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.

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. ***

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). ***

In a somewhat shocking decision, the California Supreme Court recently agreed with the Schwarzenegger administration that physicians who are non-participants in a patient’s health insurance coverage plan may not charge usual and customary fees exceeding the insurance reimbursement to the patient in ER and on-call care. This has to be unconstitutional on its face. But it speaks to the angst about rising costs. Unfortunately, many California doctors may feel they can no longer take call, given low insurance reimbursement, no reimbursement from many patients, and high malpractice risk

The rising costs of health care are causing similar seemingly draconian actions on many fronts. But when doctors are unable to negotiate fair compensation contracts with insurers, they ought to have a right to go outside the insurance company and still see patients, who have the right to choose a different doctor. The California law pertains to EMTALA-related care where patients often do not have the option to choose another doctor, or shop around for better charges, but it is likely to be interpreted broadly by the insurance companies, which could see it as a means of paying whatever they want and giving physicians no recourse for negotiating fair reimbursement. Just more troubling signs of the times, and another reason we need real national payment reform.

When we recognized last week that we were not likely going to be among the limited number of invitees to President Obama’s much ballyhooed Health Summit (we were in competition with CEOs of major businesses, health insurers and mega institutions), I did some serious scrambling and secured a place for ACC President Doug Weaver, M.D., F.A.C.C., to participate. Doug did an excellent job of distinguishing ACC from the relatively few other physician representatives by focusing on the things we can be accountable for fixing in terms of improving quality and reducing unnecessary spending using our commitments to science, quality systems, the NCDR, appropriate use criteria and other innovations. Weaver challenged the new administration to work with us on solving problems.

Tort reform was raised, and President Obama noted it was an issue. He said, even considering defensive medicine costs, it is not seen by OMB as one of the mega-cost-issues that is wildly out of control, and that this Congress does NOT want to take it on. At least he sees it needs to be considered. For ACC, it will be a major aspect of our state advocacy activities, and we will keep emphasizing the impact of defensive medicine costs.

ACC leaders and I recognize that practicing members out there are worried about more than quality, variation, and rising costs. Many practices are becoming increasingly non-viable -- even in cardiology -- and we have to fight for fair and reformed compensation systems too. But we can’t do that if we’re not at the table. We only get there by agreeing to be accountable on fixing things only we physicians and teams can fix, and so that’s we are emphasizing. Have patience out there. The irony is that we’ll do a better job of protecting compensation by keeping the interests of patients and the health of society first.

The President wants a bill to come of Congress for final “mark-up” by June (three months!); and he expects the reform process to begin being seriously implemented as soon as in 12-15 months. That’s an aggressive timetable. Hold on to your britches.

Most importantly, we weren’t on the menu this time — we were at the table, and we will be for the upcoming discussions related to how this reform process might best unfold. We somehow need to get the non-involved practices to better understand what the College is doing related to the opportunities of being at the table, and the serious threats of not being there!

The ACC is in the process of collecting comments from members on health care reform and will feature them in a post later this week. Check back for updates!

*** Image from Flickr (Cedric). ***

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!

After getting shot down on his health reform strategy by the Legislature (and a massive $40 Billion budget deficit), ‘Ahnold’ is still working on reforming the system. This time he appears to be listening to the ACC on our “Fixing Health Care from the Inside Out” theme (as, by the way, is Boston surgeon and columnist Atul Guwandi, who is using our theme as if it’s his -- I guess that’s flattery). Schwarzenegger has developed the Right Care Initiative to improve quality and efficiency of care across California to improve quality, and hopefully reduce public coverage costs of unnecessary care. He is focusing first on diabetes and CV care. I have been asked to chair their Right Care Task Force on Payment Incentives to Promote Quality and Outcomes. California sponsored the first meeting of the taskforce this week in Southern California -- and it includes the CEOs or CMOs of PBGH (the nation’s largest private purchaser), insurers, medical groups, integrated systems, and the IHA (Integrated Healthcare Association -- the nation’s largest P4P system with over $500 million in payment rewards to docs per year).

Basically, given that California generally has a lead other states in widely testing these concepts and in IT adoption, the Governor notes that the actual conformance to managing BP< 140/90, LDL<100, and HbA1C < 9 in California is not much above the national average, and they want to know why, and how to turn that around. The state wants to consider how they might reassess how to provide the incentives for docs, patients, and health insurers to achieve better results. I definitely will also be able here to highlight the potential for physician networks, insurers and Medi-Cal in the state to begin working with ACC on NCDR and IC3 and AUC projects, and perhaps on imaging and CAD improvement projects. What an opportunity!

Lots of news is coming from the state level: In New Mexico, ACC members have developed draft legislation establishing liability protection for physicians and nurses who respond to disasters. Other states will likely be added to this list later.

An Arizona bill proposes Appropriate Use Criteria and guidelines requirements for all medical services.

Arkansas lawmakers are following in the footsteps of their counterparts in Maryland with a bill that would ban self-referral.

In Kentucky, we’re hearing legislators may introduce a bill allowing PCI without surgical backup. A few of our Kentucky members feel the data from a pilot have not been sufficient to warrant the change.

Health care advocates in Pennsylvania successfully have blocked the proposed merger between Highmark and Independence Blue Cross. Opponents of the match argued that a merger could have serious anticompetitive effects and cause significant injury to physicians by lowering fees. This wouldn’t have happened without the AMA’s leadership. My old CMA General Counsel and colleague, Catherine Hanson, provided AMA’s legal background and arguments in this case — very impressive advocacy.