... or not. A study released by the American Heart Association shows that even tiny amounts of air pollution and cigarette smoke can dramatically increase your risk for cardiovascular disease. Researchers from Brigham Young University analyzed data from more than 1 million adults, noting smoking habits and exposure to secondhand smoke and air pollution. Their findings suggest breathing in far less than one cigarette a day worth of smoke increases your risk of cardiovascular disease by 20 percent to 30 percent. Wow. We all need a breath of fresh air.

Meanwhile, two new studies -- one in the Journal of the American College of Cardiology and one in AHA's Circulation -- publishing Sept. 29 found that smoking bans cut heart attacks by 17 percent and that this effect increases over time. (See CardioSmart for more coverage of these studies.)

It was amazing being in Spain at ESC -- there is smoking everywhere, and it’s very obnoxious in restaurants and public areas. We’ve made a lot of progress in these regards, but more is needed.

*** Image from Flickr (SuperFantastic). *** 

¡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). ***

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.

As I discussed briefly last week, the Energy & Commerce, Education & Labor, and Ways & Means committees introduced their tri-comm health care reform bill, America’s Affordable Health Choice Act of 2009 (HR 3200, hyperlinked here for your reading pleasure). The President and others celebrated it as a landmark bill at the White House, while the Congressional Budget Office (CBO) Director, economist Doug Elmendorf, ruined their party by proclaiming the bill as an unsustainably expensive instrument that will destabilize the economy unless modified to reduce costs over time. CBO has always been the "skunk at the garden party" or worse, but this time they made House leaders and the President quite upset.  

What's In It
We strongly support access for all. But the CBO concerns are legitimate. Congress has espoused a set of worthy visions to improve quality and care coordination and efficiency, but the teeth for getting that done -- other than with the same old ineffective price controls -- aren’t yet there. A reform bill that works is certainly still possible after the debate gets going more openly. But, beyond the unspecified vision, the implementation strategies are not there. And, there are a lot of provisions in HR 3200 (many inspired by organized labor) that will alarm many of you if you read all the detail -- just understand this is a political process, and the House knows that most of that won’t survive the Senate’s scrutiny. One real concern for us is that there is no tort reform in this House version, and there probably won’t be anything to start with in the Senate health or finance versions either. 

We applaud the House for its commitment to provide access to health care to basically all US citizens, and in particular for eliminating the SGRrrr for the next 10 years. That’s huge -- $230 billion worth of what would otherwise be cuts to physicians. We praise their huge Medicaid coverage expansion, combined with taking the payment of that program away from states (which have paid on the CHEAP), and providing better payment to physicians. They put a good deal of new money into prevention and primary care, and they add money to offset physician workforce shortages. We also appreciate their establishment of a positive future Medicare physician payment updates (MEI) and favorable spending targets for updates in the future. We’re also well positioned with NCDR and the IC3 Program for their significant payment and delivery reform models, such as incentives for physicians and their expansion and improvements to the Physician Quality Reporting Initiative (although this program still lacks sufficient payment incentives ... a 2% "incentive" is close to useless for most practices). 

ACC President Fred Bove has expressed our praise of these positive elements to the three committees (that would infuse almost $300 billion of new dollars to delivery of patient care), but without praising or referring at this point to the elements of the plan that are undefined (the public option, for example), or to those we must work to amend because they are just plain bad policy (the imaging cuts, their attempt to undermine specialty hospitals, and their attempt to prohibit opting out of public coverage programs). We will work with House and Senate members to eliminate those elements -- none of which should survive Senate Finance scrutiny thankfully. The Senate will not buy the House’s income tax funding approach for HR 3200 as currently configured either. More...

Sweet News, Alabama
Good news from Alabama — our lobby day efforts resulted in a resolution introduced in the House supporting the “Assault on Alabama Cardiovascular Mortality” (H.R. 718). The “Assault” is an ongoing campaign by members of the Alabama Chapter to educate the public about the risk of cardiovascular disease. This campaign is another great example of how our members are carrying the Year of the Patient concept nationwide to citizens in states like Alabama, which has the fourth highest death rate in the nation for cardiovascular disease. 

Florida Gets It
Immediate Past President Doug Weaver attended the North Florida ACC Cardiovascular Symposium. Dr. Weaver spoke to the attendees about the gaps in our current health care system and the need for care and payment reform. “Florida is a tough group and, in general per the Dartmouth Atlas, over-utilizers,” Dr. Weaver says. “But these people got the message and its importance and are ready to join us in efforts to improve quality.” Florida has been a particularly beleauguered environment on both the insurance and the Medicaid government payment programs in recent years. 

Hold on to Your Caps in Colorado
The ACC and other medical associations were instrumental last week in defeating H.B. 1344 in Colorado, which would have changed the state's fixed $300,000 cap on non-economic damages for malpractice suits to one that would adjust annually for inflation.

*** Alabama residents listen to "Assault on Alabama Cardiovascular Mortality" presentation. ***

I was invited this week to testify on behalf of ACC before the House Appropriations Subcommittee on Labor-HHS this week. We advocated for a 7 percent increase in funds for NIH in 2010. The NIH received $10 billion in additional funds over the next two years in the stimulus package. But the ACC, along with other patient advocates, believes NHLBI still needs a 7 percent increase from 2009 funding for fiscal 2010. A critical part of our quality agenda is support for the evidence that should form the foundation of care. WE also recommended increases for AHRQ for comparative effectiveness and registry projects beyond the stimulus dollars they got. We also asked for more CV prevention dollars for CDC, and for more AED education and funding for the HHS Health Resources and Services Administration (HRSA).

In DC, where there’s smoke, there are usually mirrors. But we see real progress in getting the “Family Smoking Prevention and Tobacco Control Act” passed -- finally.

AHA and ACC and others have been working on getting this bill passed for several years. It is bipartisan legislation that would grant the U.S. Food and Drug Administration (FDA) authority to regulate tobacco products. This legislation passed the House last July 30^th by an overwhelming and bipartisan vote of 326 to 102. Similar legislation passed the Senate Committee on Health, Education, Labor and Pensions and had 60 sponsors/cosponsors in the 110^th Congress.

Just introduced yesterday, the bill will hopefully be quickly passed by both Chambers within a few weeks at most.

Some of our members are working so hard -- heads down -- diligently taking care of their patients -- that they are genuinely curious and seemingly not yet fully aware about what’s going on (threats and opportunities) here in the Capitol these days. ACC officers and I are frequently asked when we are out in the Chapters "why is ACC so engaged in the health system reform issues?"  It’s amazing to us. But it’s also hard to get the message out effectively to the grass roots about how fast things could possibly (or possibly NOT) move in these reform discussions this year. But, to give you an idea — here are just a few of the things cooking here this coming week alone:

• Discussions of the federal budget and health reform are likely to dominate the week, with various meetings and discussions in Congress and CBO (this will have implications for us folks).
• President Obama has convened a Fiscal Responsibility Summit today at the White House, followed by a presidential address to Congress on Tuesday night that will focus in large part on what to do about the looming Medicare projected shortfalls (5 times larger than the Social Security deficits);
• The Office of Management and Budget (OMB) will release of a budget framework on Thursday – including all of CMS’ new projections on the nation’s health spending Monday (again, these will be critical for medicine!).
• Meanwhile, both the Senate Finance Committee and the Senate Health, Education, Labor and Pensions Committee (HELP) again turn their attention to health reform with hearings next week (believe me, we need to monitor and react immediately to this stuff for all of you out there!). The topics are--
  • Senate HELP Hearing (2/24) – The Health, Education, Labor and Pensions Committee holds a hearing to examine the issue of the underinsured in the context of health reform.         
  • Senate Finance Hearing (2/25) – The Finance Committee holds a hearing with CBO Director Elmendorf to examine scoring issues and budget options for health reform, including physician payment and SGR reform.
• Healthy People 2020 – The HHS Advisory Committee on National Health Promotion today meets to discuss efforts to promote healthy lifestyles and prevent disease, with a particular focus on CV disease. 
• The CMS will hold Open Door Forums on rural issues on Tuesday and on hospital and hospital quality issues on Wednesday.

This doesn’t include what the private sector activities are. IOM is having meetings this week on various quality related topics as well. Busy week!

But all of you need to plan to set up a meeting with your own members of Congress later this spring. Start scheduling the meetings now for April or May in your district offices. There will be plenty to talk about!!!! And, we’ll help you with talking points on key issues. Of course, plenty’s happening in all your state legislatures as well at the same time. Whew!

No surprise here, but all the major unions are encouraging Sen. Ted Kennedy (D-Mass.) and his staff to structure his health care reform legislation around a single payer model, similar to H.R. 676. In a recent letter to Sen. Kennedy, the All Unions Committee for Single Payer Healthcare argued against multiple payers, saying

Any plan that keeps the profit-making insurance companies in the mix will add layers of bureaucracy, will not be able to control costs, and will fail in the noble effort to bring good care to all.

Kennedy will have his plan ready after the first of the year sometime. But it was rumored that Senate Finance Chair Baucus was working with him. Apparently not so. Baucus says Kennedy didn’t work on his plan, but has read it and ‘likes it.’ Time will tell there -- and whether the unions are having any influence on Mr. Kennedy.

But, Sen. Baucus released what he calls his Call to Action—Health Reform 2009 report independently. His is based on a mainly employer-based concept, where employees or employers can opt, with consequences. He demands universal coverage be the goal (Obama has not gone there as of yet).

ACC has a detailed summary of Baucus’ strategy with annotations according to our policy views. Baucus did not propose this as a bill. The bill or bills will come later after the first of the year. But here are the essentials of his 89-page proposal from my read: More...

Stephen Schoenbaum, M.D., M.P.H., EVP at The Commonwealth Fund, commented last week to national leaders in D.C. on the United States’ continued poor performance on measures like mortality amenable to health care, life expectancy and infant mortality. Infant mortality has actually slipped backwards over the past 2 years. According to Dr. Schoenbaum, this is due to flawed preventive care and a broken health care system that often fails to identify underlying chronic conditions. With respect to infant mortality, our performance is complicated due to some of our unique social issues like drug abuse and obesity. Dr. Schoenbaum calls for health system reform with an emphasis on measured quality for prevention — sound familiar?

Dwindling 401k’s are not just a headache. They could result in serious health problems for Americans who are delaying care for chronic conditions due to financial concerns. The New York Times reported yesterday that Americans are cutting back on meds, and the Washington Post reported last week that the economic downturn is prompting many Americans to perform self-triage, delaying preventive and other regular care for a variety of conditions. Gruentzig may have performed coronary catheterization on himself on the kitchen table, but I don’t recommend to others. This will hurt prevention efforts.