A Washington D.C. Circuit Court recently ruled in favor of physicians and our privacy. The court found there is no public interest in disclosing to the public global Medicare payments to individual doctors. Consumers’ Checkbook had sought these disclosures through a Freedom of Information Act (FOIA) request. We owe major gratitude to the American Medical Association for intervening with the court on behalf of physicians and their private payment data.

Nonetheless, this issue will re-surface I predict. Congress will be asked to write a law that allows such releases.

How do we get it through to colleagues in cardiology and other specialties that "public reporting" on quality is not an option -- it’s already ineptly happening in multiple venues using claims and administrative data. Our polling indicates that most ACC members do not suffer from 'mural dyslexia' (the inability to see the handwriting on the wall), and see that public reporting on quality is a reality that we need to address head on.

If we are a profession, then society will rightfully expect us to be altruistic (patient centered), focused on assuring that our special expertise is based on valid data, and self regulation in terms of quality, ethics and accountability. Thus, we need to be the purveyors of the information that is publicly reported -- or we will dread what we see. What’s currently happening through CMS (PQRI), employer-insurer coalitions (Bridges to Excellence, PBGH, IHA, etc) and consumer groups needs major work to be valid. For large networks, we should work on using clinical data (like the National Cardiovascular Data Registry) to measure outcomes. At the individual doctor level, we may never be able to have a patient denominator and/or risk adjustment system sufficient to reasonably assess outcomes. But, we could assess the process measure of "adherence to guidelines and performance measures". Adherence to guidelines should not mean adherence to a cookbook approach to care, but rather to a 'learning system' of assuring that the best scientific evidence is applied to all clinical care -- and that when the guidelines typically do not apply 100% to the patient before us, that we take the time to report back as to why not. 

Health system reform will absolutely need to address physician and hospital payment reforms as a central part of delivery system reform and of essential quality and efficiency improvement. These are not issues that we can afford to delegate to non-clinicians to determine and oversee. These are our core responsibilities and accountabilities. I hope -- I pray -- we figure this out and step up to the challenge and opportunity here as a profession.

I guess the biggest challenge is: how do we reach out to our many colleagues who have their heads down taking care of patients, and don’t see the tsunami approaching?

Washington is really buzzed now!

HHS Secretary-designee Daschle had what was mainly a “love-fest” first confirmation hearing this week. He will surely be confirmed. It is interesting that the Transition is alleged to prefer Sanjay Gupta for Surgeon General (SG) over UV Provost Tim Garson. Garson wants to help—and has a lot to offer. But, even if the selection relates more to a “known voice” over “known expertise,” in my view Garson would make a great Asst. Secretary for Health (the SG's boss). The FDA post seems wide open still. But, the HHS team is hoped to be formed shortly after the Inauguration, somewhat dependent on getting Mr. Daschle’s confirmation completed.

I was privileged to have a chat with Sen. Daschle last week (Mr. Obama made an excellent cabinet choice here). Mr. Daschle is interested in establishing support for a national health board to wrestle with the really tough policy and reform issues -- a good idea. Daschle is optimistic about using the stimulus dollars to advance health IT in the short term, and he appropriately promoted health IT, rural health, community clinics, payment reforms, the sunset of the SGR, and promotion of other quality improvement incentives in the first hearing. He is interested in the College's views on health IT adoption strategies, on quality reporting, and on how to engage physicians and the ACC in the reform process. We hope to set up a leaders meeting with him soon. Daschle has become a health care visionary, and he has the trust and support of Congress -- what a dynamite combination!

sCHIP: It appears the House could move a stand-alone sCHIP (state-Children's Health Insurance Program) bill this week. The intention is to move identical CHIP bills through the House and Senate; therefore, no conference committee would be necessary. Timing on the Senate CHIP bill is less certain. The program has to be reauthorized by March 1 for sure. But, getting it done sooner would make major system reform discussions less complicated in the next two months.  The current new funding for sCHIP is rumored to be coming from a tobacco tax increase and an offset of some sort involving specialty hospitals (uh-oh?).

Stimulus: I suspect the stimulus package timeline could be delayed until almost the spring. President-Elect Obama has signaled to Congress that he wants to sign a stimulus bill by mid-February, but the Senate wants more time to consider what the specifics would be for ideas being floated about increased funding for comparative effectiveness, FMAP relief (the Medicaid state funding formula), and for COBRA insurance extensions for unemployed workers. Health IT is still a big stimulus priority too, but the interoperability and privacy issues are very controversial. We might see pilot projects rather than sweeping changes.

When Thomson Reuters published its list of Top 100 CV Hospitals last month, it got me thinking about how richly our National Cardiovascular Data Registry (NCDR) contributes to quality care. Consider the following statistics:

• 100% of hospitals on the U.S. News & World Report Best Hospitals Honor Roll 2008 participate in the NCDR
• 100% of hospitals on the 100 Top Hospitals(R) Performance Improvement Leaders 2007 - Large Community Hospitals participate in the NCDR
• 98% of hospitals on the U.S. News & World Report 50 Best Hospitals Heart & Heart Surgery 2008 participate in the NCDR
• 97.5% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Teaching Hospitals without Cardiovascular Residencies participate in the NCDR
• 96.7% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Teaching Hospitals with Cardiovascular Residencies participate in the NCDR
• 96% of hospitals on HealthGrades® America's 50 Best Hospitals – 2008 participate in the NCDR
• 95% of hospitals on the 100 Top Hospitals® 2007 National Benchmarks for Success - Large Community Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals® 2007 National Benchmarks for Success - Major Teaching Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals® Performance Improvement Leaders 2007 - Major Teaching Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Community Hospitals participate in the NCDR

Wow. Now we just have to get the word out to the hospitals not on the lists about how to get there: Participate in the NCDR.

A couple of weeks ago, I talked about offsetting the decrease in payment from the Medicare 2009 Physician Payment Schedule by participating in the PQRI (in the future through the IC3 quality improvement program affiliated with NCDR). Ganpat Thakker, M.D., F.A.C.C., governor of the ACC West Virginia chapter, commented on the post: “Most of us who reported PQRI measures for 2007 did not get [an] incentive payment. CMS did not have necessary setup, and there is no appeal option. I am almost positive that we will not receive any reward for 2008 either.” The reality is that CMS lacks the capacities to run PQRI effectively -- it is a crude beginning of a quality monitoring and incentive program. A few of our larger practices got some actual reward from PQRI, but not many.

My message to all of you exasperated physicians on this topic is: Think of PQRI as an awkward baby step in the potentially good direction of substantially increasing payment for improved quality and risk-adjusted outcomes. I emphasize potentially. We are advocating to Congress and the payers for real "value" and quality-improvement reward programs with significant incentives (at least 7 – 10 percent payment increase). We are further working on Congress and insurers to appreciate the value in using our NCDR systems and the new IC3 quality improvement program to members and primary care practices to collect and populate CV performance data. If we, as the profession, are not engaged in designing and helping to implement quality improvement and reporting programs, they won’t work.

The ACC applauds all of you who made the effort to participate in the PQRI, realizing full well that it was as frustrating for most of you as the Blagojavich Senate seat selection process has been for the people of Illinois. But, since quality reporting is coming for certain, at least those of you who tried to participate are getting ready for the inevitable, and a future program that will hopefully offer real value to patients and doctors.

Please join the conversation on the topic of quality reporting and tell us what you think. Don’t use any four letter words though -- please -- if you’re a PQRI participant. We’re going to make it better.

ACC had an exciting meeting this week with Wellmark, the leading Blue Cross-Blue Shield insurer in Iowa and South Dakota to discuss ways of collaborating on continuous quality improvement and “value” based reporting initiatives. ACC Science and Quality SVP Janet Wright, M.D., F.A.C.C., and her team led the discussions, which I discovered could be fruitful in meetings earlier this year with BCBS.  This company is one of the most progressive of the BCBS plans nationally.  And there appears to be a general interest in working with NCDR, IC3 and ACC in developing some interesting projects.

Thomson Reuters has released its annual list of the 100 Top cardiovascular hospitals. The firm analyzed outcomes for CABG and PCIs at hundreds of hospitals nationwide using Medicare data. The analysis produced 100 hospitals that outperformed their peers on risk-adjusted measures of mortality and complications.

Our National Cardiovascular Data Registry (NCDR) has better data than CMS. I believe it’s time for the ACC to make a name for itself in quality rankings. In an online discussion of this topic this week, ACC leaders suggested reaching out to U.S. News and World Report to work with us on a similar “top hospitals” ranking (of course with permission of the hospitals in question), as well as creating an annual report on trends and disparities similar to the Dartmouth Atlas.

The College is also developing an NCDR recognition program to launch in 2009. For the first time, we offered a "silver award" for ACTION (our acute coronary syndrome registry) sites this year and received tremendous enthusiasm from our eligible participants. The criteria for the award were based on target achievements related to clinical composite measures. 

*** Image from Flickr (alasam) ***

Billy Beane, general manager for the Oakland Athletics, teamed with former Speaker of the House Newt Gingrich and Sen. John Kerry (D-Mass.) to pen an op-ed in the New York Times earlier this month advocating for evidence-based medicine. “Remarkably,” the authors said, “a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures.”

We certainly agree. But Billy, Newt, and Kerry appear not to realize that ACC already has the inpatient data for CV care they are seeking in 2400 U.S. hospitals. Maybe we should start a fantasy medical care team competition to attract more attention.

The ACC held its seventh annual Medical Directors’ Institute (MDI) last week. This year's meeting was the largest ever, with 100 participants, including ACC leaders, health plan representatives, and other stakeholders.

Our primary focus was the current hot topic of “efficiency,” and the lack of a standardized definition about what it is among payers, physicians, policymakers and patients. In an effort to address this issue, MDI participants heard from CMS and public (AHRQ), private (NQF), for-profit (WellPoint) and non-profit (PHRI) stakeholders about their strategies, initiatives and challenges in the health care efficiency arena. Participants had the opportunity to identify areas of convergence and opportunities for alignment, while also providing concrete ways for cardiology to influence and improve efficiency in collaboration with key stakeholders. It was a spirited set of discussions.

The ACC continues to be recognized by health plans for being ahead of the curve in the health care arena when it comes to quality. Our NCDR registries and Appropriate Use Criteria (AUC) continue to get great reviews, while the ACC's new IC3 outpatient registry program and our Cardiovascular Recognition Program (CVRP) are seen as having lots of partnership potential with insurers. What’s missing is major collaboration between insurers and doctors on these kinds of efforts. Everyone seems to have a plan for reforming the health care system. The MDI and other events put us one step closer to developing a plan that works for us all.

House Ways and Means has directed the Government Accountability Office to perform a project to measure “efficiency” of physicians in internal medicine, cardiology, orthopedic surgery and diagnostic radiology. Health Subcommitee Chair Pete Stark ordered the study. They will use a year of aggregated claims over various risk categories of inpatient and outpatient physician care diagnoses (based on average annual expenditures) and a per capita method to estimate “efficiency” for each of the four specialties. They will report back to individual physicians in a confidential feedback report after the data is collected and analyzed. Do we think it will stay confidential in future years, rather than going to public reporting? (Or, does a chicken have lips?)

ACC President Doug Weaver, President-Elect Fred Bove and I talked this week with GAO staff to advise them about challenges they will face that will confound accurate results in terms of the diversity of CV practice types and patient mix (e.g. general cardiology vs. transplant care vs. heart failure specialization). We felt their plans need some work to succeed, and we also discussed how they might choose to report back to cardiologists in a way that would be meaningful (like having enough of a denominator of a single diagnosis or treatment code to suggest valid data on comparative resource uses). We noted that without quality measures attached to resource use measurement, the worst care could look best just because it is cheaper! Nonetheless, the data on geographic and regional variation published by Jack Wennberg and the Dartmouth Atlas suggests that there might be some value to the work if it is done carefully. That could be tricky.

Timing is uncertain; the GAO wants to begin reporting to Ways and Means and doctors as soon as possible in 2009. Spring?