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). *** 

Today’s post comes to us from Harlan Krumholz, M.D., F.A.C.C., the Harold H. Hines, Jr., professor of medicine at the Yale University School of Medicine. Harlan is a well-known leader in advocating for improvements in cardiovascular quality. Not only did he lead ACC’s successful quality improvement program “D2B: An Alliance for Quality,” he currently serves as the co-chair of the Hospital to Home (H2H) steering committee. Outside of his work with the ACC, Harlan is also heavily involved in the Centers for Medicare and Medicaid Services’ efforts to develop national measures for public reporting of hospital performance.

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Over the last several decades, the cardiology community has led our profession in generating new knowledge and seeing it applied for the benefit of our patients. Recently, we dramatically improved door-to-balloon times – moving in rapid progression from an era where only one-in-three patients were treated within the guideline-recommended 90-minute timeframe to now, where almost 90 percent of our patients are treated within that benchmark. Remarkable.

Another chance to lead lies before us. On Oct. 22, the ACC, in partnership with the Institute for Healthcare Improvement, will launch a major quality improvement initiative called Hospital to Home (H2H)… this time focusing our quality efforts on readmission rates. Currently, about 20-25 percent of our patients hospitalized with an acute myocardial infarction (AMI) or heart failure are back in the hospital within 30 days. Many of these admissions are preventable through improvements in the transition from inpatient to outpatient status. Unfortunately, we have often neglected this vulnerable transition period for patients.

Gaps in Care
We have many obvious gaps in care – patients often leave without information about the hospitalization being transmitted to other caregivers in a timely way; without access to medications; without appointments being set; and without an emergency plan for if their condition suddenly worsens. Studies have shown since the 1990s that improving the handoff between the hospital and the “home” can lead to a reduction in readmissions by addressing these gaps. Our fragmented health care system places many barriers in front of health care providers in putting known methods into practice. To reduce readmission rates, we’ll need to make special efforts to focus on transitions and most importantly – to focus on the patient, specifically, making efforts to ensure that the patient is ready and knowledgeable enough to manage their care – and that the system is poised to provide the support they need.

H2H Goals – Just the Beginning
H2H will assist providers in overcoming the systemic barriers to improving readmission rates. The initiative is committed to reducing 30-day all-cause, risk-adjusted readmission rates for patients with a diagnosis of heart failure or AMI by 20 percent nationally by 2012. In HF, that would take the rate from about 25 percent to about 20 percent. This goal is ambitious – but we aspire to produce a substantial benefit for patients.

H2H will leverage other national initiatives contributing to a reduction in readmission rates and will harness the collective knowledge, creativity and energy of its key strategic partners -- Kaiser, the Veterans Administration, the American Hospital Association, The Joint Commission, PREMIER, HCA -- and others to reach this goal. In my opinion, the 20 percent reduction is just the beginning of what we can achieve through our collaborative efforts. The path is more challenging than ever because of our goal of actually affecting patient outcomes, but we are bringing together expertise, resources, tools and a mechanism for us to learn from each other to meet this goal.

For those of you who want to be part of this effort, you will not be alone. We already have more than 250 facilities (e.g., hospitals and medical practices) that have joined us. Teams will be anchored at hospitals but will stretch across the continuum of care. We will track progress and, ultimately, assess whether we decreased preventable readmissions through improved care. We want this effort to equip teams for success.

Join Us in Reducing Preventable Readmissions
For more information, visit: http://www.h2hquality.org/, or email hospital2home@acc.org. H2H officially launches Oct. 22 with a Webinar explaining the initiative in greater detail. To join the Webinar, please register in advance online. If you are unable to attend on Oct. 22, you will be able to access the Webinar archive through our Web site.

We want to again show the nation that the cardiovascular community knows how to get results for our patients. We hope you’ll join us for this exciting initiative.

* Dr. Krumholz'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!

To kick off our 2009 Legislative Conference coverage, former ACC Texas Chapter Governor and current ACC Board of Trustees member George Rodgers, M.D., F.A.C.C. will discuss a recently released study on the impending cardiovascular professional workforce shortage, which appears in the Sept. 22 issue of Journal of the American College of Cardiology. Dr. Rodgers is president and chief medical officer of Biophysical Corporation, a company dedicated to advancing clinical knowledge through its research in the field of biomarkers, and a practicing cardiologist in Austin. As part of the release of the study, Dr. Rodgers and ACC SVP of Science and Quality Janet Wright, M.D., F.A.C.C., conducted a phone conference with reporters, which is available at the end of this post.

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There are many issues that cardiovascular professionals need to talk to lawmakers about to better inform health care policy and improve the health care system. As Margo Minissian, CCA, said in her post last month: Cardiovascular professionals are the “experts on health care and our lawmakers need us to get up-to-date on the different issues.” My commitment to advocacy is why I’m here in Washington, D.C., for the ACC’s 2009 Legislative Conference.

At this moment, two of the hot topics are payment reform and health care reform. However, an underappreciated advocacy topic for cardiologists, but one I feel is highly important, is addressing the cardiology workforce crisis. My colleagues on the ACC Board of Trustees Workforce Task Force and I on Thursday published in JACC the results of a survey finding that an inadequate supply of cardiovascular specialists will be available to treat the projected 20 million more Americans that will have heart disease by 2020.

Some of the study's findings:

• Currently there is a significant shortage of over 3,000 cardiologists in the workforce.  Only approximately 800 new cardiologists complete fellowships every year in the U.S.
  
• Forty-three percent of cardiologists in the current workforce are over the age of 55 – nearing the point in their careers that they might consider retirement. 
  
• There are going to be much greater demands in the next 20 years for cardiology services based on such drivers as population (baby boomers), the epidemic of obesity and the anticipated increase in prevalence of diabetes and concomitant cardiovascular diseases.
  
• Health care reform may further drive demands for more cardiovascular specialists.

Disparities
Not surprisingly, the report also found significant disparities in representation of women and minorities. Women represent about 12 percent of general cardiologists, 10 percent of interventional cardiologists and EPs and 30 percent of pediatric cardiologists; however, compare these rates to the rate of female medical students – 50 percent – and it’s clear how much room for improvement there is in encouraging women to pursue cardiology. Meanwhile, Hispanics and African Americans represent only 6 percent of the current cardiovascular workforce, compared to 25 percent of the general U.S. population.

What To Do About It
What does this all mean? In order to meet the growing demand for cardiovascular services, more is going to have to be done to recruit cardiologists and other nonphysician practitioners to the cardiovascular world. Part of this can be done through advocacy: we need more government funding for fellowship training positions in general cardiology. The government needs to help promote practice efficiency, such as subsidies for EHRs, a reduction in administrative burden and tort reform. Advocacy also will be needed to create more opportunities for under represented minorities, including shorter fellowship training and increased mentorship. We’re also able to meet the growing demand through increased use of team-based care, which will require more funding to train nurses and physician assistants on cardiovascular-specific care.

The shortage of cardiovascular professionals is a significant problem that will only get worse if no action is taken. Read more about the workforce study, and additional ways to reduce the shortage, in the most recent issue of JACC.

* Dr. Rodgers' 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!

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). *** 

Today's post comes to us from ACC's Advocacy Committee Chair Vincent Bufalino, M.D., F.A.C.C. In this position, Dr. Bufalino leads ACC efforts at advocating for changes to the health care system, in particular the payment system. When he isn't busy lobbying Congress, Dr. Bufalino is president and CEO of Midwest Heart Specialists in Naperville, Ill.

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The cardiology community is in frenzy over the latest insult offered by CMS. As well we should be – CMS has proposed reducing overall Medicare payments to cardiology by 11 percent. That overall figure is misleading – the proposed cuts to core cardiology services range from 10 to 40 percent. It also doesn’t include the regularly scheduled SGR cuts of more than 20 percent. The total result? Cardiology practices could see cuts at little 25 percent (ha!) to as much as nearly 50 percent. In just one year.

This is insanity. Cuts as massive as these will have enormous effects on the practice of cardiology – not just for the practices, but more importantly, for the patients. Here’s what the cuts could mean for patients:

1. Reduced access. Practices won’t be able to afford to provide certain services to patients, which means that they’ll need to go to the hospital to receive the care. This will require them to take extra time off work and pay higher copays. In low-access areas, the nearest hospital could be hours away. This just isn’t feasible for everyone. CMS may not have intended to reduce access to much-needed cardiovascular services, but that’s just what they’ll be doing if these cuts go through.
   
   
2. Staff lay-offs. With drastically reduced incomes, cardiology practices are going to have difficulty maintaining current staffing levels. This will have negative effects on the customer service offered to patients, as offices try to do more with less.
   
   
3. Reduced quality. Cardiologists have led the way in improving quality. Morbidity and mortality for heart disease have dropped 29 percent over the last eight years. This is because cardiologists are committed to quality. We’re a leader in our creation of clinical documents. Not to mention our incredibly well-developed group of registries that improves patient care. Large numbers of us participate in the Physician Quality Report Initiative. We use electronic health records at higher rates than other specialties. We are specialty committed to improvement. That said, our participation in quality improvement activities – which often require a heavy administrative burden – is threatened because we won’t have the funds to maintain the staff needed to submit the proper paperwork or the time to complete it. As fellow ACC member Patrick Anonick, M.D., commented on this blog: “We are rapidly approaching a point where we cannot afford the overhead to focus on these issues.”

This is serious. In my practice, we have a group of 50 physicians covering much of suburban Chicago.  If these cuts go into place it will put undue hardship on our practice. We would have to stop hiring new physicians and begin to shrink our staff base to maintain a stable fiscal base. It would clearly affect on our service and stop us from doing the free community work that we have become known for in the area. As we decrease our staff, the added extras that have become a part of our service will just go away. Many of our smaller counterparts will possibly have dire consequences to their longevity.

Here’s what the ACC is asking us to do:

1. Call, e-mail or visit with your lawmakers to point out the serious consequences of the proposed rule. The ACC has talking points, patient materials and a sample letter available on www.acc.org/can. Advocacy staff (Molly Nichelson and Justin Beland) can help you schedule appointments with your lawmakers, which will be especially effective if you visit during the August recess when they are back in their districts.
   
   
2. Take part in the ACC's "Cut the Cuts Roadshow" and volunteer to give your own or facilitate an ACC-taped presentation on the implications of the cuts on cardiology to your hospital or practice group. Email qualityfirst@acc.org for more information.
   
   
3. Now is also the time to give to the ACC Political Action Committee if you have not already done so. 
   
   
4. Attend this year’s Legislative Conference, Sept. 13-15 in Washington, D.C. This is a great opportunity to help educate Congress about these effects of these cuts. Registration is available here.

More than ever, Congress needs to hear from us. Please leave a comment below to say what you think would be the effects on your practice if the cuts were to go through, but make sure you also do one of the four things listed above. As Jack said earlier this month, “It’s time to roll.”

-- Vincent Bufalino, M.D., F.A.C.C.

* Dr. Bufalino’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 (Sir Twilight King). ***

This month’s post comes to us from Robert Hendel, M.D., F.A.C.C., chair of the Cardiac Radionuclide Imaging Writing Group, member of the Appropriate Use Criteria Task Force AND chair of the Evaluation and Implementation of Appropriate Use Criteria. As you can see, Dr. Hendel has quite the interest in improving quality. He also led the way in demonstrating the effectiveness of appropriate use criteria to reduce inappropriate testing when he released the results of a pilot with UnitedHealthCare on SPECT MPI.

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President Obama’s speech to the American Medical Association last week has been the topic of much discussion within the health care community. While outlining many components of his vision for health care reform, his emphasis on quality care resonated with me, largely due to the ACC’s continuing focus on this area. As the President stated, “…the bulk of our costs is the nature of our health care system itself – a system where we spend vast amounts of money on things that aren't making our people any healthier; a system that automatically equates more expensive care with better care.”

Unfortunately, cardiology was specifically mentioned in a less than flattering fashion, when he cited the recent JAMA publication that found only half of all cardiac guidelines are based on scientific evidence.

Improving Care through Clinical Documents
However, this conclusion is misleading with regards to the value of practice guidelines and the overall aim of providing the best care. Not every clinical scenario has robust literature support and in its absence, expert consensus opinion must fill the void to assist cardiologists in decision-making. The ACC, in conjunction with the American Heart Association and many subspecialty organizations, has been a leader in the medical world in developing documents to guide clinicians. Through practice guidelines, performance measures and appropriate use criteria, the College has been instrumental in improving cardiovascular care.

Beyond documents that define optimal, “must do” therapeutics, such as performance measures, clinicians need guidance in selecting the right test for the right patient at the right time. Since the inception of appropriate use criteria, which seek to define what test or procedure would be reasonable to perform for a given clinical situation, there has been a growing acceptance of this approach. The appropriate use criteria movement has been carefully followed by the Centers for Medicare and Medicaid Services (CMS) and private health plans, receiving almost universal praise.

Because of their basis on a strict, well-accepted methodology and that they are continually modified to provide contemporary application for resource utilization and reimbursement, appropriate use criteria have been recognized by national quality organizations. The most recent criteria, which are a revision of the radionuclide imaging criteria originally published in 2005, now have closed many of the gaps in the criteria’s application and are based largely on patient care flow diagrams. Other appropriate use criteria documents are now being revised and a multimodality approach to imaging criteria is underway in conjunction with the American College of Radiology.

Implementation, Evaluation
While creating these documents is very important, the ACC also is committed to the implementation and evaluation of appropriate use criteria, a critical component to actually affecting health care. In March, I presented the results of the multicenter pilot examination of the SPECT [Single Photon Emission Computed Tomography] Appropriate Use Criteria done in partnership with United HealthCare, which revealed the feasibility of applying the criteria to improve care. The pilot also was helpful in identifying areas of improvement in the use of SPECT.

CMS now has begun planning for a $10 million demonstration project testing appropriate use criteria and has involved ACC directly in the dialog. Furthermore, appropriateness is now a key focus of national medical quality organization, like the National Committee on Quality Assurance, AQA Alliance and others.

Physicians as Quality Drivers
We, as cardiologists, along with our representative organization, the ACC, must not lose momentum. We have to continue to drive the process from the physician perspective, with emphasis on quality and patient access. If we lose our focus, we risk having external forces, such as radiology benefits management companies, dictate the practice of cardiology. While the realigning of incentives to encourage quality is clearly needed, we must also do all we can right now to ensure that our patients receive the highest quality of cardiovascular care by using clinical documents to guide care choices.

- By Robert Hendel, M.D., F.A.C.C.

* Dr. Hendel'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!  

This month’s post comes to us from past president of ACC’s Virginia Chapter, John Brush, Jr., M.D., F.A.C.C. In addition to serving three years as Chapter president, Dr. Brush practices at Cardiology Consultants, Ltd., in Norfolk, Va., and is an Assistant Professor of Clinical Internal Medicine at Eastern Virginia Medical School. He also has been a leader in quality improvement, assisting ACC efforts with “Door-to-Balloon: An Alliance for Quality” and the IC³ Program, and as a member of ACC’s Clinical Quality Committee.

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In the current health care reform debate, there has been considerable discussion about comparative effectiveness. This method of evaluation could provide valuable information on the relative value of competing drugs, devices and treatment strategies, which in turn could improve outcomes, efficiency and satisfaction. Critics are concerned, however, that comparative effectiveness could be used to deny coverage, squelch innovation and ration care. Because of these concerns, some stakeholders forcefully argue that comparative effectiveness evaluations should be totally devoid of cost considerations.

But how can you compare competing treatments and ignore costs? To use heart failure as an example, could you really compare the relative effectiveness of ACE inhibitors and left ventricular assist devices and ignore the wide difference in costs between the two treatments? And isn’t the public’s desire to gain “more bang for the buck” what’s driving health care reform in the first place?

The Case for Cost Effectiveness
Cost effectiveness research is difficult and has recognized limitations. Yet no method of research is perfect or definitive. Although cost effectiveness research has some limitations, we should not reject the useful information that it provides for comparative effectiveness analysis.

There is a compelling need to contain costs in order to extend health care coverage universally in America.  Comparative effectiveness research will give policy makers important information that will help set priorities for spending.  As with clinical practice guidelines, comparative effectiveness analysis should inform, but not dictate clinical decisions.  Personalized decision-making for individual patients should always trump broad policy recommendations.

Comparative + Cost Effectiveness
Comparative effectiveness research and analysis will require a disciplined approach.  Comparative effectiveness research should be a transparent scientific process, absolutely free of economic influence.  Advisory boards that oversee this research and analyze the results should be shielded from undue political influence.  For years, NIH has distributed billions of dollars in funding, using established methods that are generally respected as fair and non-biased.  Similar independence and discipline can be established for overseeing comparative effectiveness research and analysis. 

Comparative effectiveness research using cost considerations should be a two-stage process.  The first stage should pertain to relative clinical effectiveness and the second stage should deal with costs.  For competing treatments with similar clinical effectiveness, no further cost effectiveness research is needed because direct cost comparisons would be simple.  But in comparisons where one treatment is more effective, careful analysis of costs will be necessary to estimate the monetary value of the increased effectiveness.

Constructing a Firewall against Undue Influence
To maintain the integrity of this process, and to shield the process from political and financial influence, a firewall should be constructed between comparative effectiveness evaluation and insurance coverage decisions.  The funding level for coverage is a political or a business issue, not a scientific issue.  The funding level for Medicare is up to Congress, and, ultimately, to taxpayers.  The funding level for private health plans is up to the purchasers and benefit design managers.

Comparative effectiveness analysis can be separated from coverage decisions by borrowing the method used in the process of grant funding:  

• When judging grants, the judges evaluate the grants based on the scientific merit of the grant, without consideration of whether the grant will actually receive funding.
• Grants are graded on a relative scale.
• Top grants that fall within the funding range receive a grant.

Is that rationing?  Perhaps so, but this explicit method of determining coverage seems more rational than the current method for rationing where we deny care to nearly 50 million Americans because they lack employer-based insurance or don’t meet the criteria for Medicare or Medicaid.

The device and pharmaceutical industry is predictably worried about comparative effectiveness.  Undoubtedly, comparative effectiveness would provide pressure on pricing, which is generally lacking when providers and patients pass on costs to third party payers. Transparent comparative effectiveness would give consumers of health care an opportunity to shop for greater value, which will help contain overall costs. 

We Can’t Have it All
This is the unfortunate truth: the growth in health care spending is unsustainable and is making health care unaffordable for average Americans.  In health care, we can have nearly anything we want – we just can’t have everything we want.  Because of escalating costs and limited funding, we need mechanisms to differentiate medical treatments with high value and those with little incremental value.  Without a method to objectively analyze the relative value of treatments, the costs of medical care will continue to rise to unaffordable levels.

-- John E. Brush, Jr., M.D., F.A.C.C.

* Dr. Brush’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 morgueFile (jdurham). ***

This post comes from ACC Secretary and Board of Governors (B0G) Chair John Gordon Harold, M.D., F.A.C.C. Dr. Harold is cardiologist at Cedars-Sinai Medical Center, and has held a number of leadership posts within the College, including as a past president of the California Chapter and immediate past governor for Southern California. As BOG Chair, Dr. Harold will champion the 2009-2010 BOG priorities, in particular focusing on state advocacy.

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At any given moment, states and their lawmakers are thinking about, drafting, considering or even voting on legislation that will impact the way you practice medicine. As a practitioner, you may never hear about these initiatives – even though you could be directly affected.

This is where your local chapter comes in. ACC chapters work together with the ACC to pursue critical state legislative initiatives, such as maintaining access to office-based imaging, ensuring appropriate STEMI care, championing health advocacy and promoting public safety. The chapters and the ACC also work closely with the Board of Governors (BOG) Steering Committee and State Advocacy Work Group (formed by the BOG in 2008 with a mission to increase and improve state advocacy and outreach). This group maintains regular contact with Jim Boxall at the ACC, who is a virtual clearinghouse of information on legislative and regulatory issues and how-to tips for expanding Chapter state advocacy programs. 

Through these collaborations, the College is pursuing a multi-faceted policy and legislative agenda that reflects the diverse needs and interests of members. This agenda includes holding enhanced lobby days and “Cardiologist for a Day” programs, improving online advocacy tools, and increasing collaboration with the American Heart Association (AHA) and other groups.

In addition, the College, through its State Advocacy Workgroup, is working closely with six chapters that have the staff and resources to be models for other states. Using ACC National Funding Proposals, these chapters -- Alabama, Arizona, Iowa, Kentucky, Rhode Island and Washington -- will build relationships with other medical groups and their respective state legislatures to influence policy.

California Chapter: An Example

In my chapter, the California Chapter (CA-ACC), we have a history of state legislative victories. This is because Chapter staff, in cooperation with ACC state advocacy staff, closely monitors all legislation and actively lobbies to defeat adverse legislation while supporting legislation to promote the quality of cardiovascular patient care.

In one particular example, Chapter leadership reached out to colleagues at the American College of Radiology through the California Radiologic Society (CRS).  The discussion revolved around a proposed Assembly bill that could potentially limit office-based cardiac imaging. When the bill came up, I recommended contact with CRS to see where we could find common ground, as the stated focus of the bill was eliminating "fraud and abuse." The inter-society discussions went well and both groups agreed to focus on mutually acknowledged areas. Both the CA-ACC and CRS lobbyists worked together and came to an agreement on bill language.

For other state chapter examples, visit the ACC Chapter Web site. 

Get Involved!

The ACC is only as strong as its members. You can help advocate for quality health care—and influence health care policy—at both the state and federal level in several ways: 

1. Get involved with your ACC Chapters by contacting the Chapter Executive in your state.
   
   
2. Get involved at with ACC’s grassroots efforts (www.acc.org/CAN) and help shape health care policy at the federal, state and local levels.
    
   
3. Support candidates who understand the importance of cardiovascular care by donating to the ACC Political Action Committee (PAC).
   
   
4. Attend the American College of Cardiology’s 2009 Legislative Conference taking place Sept. 13-15 in Washington, D.C. Take advantage of this opportunity to help educate Congress about the needs of cardiovascular professionals and patients.
   
   
5. Visit the Web site of ACC’s health care reform campaign, Quality First, and visit often! Here you can learn about how the ACC is working to transform health care from the inside out, as well as the latest Quality First news and events.

- By John Gordon Harold, M.D., F.A.C.C., Chair, ACC Board of Governors

* Dr. Harold'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! 

*** California State House. Image from Flickr (fusionpanda). ***

This post comes from ACC President-elect Alfred Bove, M.D., Ph.D., F.A.C.C. Dr. Bove, who will take over for current ACC President Douglas Weaver, M.D., F.A.C.C., later this month, is a professor emeritus, medicine, at Temple University School of Medicine. As president, Dr. Bove will usher in "The Year of the Patient," in which the needs of patients will be at the forefront of all the College’s efforts.

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The world of cardiology is replete with new technology. There are advanced imaging techniques, new implanted devices that measure heart failure status, exercise levels, that pace the heart in complex algorithms and ICDs to prevent sudden cardiac death.  We have a plethora of new medications for the variety of acute syndromes, and have developed life saving programs, like D2B: An Alliance for Quality, that have helped reduce the risk of serious myocardial damage after an acute MI.

However, even in our technology-laden world, the great majority of cardiology patients still come to the outpatient office for the day-to-day maintenance of their condition. It is in the outpatient setting where patients are evaluated for their cardiac problems, receive therapy for their disorder, get advice about minimizing cardiovascular disease risk and learn about the detrimental effects of a chronic cardiac condition.

We live in a reimbursement world that encourages testing and procedures, but does not support the cardiologist who follows a patient for years, maintaining a state of reasonable health, avoiding progression to overt symptoms, and allowing the patient to experience a reasonable quality of life with chronic heart disease.

It is this commitment to good patient care that the ACC wishes to emphasize in the Year of the Patient.  The emphasis is not only on respecting the cardiologist who provides continuous cardiac care to keep patients active and symptom free, but also in bringing patients into the care team and empowering them to participate in their care decisions. ACC’s health care reform goals are to provide reimbursement for the coordination of care that often requires care management time spent beyond the actual office visit, and to recognize quality as a component of reimbursement. 

The movement toward a “Patient-Centered Medical Home” seeks to reward the primary care physician with added reimbursement to integrate care, provide continuity and manage chronic disease.  However, we as cardiologists perform the same duties with our heart patients and should consider developing a Cardiac Medical Home for patients with chronic heart disease.  This concept embodies our goals of patient empowerment, improved quality, adoption of electronic health records and the incorporation of non-physician providers (nurses, nurse practitioners, physician assistants) into a single entity that will optimize care of patients with chronic heart disease.

This team approach, with the patient as part of the care team, is the future of our practices. We will soon find demand for our care increasing to unmanageable proportions due to the aging population and a shortage of both physicians and nurses who can provide cardiac care.  Information technology and a team approach will allow us to manage a large number of patients with heart disorders.

For the next year and beyond, the ACC will emphasize the care team consisting of physicians, nurses, nurse practitioners, physician assistants and the patient, with the hope that we will succeed in increasing reimbursement for continuous cardiac care, and begin a movement that recognizes the cardiologist who chooses to emphasize continuous patient care.

- By Alfred Bove, M.D., Ph.D., F.A.C.C., ACC president-elect

* Dr. Bove's post is the fifth in a new 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!

This post comes from ACC immediate past President James Dove, M.D., M.A.C.C. Dr. Dove is a clinical professor of medicine, Division of Cardiology, at Southern Illinois University, and a founding partner of Prairie Cardiovascular Consultants, Ltd., a 42-member group of cardiologists. As president, Dr. Dove set in motion ACC's efforts in implement quality in cardiovascular care.

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For 25 years, the American College of Cardiology Foundation and the American Heart Association have produced clinical practice guidelines.  These guidelines carefully review the available evidence, rank the importance and significance of major trials and the voluminous medical literature. The results are lengthy guidelines with a series of recommendations, classified as I, IIa, IIb, and III, depending on the strength of the recommendations.

The documents are a wonderful distillation of the literature and serve as a tremendous resource guide to practitioners.  They are, however, difficult to apply at the bedside.  Numerous attempts have been made by the College to help address that difficulty.  Wall charts, pocket guides and other tools have been produced in an effort to facilitate clinical application.  These processes, while helpful, have failed in the application of the Class I guideline recommendations 100% of the time in every patient in whom the recommendations are appropriate.

Best practices in the future will use computer decision-support tools (CDS) that function well within the clinical workflow and facilitate decision-making as well as providing reminders at the point of care.  These tools can also automatically collect process measures without requiring additional time-consuming chart reviews.  Computer decision-support tools will allow us to apply the guidelines every time to every patient for whom the guideline is appropriate and to document clearly the reasons a specific recommendation is not appropriate for a given patient.

The time is now to adopt and develop these computer decision-support tools to function at the point of care, document quality and facilitate our adherence to best medical practices. 

This is not cookbook medicine – instead, it allows us for the first time to effectively collect data about adherence to guidelines, appropriate deviations from guidelines, and eventual correlation of process measures and the effects of those measures on clinical outcomes.   There is no better way to document the significance of process measures of all classification levels than to do so at the point of care and correlate that information with clinical outcome in thousands of patients.

- By James Dove, M.D., M.A.C.C., ACC immediate past president

* Dr. Dove's post is the fourth in a new 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!

This blog post comes to us from ACC Informatics Committee Co-Chair Michael Mirro, M.D., F.A.C.C. Dr. Mirro is medical director of the Clinical Research Center at Parkview Hospital in Fort Wayne, Ind., and is a clinical professor of medicine at Indiana University School of Medicine. As co-chair of the Informatics Committee, Dr. Mirro leads the way in coordinating the health information technology activities and policies of the College.

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The year 2009 will potentially bring a significant movement in the implementation of health information technology (health IT) into clinical practices. The Obama administration has indicated the intent to invest $50 billion in health IT over five years. Meanwhile, the CMS e-prescribing initiative that started Jan. 1 represents the first tangible incentive program for health IT use.  

The adoption of health IT to improve the U.S. health care system is central; health IT can improve safety and convenience, and save valuable time and money.  Substantial bipartisan support has built over the past two years to support a national agenda to accelerate integration of health IT into physician practices.  The role of the federal government in health IT is significant, and currently includes the following:

1. Development of health IT standards
2. Assisting in EHR vendor certification
3. Developing financial incentives for health IT adoption
4. Developing pilot programs in data storage and data exchange

Of the recent activities to accelerate health IT adoption, the CMS e-prescribing initiative will likely have the greatest impact. The current adoption of health IT has been slow (13% of practices) due to the lack of clear return on investment; fear of lack of functionality that slows the patient encounter process; uncertain security standards; and doubt that EHR systems will interface for proper information exchange (interoperability). 

The development of e-prescribing incentives by CMS will clearly move the needle for health IT.  Currently, as of 2007, only 2% of the 1.5 billion eligible prescriptions are electronically prescribed.  The current incentives that are in place include a 2 percent payment bonus for 2009-2010 if physician practices use a qualified e-prescribing system., which is then reduced to 1 percent in 2011 and 2012, and 0.5 percent in 2013. A 2.0 percent penalty will occur in 2014. The goal of this program has been to utilize the Medicare payment system as an initial model of introducing health IT in a limited fashion into clinical practices.

The ACC will be carefully monitoring member experiences with the program. Numerous potential administrative issues may arise, just as was observed with the Physician Quality Reporting Initiative program. This modest investment by the federal government will help -- but will not support long-term -- health IT system implementation. Robust health IT requires an investment up to $25,000 to $45,000 per physician just to "plug into the system" and annual maintenance costs of about 12 to 20 percent of initial costs, according to CBO. Meanwhile, physicians are under increasing reimbursement cuts from Congress and others and must deal with more administrative burden than ever.

The ACC supports the federal agenda and has attempted to prepare its members for health system transformation. As part of this, the ACC has established a health informatics committee with participation by members in many activities related to health IT interoperability, standards harmonization and the development of electronic health record adoption tools.

In addition, the ACC has been aggressively supporting other physician payment incentive programs. One example of this is the ACC outpatient quality improvement program, IC3, which if implemented electronically could ultimately provide robust in-office quality improvement with measureable reductions in health expenditures.

More about ACC’s commitment to health IT can be found at http://www.acc.org/healthIT. 

My question to readers: Do you want to leave money on the table from Medicare Part B by not participating in the program? If you participate in the e-Prescribing program, then give the ACC feedback on implementation and Vendor use by commenting below.

- By Michael Mirro, M.D., F.A.C.C., Co-Chair of the ACC Informatics Committee

* Dr. Mirro's post is the third in a new 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!

This is the second part of this month's guest blog post from ACC Vice President Ralph Brindis, M.D., F.A.C.C. Dr. Brindis is the Senior Advisor for Cardiovascular Disease for Northern California Kaiser and a Clinical Professor of Medicine at the University of California-San Francisco, and has been a leader within the College's NCDR for years.

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CMS is increasingly looking to “Coverage with Evidence Development” as a means of improving patient value and ensuring the most cost-effective care. CMS established CED in 2006 as a way to allow the agency to offer conditional national coverage for new technologies while requiring the collection of additional patient data to supplement standard claims data, either through participation in registry or clinical trial.  CED, then, would allow and encourage the diffusion of new technology into the marketplace and the CV community through its coverage and reimbursement component. Even more importantly, if appropriately applied, it would promote the acquisition and collection of key outcomes and other patient data to allow clinicians and payers alike to best understand not only issues surrounding safety and efficacy, but also the true role of a new technology. The CED strategy has been successfully implemented in NCDR’s partnership with CMS for our ICD Registry.

Unfortunately, there often is resistance to the concept of CED by payers and also at times by practicing physicians. Payers balk at its implementation, feeling the technology is not “mature” enough to justify coverage and reimbursement even through the CED mechanism. Clinicians sometimes balk at CED implementation, feeling the technology already has a substantial “evidence base” justifying coverage through clinical trials and the premarket approval process, and that participating in a CED mandate is extra work. There are also “behind the scenes” political pressures exerted by lobbyists representing competing professional or industry interests that stymie CED implementation. The losers, unfortunately, in this situation are our patients and our CV science.

The NCDR is well positioned to play an active role in any future CED mandate – but only if payers and clinicians alike are able to embrace the terrific opportunity and mechanism for new technology assessment offered by CED.

- By Ralph Brindis, M.D., F.A.C.C., ACC Vice President

* Dr. Brindis' post is the second in a new 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!

This month's guest blog post comes to us from ACC Vice President Ralph Brindis, M.D., F.A.C.C. Dr. Brindis is the Senior Advisor for Cardiovascular Disease for Northern California Kaiser and a Clinical Professor of Medicine at the University of California-San Francisco, and has been a leader within the College's NCDR for years. 

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The College has positioned itself as a true leader in the assessment and promotion of cardiovascular quality through the development of data standards, clinical practice guidelines, performance measures and appropriateness use criteria. Data collection via the NCDR registry portfolio is another key asset that is continuing to evolve since the first registry, CathPCI, was launched in 1998.

To date, the NCDR has become an important advocacy vehicle for our ACC membership in meeting mandates from national and state governments, payers and consumer demands for quality assessment. There have also been well over 100 NCDR publications advancing the field of CV outcome research, answering questions that clinical trials cannot – particularly on select subgroups of patients typically not included in clinical trials. 

Moving forward, the FDA is increasingly turning to NCDR because of its huge potential to be a vehicle for post-market device/drug surveillance. To date, our main challenges for post-market device/drug surveillance – or for that matter, for assessing long-term clinical outcomes – is harnessing viable financial models and developing the scientific ability to accomplish true longitudinal follow-up of our patients.    

Another exciting potential role for the NCDR is in aiding the diffusion of new cardiovascular technology into health care practices. Our present approval system for small clinical trials for new devices misses opportunities for evaluations of broad-based community use of these devices in older patient subgroups and for off-label indications. Meanwhile, imaging technologies typically are released into the marketplace with very few or no clinical trials assessing their impact on clinical outcomes or even intermediate outcomes and clinical decision-making. Coverage and payment decisions for these newer procedures and technologies is complex and typically quite variable because of local CMS coverage decisions, variable private payer coverage decisions and even national CMS coverage decisions.

- By Ralph Brindis, M.D., F.A.C.C., ACC Vice President

* Dr. Brindis' post is the second in a new 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!

This blog post comes to us from ACC President Dr. Douglas Weaver. Dr. Weaver is the Division Head of Cardiovascular Medicine, the Darin Chair of Cardiology, Director of the Henry Ford Cardiovascular Institute at the Henry Ford Health System and a professor of medicine at Wayne State University. On top of his numerous prestigious positions, Dr. Weaver is a resident ACC expert on cost-effectiveness.

The soaring cost of health care is arguably one of the largest problems within our current system. Health care costs in the US are projected to run $2.7 trillion in 2010, up nearly 30 percent from 2004. CMS estimates that health care spending will reach $4.3 trillion by 2017. By 2082, health care’s portion of the GDP will reach 49 percent, assuming that health care grows at only one percentage point more than the GDP (which is lower than the historic average of 2.5 percentage points), according to CBO. Of course, most of us may not be here in 2082, but how do we want to be remembered?

This rate of expenditure growth is both unacceptable not sustainable. As important is the fact that despite these rising costs, there is evidence that we are actually lagging in the provision of evidence-based care — by many measures we are slipping in producing a healthier America. Because of this, there can be no doubt that we will soon have some payment reform to both physicians and hospitals. It is the view of the ACC that physicians should be amply rewarded for providing the right care, for every patient, every time, instead of a system which rewards only volume and complexity of care. As it stands now, physicians would likely lose if they worked to improve prevention, continuity of care and eliminated that of either questionable or unproven benefit.

But while Congress and CMS contemplate and plan payment reform, we want to insure that the ACC is at the table to guide them to make decisions that will work. Cardiologists must get prepared by putting together the processes and measures to demonstrate the highest possible quality care to patients at every encounter. This means making the conscious decision to choose what works best at the lowest cost and apply it until we have found something of better value and more cost-effective to replace it. That’s it. No exceptions.

Last month, Health Affairs’ featured a section focused on the ability of “disruptive innovation” to spur health care change. In one article, the authors argue:

The achievement of lower costs ... requires the health care delivery system to get off a path where every new product and process aims at improving quality, regardless of cost, and onto one where changes in care reduce expenditures. This new path is not one of paying physicians, hospitals and drug manufacturers less to do what they have been doing .... What is needed is the development of new and different products and processes ....

One of these processes must be improving our application of guidelines and appropriate use criteria to every patient. We must take what we know to work and apply it in every situation possible. Plus, we must actively seek feedback on our performance to improve the care we provide.

The authors optimistically conclude – and I wholeheartedly agreed – that cost effectiveness is indeed possible:

Other industries have demonstrated the ability to deliver higher quality at lower prices, and there is no reason why health care cannot do the same.

Reform to the system is coming, no doubt about it. And in order to work, it’s going to have to address costs and the value received. If we can increase value and slow the rate of increase in cost, say to 1% or so greater than the GDP -- the impact will be enormous and yet we will not stunt innovation and further technological advances Let’s step up to the plate now and show Congress we’re ready to take an active role in cost and quality-related changes to the system.

- By W. Douglas Weaver, M.D., F.A.C.C., ACC President

* Dr. Weaver's post is the first in a new 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!