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). *** 

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.

The ACC annual Medical Directors’ Institute (MDI) was held this week at the Park Hyatt and Heart House in Washington. The topic was comparative effectiveness research and implementation. It was a terrific policy discussion which included dynamite presentations from AHRQ Director Carolyn Clancy, the UK’s CER agency NICE, Canada’s similar entity, the US Veterans’ Administration, the CMS, the National Health Council, and many other stakeholders in addition to ACC senior leaders, governors, and staff. We strongly support CER, and also want to make sure it proceeds along the lines of a patient-centered, socially responsible, and scientifically excellent path through some difficult political minefields.

The timing for this MDI was perfect in that ACC had just published our own CER policies and principles, called “ACC 2009 Advocacy Position Statement: Principles for CER.” The position statement offers nine principles for CER, outlined in brief below:

• The ACC strongly supports CER as a way of having informed decision-making.
• CER priorities should be set by a multi-stakeholder group to ensure that the research agenda reflects the needs of the country. The research agenda should be based the burden of the disease being considered, mainly morbidity and mortality.
• The ACC recognizes that the research on comparative effectiveness is “only the first step in improving the quality, equity and efficiency of medical care,” and stresses that improving quality must be the primary aim of CER.
• CER should be distinct from entities that create coverage and benefit programs, and requires close monitoring to avoid adverse consequences on access, quality or safety.
• The ACC recognizes that CER will require substantial and long-term financial support.

The paper then goes on to outline how the ACC can participate in the CER process, including informing priorities through our clinical documents, like guidelines and appropriate use criteria, as well as our registries (NCDR) and providing standardized data elements and definitions. In addition, the ACC has the ability to disseminate CER findings to patients through our large membership. The policy statement concludes: “The ACC believes CER research, when conducted correctly, is a useful tool that assists physicians and other providers in delivering high-quality, equitable and effective health care to patients.”

Comparative effectiveness is a frequent topic on this blog (see the post from John Brush, M.D., F.A.C.C.), and clearly has the potential for good – improved quality – and, if done poorly, a potential for evil – reduced access to needed treatments. Because of its potential for evil, I strongly believe that comparative effectiveness needs to happen separately from any cost comparison. This is necessary to maintain physician and patient (consumer) trust that CER is untainted scientifically from societal/government pressure to reduce costs.

Those are my thoughts on CER ... but there have certainly been some spirited discussion by our CER experts here at MDI that disagree with me. We’ve had some great speakers, including a senior scholar at the Institute of Medicine Michael McGinnis, M.D., M.P.P., Myrl Weinberg, president of the National Health Council, panels that include representatives from the Canadian Agency for Drugs and Technology in Health and U.K.’s NICE, and Carolyn Clancy, M.D., of AHRQ representing the U.S., and a briefing from Michael Rapp, M.D., of CMS, among many others.

UPDATED 10/28: New CVN video on "Perspectives on CER" with an introduction from SVP of Science & Quality Janet Wright, M.D., F.A.C.C., and thoughts on CER from attendees of MDI.

We still have no responses from HHS or CMS (Medicare) to the strong letters of concern we sent to them from an impressive number of more than 25% of the members of Congress regarding the impending and flawed 2010 Medicare Physician Payment Rule. Our campaign on this issue has been and continues to be powerful. This silence is both frustrating and unnerving.

We are hopeful the White House and HHS will be motivated to meet with us and to modify the Rule at this point. I did have a chance to meet with Health Czar Nancy Ann DeParle and her team about our concerns with the Rule in the White House this week. They are all aware it is a mess.

What are our options at this point? As we draw ever closer to the Nov. 1 deadline for the issuance of CMS' final rule, many of us are hearing conflicting reports about our options and what CMS may or may not do now.

Here’s the story: CMS by law must have a rule publicly issued by Nov. 1 (that’s a Sunday, so we’re expecting news by close of business Friday, Oct. 30).  That rule, of course, needn't be the current proposed rule. CMS can:

1. Place a moratorium on implementation until it can analyze the data and recommend changes;
2. Use the 2005 data with or without inflation adjustment;
3. Blend the 2005 and Physician Practice Information Survey (PPIS) data;
4. Phase in new recommendations as outlined above in No. 2 and No. 3; or
5. Let the rule stand.

We are urging the first possibility. We would have to evaluate the details of the following three bullets, if proposed. We would vigorously oppose letting the Rule stand, of course. While CMS can change the PROPOSED rule, only Congress could change or prevent the FINAL rule. One other important point: The Secretary of HHS signs off on the Rule, but must have the review and approval of the White House OMB (Mr. Orszag) as well -- so advocacy there may be important going forward if HHS isn’t communicating a workable option to prevent the demise of outpatient and community cardiovascular practices.

In any case, even with the temporary reprieve resulting from option 1, there would likely still be modest cuts to payment for cardiologists -- just not as draconian as those that would result if the proposed Rule went into effect. 

Continue your calls to your lawmakers about this critical issue. This battle is not about preventing the cuts; it's about saving the private practice of cardiology, and preserving access to care for the vast majority of CV patients who rely on these practices.

*** Image from Flickr (Suviko). ***

Zia Roshandel, M.D., F.A.C.C., a cardiologist with Blue Ridge Cardiovascular Associates in Culpeper, Va., wrote in to the ACC shortly hearing about the proposed cuts. He's been featured in Cardiology and taped a CVN video (below), a version of which will be offered to Hill staffers during the 2009 Legislative Conference office visits by ACC members today. The post from below Dr. Roshandel explains why he took action.

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Today, I’m going to Capitol Hill to fight for the continued existence of my cardiology practice in Culpeper, Va. My partner and I established the practice five years ago, but as the economy has struggled, the number of uninsured patients has grown and we struggle to cover our costs. Over the last year, we have taken many savings measures, including forgoing our salaries, reducing the number of employees, renegotiating our health insurance and reducing employee hours.

Given all that we’re done already to keep from closing our doors, when about two months ago I heard for the first time about the CMS cuts for 2010, I was stunned. My practice cannot withstand even a 10 percent cut, not to mention the 20 – 40 percent cuts proposed by this rule. I tried to contact my legislator in Virginia, but never got to speak to anyone. I sent them several e-mails to explain what effect these cuts would have on my small practice.  In addition, I took steps to educate myself on the cuts and talk to my colleagues. I urged them to take action, to educate each other and to educate CMS about the real life of a CV specialist in the community. 

Cardiologists need to band together to talk to Congress to inform them about the effects that the CMS cuts will have on cardiovascular practices. That’s why I’m here at ACC’s 2009 Legislative Conference. I hope to make lawmakers understand that if these cuts go through, practices like mine – that struggle as it is – will be forced to close and patients forced to look for care elsewhere. For patients in my small rural town, that means significantly longer drives to receive regular cardiac care and significant delays in treatment for every patient with chest pain, congestive heart failure, arrhythmia or any potential cardiac disease presentation as they are transferred to the closest hospital with a cardiac specialist, which is 45 to 50 minutes away.

Certainly, I’m not the only cardiologist who will be affected by these cuts. In fact, I would imagine that there are few cardiologists who won’t be affected by the cuts. Here is Washington this week, there are over 350 cardiovascular professionals fighting against the cuts, but while such a strong turnout is impressive, it will not be enough to prevent these cuts from taking effect. We’ll need every cardiologist and cardiovascular professional to step up, speak out and take action in determining your professional future before it is too late.

For more on my story, view the video below.

President Obama on Wednesday addressed Congress with a plan for health care reform that would cost $900 billion over 10 years and address rising costs, access to care issues and professional liability. Obama’s plan would:

• Provide several consumer protections against insurance companies, including barring insurance companies from denying coverage for pre-existing conditions, rescinding coverage, placing year or lifetime caps on insurance benefits and limiting on maximum spending for out-of-pocket expenses
• Create a new “insurance exchange,” which he described as a “marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices”
• Require individuals to have health insurance, and require medium and large businesses to offer coverage to employees or pay into a fund to cover the costs of their works
• Create a public insurance option

Obama promised that the plan would be budget neutral and said the savings would result from eliminating waste and abuse within the existing health care system, as well as reducing payments to Medicare Advantage plans. Another form of financing would be a fee for insurance companies’ highest cost plans to “encourage them to provide greater value for the money.” Obama also addressed medical malpractice. He said, “I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine.” He proposed authorizing the Health and Human Services secretary to test potential solutions as demonstration projects in states.

Reflections
President Obama is a remarkable orator, no doubt about that. He made his case for health system reform fairly effectively despite the Republican cold shoulder and overt heckling. It was pretty apparent to me that the public option wasn’t “off the table” from the smile and almost jack-in-the-box bobbing up and down of Speaker Pelosi behind him during his remarks, but there were some code messages in the address that may not have been apparent to many.

First, his apparent enthusiasm for the public option was tempered significantly by his acknowledgment that it was not an essential part of the strategy. That frees Mr. Baucus up to propose something different (the Snowe amendment).  And his comment that health care reform will not contribute one dime to the deficit is another way of possibly approaching that the solution for getting a bill passed will be reconciliation. Reconciliation is an extreme measure in the U.S. Senate that only requires a simple majority of 51, rather than the 60 votes otherwise required in the Senate. To use reconciliation, which the Republicans will hate (although they used it to get the Bush tax cuts passed), the net has to be budget-positive or budget-neutral.

There are some problems with reconciliation that could affect our issues in reform. Under our health care reform campaign, Quality First, the ACC has endorsed six principles for health care reform, including: universal coverage; coverage through an expansion of public and private (pluralistic) programs; focus on patient value—transparent, high-quality, cost-effective, continuous care; emphasis on professionalism; coordination across sources and sites of care; and payment reforms that reward quality and ensure value. However, among many other reasons, not all of these are able to be scored by CBO, which would make them more difficult to include in a bill pushed through with reconciliation.

ESC’s Congress is just one meeting of the many international meetings the ACC leadership team and I attend each year that foster relationships with other international societies, although it is certainly the largest. In the five brief days we'll be in Barcelona, we’ve met with 14 international cardiovascular societies, along with Huon Gray, Chair of our new International Council, and that's not counting the informal conversations we've had along the way. This is a reflection of how strongly the ACC feels about working with international societies.

As mentioned at the start of the Congress, cardiovascular disease is not just a problem in the U.S. – it’s a problem across the world. And if all the countries across the world work together to find what works best for treatment CVD, then patients everywhere benefit.

One area in which this is particularly evident is comparative effectiveness research. Comparative effectiveness research has the potential to do so much: from informing the practice of medicine to improving care. Not only do we need to work together with international societies to collect comparative effectiveness data to improve care, we also need to work with other societies to disseminate these best practices. It’s not good enough that the information stay within the U.S. or the originating country; the information needs to be spread as far and wide as possible. By keeping the lines of conversation open at meetings like ESC’s, hopefully we’ll be able to increase our collaborations to benefit patients around the world.

*** Image from Flickr (katmere). ***

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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