC had decided not to pursue industry sponsorship of lanyards, portfolio bags and other high-value items (these would have produced nearly half a million dollars of revenue for the College). We did this in order to avoid the “NASCAR effect” of attendees as walking billboards and to visually reaffirm our commitment to responsibility and transparency in our partnerships with industry. But that doesn’t mean that well managed relationships with industry don't have real value for patients and society.

The ACC believes in responsibility and transparency in its relationships with industry, and we have taken many steps to eliminate historic practices that became acceptable to us (and are still in place with many other societies).

BUT we also believe partnerships with industry are absolutely critical to maintaining scientific progress in cardiology and other specialties. Right now, public funding for research and medical education is scarce. Cardiologists already pay for 90-95% of their own educational costs. Our attendees have to pay for everything on their own. Plus, leaving one’s office to attend a meeting like this in itself costs a lot of money in lost income! Digital education is valuable, but does not substitute for real discourse -- and folks would not go online and spend four 8-10 hour days staying up with what we presented.

Industry’s participation in our Exposition Hall (which is totally separated from any connection to educational programs or content), and some industry sponsored non-specific educational grants subsidize the meeting costs and therefore allow for reduced registration charges to the meeting (already over $800 or more for attendees). Also they create the ability to offer simulation, live cases, and innovative educational venues that attract people out of their offices to LEARN -- venues we could not otherwise afford to produce. More...

The Adult Congenital Heart Association has asked the ACC to endorse the “Congenital Heart Futures Act,” legislation introduced this week by Senator Dick Durbin (D-Ill.) and Representative Zack Space (D-Ohio), and we will. The ACC and its Adult Congenital and Pediatric Cardiology Section strongly support this legislation (see our letter to Sen. Durbin), which would amend the Public Health Service Act to coordinate federal congenital heart disease research efforts and to improve public education and awareness of congenital heart disease.

*** Image from Flickr (marie-II). ***