For the past several months I awaken each morning hoping the CMS 2010 Physician Payment Rule issue is merely a nightmare, and I can get up and help the College once again focus on constructive engagement in health care reform. No such luck. It is a nightmare, but one that is part of our reality.

Friday at 4:30 PM -- 30 minutes before the issuance deadline, the CMS (Centers for Medicare and Medicaid Services or See-a-Mess) dropped a bomb.  In a call from Jon Blum, the top political insider in CMS, he said I have “good news and bad news.”

The BAD news: the Rule adopts the AMA-collected practice costs survey data, meaning cardiology gets an average practice cut of 27-40% in private practices. (Note that academic, hospital, and integrated system salaried cardiology is largely insulated from the cuts initially, but the effects could eventually reach everywhere through market forces).

The allegedly GOOD news: CMS will phase in the cuts over four years, meaning they will impose an average of 5-7% cuts in 2010. But, what he told us is not accurate in the language we see that nuclear codes (SPECT) will be cut as much as 36% in 2010. We are working to analyze the language in the final rule, but this isn’t good news, and the Secretary and the White House have signed off on it.

Bottom line: The Four-Year-Phase-In is far better than having the full impact hit in 2010, because it will allow us to survive to get valid data and reverse the cuts completely in 2010 if necessary. BUT WE NEED TO FIGHT THIS DECISION NOW, NOT WAIT UNTIL NEXT YEAR. We need to mount a strategy to prevent even the 5-7% average cut in January and in particular reverse the nuclear/stress cuts.

Next steps
After all the hard work and excellent advocacy we’ve witnessed from all of you these past months, I regret telling you we’re not through. But, please don’t allow discouragement to cause you or others to give up. We’re not done here.

*** Image from morgueFile (jdurham). ***

In yet another attempt to reach the president and administration officials about the proposed 2010 Medicare Physician Fee Schedule, the ACC tomorrow will run an ad in four different major newspapers -- Washington Post, New York Times, Chicago Tribune and USA Today -- decrying the cuts. We're just a couple of days away from the release of the final rule; we must pull out all the stops in preventing these cuts from being finalized.

President Bove, SVP for Advocacy Jim Fasules FACC, and I met with the top brass at CMS last week to try to ascertain what’s going to happen.  We met with CMS Acting Administrator Charlene Frizzera, Deputy Jonathan Blum and several CMS physician division chiefs for a long discussion on the implications of the Rule if it proceeds as proposed. 

The CMS principals had not considered the likelihood that this rule would devastate private practice of cardiology as it will (they have been considering those predictions merely exaggerations of the effects by us). In essence, they continue to see this is an 11 percent cut (bad enough!), not wanting to connect that to the cuts in support staff, support services (echo and stress testing, etc.) that create the actual 27 percent average reduction in practice revenues. CMS leaders did cringe at the contemplation of a 27 percent cut, and I believe they are now going to have to look squarely at the implications of it for the Obama administration; this will cause a number of problems on their watch that they have not anticipated, including:

• About two-thirds of CV patient care access will be threatened as practices close — the worst effects will be in rural states, suburbs and away from large academic centers and integrated systems. Seniors will scream bloody murder.
• The same hospital-based cardiology clinic and diagnostic services cost two to four times more than equivalent payments to private practices in the outpatient setting — this will drastically increase Medicare costs at a time when “bending the cost curve” is the big goal. We must not forget that CV care is 43 percent of Medicare, and this will have an impact they have not anticipated. It’s dumb.
• The shift of cardiologists to hospital employment and other employment venues will have significant repercussions for chronic disease management. Such has occurred in parallel when a large number of general internists were forced for financial reasons to close their practices and become hospitalists.
• Medicare beneficiaries will suffer a Part B premium increase as the costs of lab services, etc., rise. It’s a veritable tax on seniors as well.

CMS wants to continue to message that the survey reflects the current environment of practice expenses fairly (perhaps with a few inevitable glitches), and that their processing of the AMA survey data was not done with any political purpose or manipulation. I believe they are sincere in this. But, one could tell they were disturbed as they confronted a 27 percent cut as reflecting accurately the actual practice costs of cardiology over the past year -- and then they weren’t thinking about implications. It just doesn’t make sense. 

Next Steps
So, what now? The secretary still has not opined on the staff submission of the Final Rule, nor apparently has OMB (Office of Management and Budget) in the White House. I would think the attendees at this meeting will probably be making a few phone calls to ask what should be done -- if anything. They were pretty frank in asking us a recurring question: “What can we tell the Secretary or the President that would explain why we shouldn’t follow our regulations and put the rule out as prescribed?” We gave them plenty of things they could say, like, “You did not validate the data;” “AMA did not validate the data;” “The data for CV practices is not valid;” “The implications on the adverse effects to private practice of cardiology will be horrific;” and “I don’t want to be here when this happens.” Neither do we. 

It is possible that some heroic measure will be attempted. But we need to start developing our legislative, legal and other contingencies because this was not an encouraging meeting. But, we’re doing a lot more than meeting again with CMS:

First -- On the Congressional front, the ACC is keeping up the pressure on Capitol Hill. More than one-third of Congress has registered concerns about the proposed rule with either by letters or calls to CMS and Health and Human Services Secretary Kathleen Sebelius. We continue to hear from members of Congress that your individual calls, letters and visits are making a difference. In several cases, the personal stories about the impacts of the cuts on patients and practices have made such a difference that members are prepared to support emergency legislation should it be necessary. 

Second -- I have met directly with Obama administration officials to highlight the gravity of the cuts, particularly at a time when the administration is looking to increase access to care as part of its health care reform agenda.

Third -- While I can fully assure you that we are at the table and working to stop the cuts, we are also working to mitigate the impacts of smaller cuts on your patients and practices, including those related to new nuclear codes slated for Jan. 1. In an effort to help your practice plan for these changes, the ACC has developed a practice expense calculator that you can use to gauge the impacts on your practice. (This is also a useful tool when talking to members of Congress about the specific affects of the proposed rule.)

Further -- See the ad mentioned above. 

Finally -- ACC President Fred Bove, FACC, and I will be hosting an all-member call on Nov. 12 from 4 p.m. to 5:30 p.m. (EST) to discuss the 2010 rule. RSVP for the call now. I strongly encourage you to attend this call, where we will provide an overview of the final rule, as well as answer your questions about next steps.

If this rule goes through as is, it will literally devastate the private practice of cardiology and outpatient access to cardiovascular care. We can’t let this happen.

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 ill-crafted Weiner-Braley amendment to HR 3200 (which would eliminate the ability of physicians to provide advanced diagnostic imaging services in their offices beginning in 2013) was not heard last week before the historic vote. But it has not gone away. Chair Henry Waxman will hold a special session of Energy and Commerce, with participation of Ways and Means and Education and Labor representatives, to hear more than 60 proposed amendments to the bill, including potentially the Weiner amendment. This will happen as soon as the House is back in September.

So we need everybody mobilized this month to meet with their members of Congress during this recess, and to be eloquent and emphatic about how damaging to access and patients this amendment would be if included (the House members are already mostly home in their Districts; the Senate will stay in session for a few more days, but will be on recess by the end of this week). We need for Congress to understand the importance of making the leap to REAL reform -- which would make this amendment and the whole self-referral debate moot. We need therefore to frame our conversation with members of Congress in terms of our support for true payment reform to promote patient-centered and evidence-based care leading to improved quality, outcomes, and efficiency.

Leading By Example
ACC Chapter Gov. George Crossley, M.D., F.A.C.C., is an example of how to do just that. He was featured in an opinion piece on health care reform in the Tennessean on July 28. Dr. Crossley writes, “There is a right way and a wrong way to reform our health care system. And while opinions clearly differ on right and wrong in the halls of government and at our nation's kitchen tables, one aspect of reform cannot be overlooked: doctors.” Crossley also addresses the payment cuts that would result from the proposed 2010 Physician Fee Schedule when he writes that the “large-scale arbitrary cuts” will inhibit cardiovascular professionals’ ability “to make great strides in how patients with heart disease and other illnesses are treated.”

Blue Dog Dems last week announced they’ve reached a compromise with Democratic leaders on House health care reform bill H.R. 3200, paving the way for a vote by the full House after the August recess. Henry Waxman’s (D-Calif.) Energy and Commerce Committee began debating the bill on Wednesday. Significant hurdles remain, though, and the Finance Committee reports it has significant issues still under debate. Blue Dogs want to reduce overall costs of reform, and are very skeptical about the public option idea.

Despite the differences of opinion between liberal Dems and Blue Dogs, the House went into August recess Friday after having narrowly secured the requisite Committee vote (31-28) to send the bill to the House floor for debate and review when they return in September.  The Senate has not made this kind of progress yet. While the Senate Health, Education, Labor and Pensions Committee has their proposal in the mark up process, Senate Finance still is not ready to put out their proposal, and the Republicans on Finance want more time to think about how a consensus proposal might yet be achieved. Finance Chair Max Baucus (D-Mont.) and his committee says they will be ready by September. Then HELP and Finance have to forge a consensus on their bills to get one vehicle to the Senate floor. Once both chambers have voted on their bills -- which will require a lot of debate before it happens -- a 'conference committee' will be formed to try to forge a single final bill. Timing will be tough to get this done before Christmas. 

But they WILL get something out this year folks -- the Dems have too much invested in this not to have something passed. Whatever it turns out to be, I guess it will likely take 3 years to fix!

Further Amendments
The House bill is still going to undergo further mark-up in September to discuss proposed amendments that they didn’t have time to hear. One of those is the frustrating Weiner-Braley amendment. But, the House DID actually insert a valuable tort reform provision! Rep. Bart Gordon’s (D-Tenn.) office offered his amendment to provide Medicare incentive payments to states that enact certificate of merit requirements and/or “early offer” programs in medical liability cases. This encouraging development sneaked through in part because it was introduced as a package of amendments (en bloc), which were accepted by both sides without a formal vote. 

*** Image from Flickr (outlier*). ***

Rep. Anthony Weiner (D-NY) and Bruce Braley (D-IA) introduced an imaging amendment last week in the House Energy Commerce (E&C) Committee that would eliminate the ability of physicians to provide advanced diagnostic imaging services in their offices beginning in 2013. Bad idea. We all know that its passage would increase inefficiencies and present significant barriers to appropriate screenings and treatments. Support for this amendment -- mainly from radiologists -- is about money and not what’s best for patients. With the E&C Committee resuming talks on HR 3200 later today, this means that the Weiner amendment also could be discussed as early as today.

But, we’re fighting this bad strategy by organizing an effort with 23 other medical professional societies who sent a letter to Rep. Henry Waxman (D-CA), chair of the E&C Committee, opposing the amendment. We also talked to Majority Leader Hoyer about it. ACC staff and leaders also continue to meet regularly with Congressional staff about the benefits of appropriate use criteria and clinical guidelines to ensure that the right tests are delivered at the right time to the right patients. Appropriate use criteria and guidelines can reduce costs and limit unwarranted imaging, while at the same time ensure that patients that need it have access to appropriate care. The ACC also supports mandatory imaging laboratory accreditation to improve the quality of imaging. It’s time to use science and evidence to eliminate unnecessary tests, rather than price controls and turf wars that can only limit access to services to patients on the lower end of the economic spectrum.

In other imaging news, the ACC is working with the Access to Medical Imaging coalition (AMIC) and our partner cardiovascular societies to fight the changes in equipment utilization rates that are in both House and Senate reform bills. Stay tuned for more information. 

*** Image from Flickr (MacRonin47). ***

I got called to appear live and unexpectedly yesterday morning on national Fox & Friends to explain ACC concerns about imaging cuts, after being quoted last week in USA Today on protecting access to imaging -- so, we are making an impact on the issue. But, it’s tough because hospitals and some others want to close down outpatient imaging altogether for their own self interest, which would devastate access to these services for many communities, and increase disparities in poorer populations.

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.

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!  

The House put out a preview of its vision for reform — Henry Waxman’s hand looms heavy in the authoring this tri-committee health care reform collaboration among Waxman (Energy and Commerce), Charles Rangel (Ways and Means) and George Miller (Education and Labor). House Speaker Nancy Pelosi’s hand is also in there somewhere. Pete Stark (Ways and Means Health Subcommittee Chair) is baaaaaack from medical leave. He’s engaged in SGRrrr relief this week. The House has not tried to create a radical departure from how the Senate proposals are shaping up, which bodes well for something to ultimately pass Congress this summer.

Comparing and Contrasting with the Senate
There are a few differences between House and Senate versions, but the similarities are what’s more striking:

• Insurance reform to eliminate underwriting and excessive profits
• Universal coverage/access via both continued employer coverage and an individual mandate with subsidies for low-income families not covered by employers
• A public insurance plan to compete with private insurers
• Purchasing cooperatives
  
• Loosely defined strategies for reducing costs of care and improving quality
• A notion of “accountable care organizations” to go along with payment reforms
• Promotion of the "medical home"
  
• Primary care, nurses, and team practice and workforce scholarships.

Employers that don’t provide coverage would get taxed (pay or play); and Medicare Advantage insurance plans get cuts. But, the payment reforms and big payment increases may not be for everybody — likely only for the integrated system types.

The House proposes to pay for reform with the same menu of options discussed by the Senate and the White House already. Taxing fat cat health insurance premiums above a median average premium cost is still on the table. The House also acknowledges there need to be more cuts  ($300 Billion worth) from health care somewhere to actually finance expanded access, which could put physicians at risk (imaging is again being discussed as a place to cut).

Senate, White House Updates
The Senate HELP Committee got its language out. We outlined that last week and will give you a link to that if you’re interested as well. It’s only 600 pages long. A great book to read, but a lot of folks may be waiting for the movie. The Senate Finance Committee is still working on its language details, but it’s getting closer to being published before “mark-up,” and will come out in a week or so.

The White House has been involved with all these committees to make sure things keep moving in parallel with them. The President’s having meetings every day with committee chairs and various constituency leaders to move the issue forward. His Wisconsin town hall promoted keeping the ‘public plan’ in the mix to keep insurers competitively priced. Obama also spoke earlier today at the AMA's meeting about the need for reform and why doctors should support his efforts. See an AP video on the meeting below, and check out ACC's statement.

Next steps
All Senate and House committees are on track to mark up their bills during July, and we appear to be heading for the introduction of both Senate and House bills before the August recess. The Conference Committees would then begin to deliberate a final bill in September. We need to start educating members about what the implications of these bills will be on cardiology -- that is, once we’ve got all the proposed language in front of us. But things could get stalled too -- like over the public plan.

The (Divisive) Public Plan
We were asked this week by four major media sources what ACC thinks about the ‘public plan,’ particularly since AMA allegedly trashed it (I don’t think they really did, but that’s how their comments were interpreted). Not having explicit policy, what we’ve been saying is:

The public plan is a legitimate issue to consider, with pros and cons; but, given that the specifics are unspecified, we have no position yet. However, ACC wants the nation to move forward and expand access and coverage to all Americans, and also use the momentum of reform to fix the SGR, to improve quality of care, and to institute payment reforms that promote quality and effectiveness. These are the key things Americans need. To derail reform over the controversies surrounding public plan as a single provision is irresponsible. If that issue that takes longer to resolve, so be it. But let’s not let one divisive issue otherwise hold back major needed reforms.

I'll be talking about these new developments in greater detail in coming weeks. Try to stay tuned.

Senate Finance Committee released last week their first draft of health care delivery system reforms. It’s not the bold agenda they had been ruminating about, but in their comments they allude to many of the payment reform innovations that are necessary to improve patient care and quality and help doctors succeed. Some of the key provisions are:

• SGRrrr reform: Rather than fix the SGR formula, the Committee opts for a two-year patch. This is disturbing, because three years from now, there’s not likely to be a half trillion dollars lying around to fix the rapidly compounding problem. They should find a way to get this nightmare off the table, which we will strongly recommend. Speaker Pelosi, House leaders AND Senate Finance Chair Max Baucus (D-Mont.) do say there is approximately $200 Billion tucked away to significantly wipe out the SGRrr debt. But it’s not apparent in this Senate Finance proposal. AMA and ACC talked this week about working to get the whole thing fixed and behind us.
  
  
• The Finance Committee's proposal provides a 5 percent bonus for primary care doctors, without asking for any particular behavioral response. They also would offer general surgeons a similar bonus if they’re located in to-be-defined surgical shortage areas. CV surgeons are in just as short a supply as general surgeons and should certainly be included. However, if these bonuses are financed by reducing payments to all other doctors as it appears, a lot of tension and infighting is likely among physician specialties. Not good. The ACC wants to help Congress identify new dollars to bolster primary care and increase general reimbursement through reduced readmissions and other efficiencies.
  
  
• Some imaging cuts seem very likely, with good news and bad news. The good news is that appropriate use criteria are referenced in the language as a way to address rising costs; the bad news is that RBMs (radiology benefit managers) are also mentioned.
  
  
• The Finance committee envisions quality of care pilots, “accountable care organizations,” use of registries and clinical decision support tools to improve quality as well as reduce readmission costs, but the details on the innovation recommendations -- including financing -- are not provided.

The Senate Health, Education, Labor and Pensions Committee and the House of Representatives are yet to weigh in. This first view from Senate Finance looks very much like the same concepts we saw in previous years. We will encourage them to be a bit bolder.

*** Sen. Baucus. Image from Wikimedia Commons. ***

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). ***

Recently, I told you about “More Fisticuffs with X-ray Doctors.” A radiologic advocacy group posted an inflammatory response to a recent National Council on Radiation Protection report entitled “Increased Average Radiation Exposure of the U.S. Population Requires Perspective and Caution.” The commentary was a pure economic and political piece which proposed non-radiologists who self-refer are responsible for egregious cost increases, inappropriate care, and the increased radiation risks of the U.S. population! ACC submitted a factual, evidenced based rebuttal, authored by President Doug Weaver and ACC Imaging Council Chair Kim Williams for posting on the NCRP site. They promptly took down the offensive radiology piece; but they didn’t put ours up! This is a victory of sorts, given that the NCRP board is mainly radiology oriented. We will release ours as a press release if we see this appear anywhere else. We also contacted the NCRP staff, and I believe they understand that we mean business here. More coverage of this issue is now available on CVN.

Note -- despite this unfortunate incident, the ACC and the ACR will continue to stay on the high road together, and work to use “appropriate use criteria” and science to reduce unnecessary imaging and radiation exposure.

A nasty brouhaha has developed over an inflammatory posting by a radiologic advocacy group on the website of the National Council on Radiation Protection (and measurement) in response to the NCRP report entitled “Increased Average Radiation Exposure of the US Populations Requires Perspective and Caution.” The NCRP report is pretty balanced.

However, the follow up press release and commentary by two academic radiologists (Gerard White, F.A.C.R., and John Boone, F.A.C.R.) is a pure economic and political piece which proposes non-radiologists who self-refer (the article presumes radiologists do not) are responsible for egregious cost increases, inappropriate care, and the increased radiation risks of the US population! 

Radiologists engage in as much if not FAR MORE self referral for dubious reasons, so this release is very unfortunate indeed, and must be responded to very firmly. We have prepared a response, which I encourage you to read.

A search of the literature on “self-referral” on MedLine reveals a huge preponderance of references related radiologists self-ordering (e.g. self-referral) CTs. Lately, for example, huge increases of CT of the abdomen to r/o aneurysm following unrelated studies have been noted, associated with questionable risk factors. There’s plenty of damning literature there for radiologists. Plus, reliable third party sources estimate that of CT radiation exposure, 96% is applied by radiologists, compared with 0.6% by cardiologists. There are some alarming things about potentially unnecessary medical radiation exposure in the NCRP report that bear careful consideration. But it’s not like radiology is uninvolved.

I called my counterpart at ACR on this, and I believe he was genuinely concerned this has occurred. ACR and ACC leaders have been working together to take the high road on changing our past dysfunctional dynamic toward working together on appropriate use criteria (AUC), multi-modality AUC, joint proposed registry quality improvement projects, and other positive efforts.

That’s why this kind of seriously skewed commentary is damaging ultimately to both ACR and ACC. We must respond to the inaccuracies and egregious accusations in this document, but hopefully we can contain it to the NCRP site and correcting the information for those who have accessed it.

This is risky business. All imaging specialties refer patients sometimes to their own practice settings -- it often makes sense for patients and efficiency. There are disclosure mechanisms that can help avoid inappropriate self-referral. The minority of imaging physicians of all specialties -- obviously including radiology as much as any other -- who engage in inappropriate self referral should not be tolerated by any of us. But this missive was all about crass competition and divisiveness. It’s sad.

NHLBI is considering several proposals for large randomized controlled trials (RCT) assessing the impact of cardiovascular imaging on health outcomes. The ACC is sending a letter detailing our strong support for such a trial. A large RCT would address one of the major problems in CV care today: the lack of robust outcomes evidence to guide optimal use of new diagnostic imaging technology.

In our letter, we recommend to NHLBI that, “A successful trial will need to take an unbiased approach, emphasize real world effectiveness and compare the full spectrum of usual care with new technology across a variety of clinical practice settings.” We don’t offer specific support for any of the proposals, but it is our hope that NHLBI will fund a trial and that in the future, we will be able to help disseminate the much-needed data to our members.