Congressman Gordon (D-Tenn.) has convinced House Energy and Commerce Chair Henry Waxman (D-Calif.) to allow his medical malpractice amendment in H.R. 3962. Gordon’s amendment would facilitate “certificate of merit” systems in states that achieve the reductions in premiums claimed in Ohio, Michigan and a few other states when such a program is designed and implemented properly. But the good Congressman has informed us he’s interested in a broader tort reform agenda, and we should help make it happen! During these tough and financially tight times, a reduction in med-mal premiums could be a godsend.

The other idea we are exploring is to provide a set of protections and/or safe harbors for those physicians who achieve the health IT-related “meaningful use.” I am working with a coalition (that we are helping to create) to explore this idea. The meaningful use process of the Office of the National Coordinator (ONC), David Blumenthal, MD, builds on allowing the federal stimulus benefit dollars to go to only those doctors who qualify as “meaningful users” of health IT. Basically, meaningful use will involve phased-in application of electronic health records, e-prescribing, clinical decision support systems, privacy and security protections, computerized physician order entry, and perhaps a few more elements of an e-office. If incorporating health IT could be accompanied by a significant reduction in medical malpractice costs (even if only for Medicare and Medicaid patients), it would be an additional big incentive to go electronic (not to mention being able to receive over $40,000 from the feds to help do it).

The PINNACLE Network™ concept is in fact the pathway to meaningful use for cardiologists and other physicians who care for cardiovascular patients. This is all happening rapidly, and we will talk to Congressman Gordon and others about expanding on his idea and giving the trial bar a run for their money before this reform process is completed.

And here’s an additional plus: This week, Chairman of our Working Group on Malpractice Insurance Bill Oetgen, M.D., F.A.C.C., and I met with the CEO and CMO of the nation’s largest physician-owned medical malpractice insurer, the Doctor’s Company. We discussed some exciting ideas that could reduce premiums for cardiologists at the same time reducing the risks of adverse events and patient safety-related incidents. This was a dynamite meeting.

Photo: http://www.flickr.com/photos/mindgutter/ / CC BY-NC-ND 2.0

The ACC recently came out with this great CVN video highlighting our recent Legislative Conference. In the video, I point out that the proposed cuts, the final version of which are soon to be announced, are distracting us from pursuing other noble health care reforms, such as promoting quality, reforming malpractice laws and increasing access. I've listed a couple of possible options for what else we COULD be focusing on right now if it wasn't for the Rule, but add your own suggestions in the comments section below.

 

Last week and this week in Washington have been even crazier than any before in the health care reform soap opera of 2009. I recently heard a modern philosopher opine (can't remember his name) that "life is a first-class opera played by a tenth tier cast." If you tuned in to C-Span this week to observe the Senate Finance hearings, you’d understand.

Actually, this health reform debate is more a soap opera, at least as Mr. Baucus' long awaited bill was received. Baucus likes the bill very much. I’m not sure anyone else in his Chamber does. Nonetheless, I predict it will be the platform for the final bill for two reasons: first, the CBO marks up the costs over ten years at less than $900 billion ($856 B), AND they say it will actually save money over time. The other two major bills cannot claim this distinction.

Second, at least one Republican might vote for it (Snowe—R-Maine). But most of what the bill contained when Baucus put it out will likely be amended away. It’s becoming a platform, not a plan. Democratic colleagues Rockefeller and Wyden have been the most critical of Baucus, particularly in requiring coverage with insufficient subsidies for lower income families.

Tri-Com Bill
Meanwhile, House leaders still think their Tri-Com bill (HR 3200) will be the real platform, with Ms. Pelosi and others clarifying that the 'public option' (not included in Mr. Baucus' bill) must be in the final legislation. But their proposal is more expensive -- even though they ‘fix’ the SGR. They don’t finance the SGRrrr fix though -- they just sort of write it off as part of the debt, not part of the next budget.

The Senate doesn’t buy that approach. They say it has to be paid for (adding $245 billion to the House bill cost if so) -- hence the Senate chose to band aid patch it for one year only to prevent the 21 percent cut in physician reimbursement from kicking in this January, even though it kicks in the following January. (They don’t yet seem too concerned about the 27 percent cut to cardiology practices looming in 2010 relating to the Medicare Payment Rule, however. The Rule has nothing to do with health system reform and these bills -- it’s just an ugly manifestation of the present mess -- but it’s a worse predicament).

It is clear that neither Democrats or Republicans on the committee are completely satisfied with the final product and those not included in the “Group of Six” negotiations over the past weeks want to have their voices heard. 

Hearing
After opening statements by members, the markup started with a tense tone as Chairman Baucus, committee members, and CBO Director Doug Elmendorf held a contentious discussion over the “safe speed” of CBO’s work to produce budget scores on the proposal and amendments. Republicans have called for “transparency,” with several hours of debate on an amendment by Sen. Bunning requiring final legislative language and CBO budget scores 72 hours prior to the committee’s final vote (the amendment failed).

The markup is slow going, with hundreds of amendments lined up dealing with coverage, delivery system, and financing and debate over many amendments lasting hours and at times becoming heated. Several attempts to strengthen the bill’s provision on medical liability have failed so far, as did an attempt by Sen. Cornyn (R-TX) to address the SGR fix. Sen. Cornyn also offered an amendment to strike the controversial Independent Medicare Commission from the proposal, but it failed. Later, an amendment by Sen. Rockefeller to modify the Commission, which is based on a bill of his, passed. So far the MedPAC on steroids piece is alive in there. The “public option” is not. 

One very controversial aspect is the creation of a new system of modifiers to payment based on quality of care in relation to resources spent. This provision would thus penalize higher spending regions with lower payment. It’s true that variation in spending is very uneven. The Dartmouth Atlas folks (Wennberg and Fisher) deserve credit for publishing that variation based on Medicare spending per capita, but it’s based entirely on claims data. And, it doesn’t include socioeconomic and credible risk adjustment data, and that must be included before variation can be fairly linked to payment or to fair comparisons of geographies. ACC has proposed using clinical data (NCDR) to help look more carefully into this variation. 

The markup continues next week.  All eyes continue to be on Sen. Snowe, who may be the lone committee Republican to vote with Democrats for passage of the bill.

Despite the controversies, and after all the amendment hubbub, the Dems should still have the votes to get a bill out in both Houses in my view. In the Senate, after Massachusetts Governor Deval Patrick on Thursday appointed Paul G. Kirk Jr., a former aide and longtime confidant of the late Sen. Edward M. Kennedy, as an interim senator, that 60^th vote should be there soon. We’ll see. 

*** Image from Flickr (Brent and MariLynn).***

On Friday I spoke with MedPage Today about the Senate Finance Bill, potential tort reform and the revisions necessary to the SGRrrr. The final video is below.

The ACC earlier this morning issued the following statement on Baucus' health reform proposal. I'll have more on this in coming days (I'm about to get on a plane for the annual meeting of the Japanese College of Cardiology), but here's our first take on the proposal.

****************************

ACC CEO Dr. Jack Lewin’s Statement on the Baucus Draft

 WASHINGTON, D.C. - Dr. Jack Lewin, CEO of the American College of Cardiology, made the following statement Wednesday regarding the Baucus draft:

"We appreciate Chairman Baucus's hard work on this very important piece of legislation.

 "I am excited to see the CMS innovation center idea that will focus on better payment and outcomes in this draft. We are also happy to see a mention of tort reform which is a step in the right direction, and we hope to see tort reform in the final package.

"While we appreciate the effort to stop the 22 percent cut to physician reimbursements under Medicare scheduled to take place next year, we believe you can't have complete health reform until you permanently eliminate the flawed Sustainable Growth Rate (SGR) payment formula.  I shudder to think of how that 1-year band-aid will lead us to spend the next year trying to fix that formula to prevent a payment disaster instead of working on the quality projects patients deserve.  Failure to permanently eliminate the SGR means patient access is threatened while Congress plays chicken with Medicare benefits year after year.

"Ironically, the highest quality care in this country is not the most expensive care.  The most effective way to bend the cost curve is to put the incentives on the table for doctors and hospitals to improve quality and care systematically by using evidence-based tools. 

"The American College of Cardiology is well positioned to lead this effort.  With over 43 percent of all Medicare dollars spent fighting heart disease, the ACC has tools in place to eliminate waste, fraud and abuse out of the system.

In its afternoon breakout session yesterday, the ACC held a panel on medical liability reform featuring James Paluskiewicz from the office of Rep. Michael Burgess (TX) and Dana Lichtenberg from the office of Rep. Bart Gordon (TN). So far in the 2009 Legislative Conference, medical liability reform has come up several times as an area that needs to be addressed in health care reform. The cost of medical malpractice (malpractice premiums and legal defense) is estimated by CBO to be at least 1 percent, or $22 billion, of overall annual health care spending in the nation.

However, the big number is the cost of defensive medicine. While the amount is controversial, it has been estimated by a number of legitimate sources (PricewaterhouseCoopers, etc.) to approximate $200 billion. Therefore, a little bit of malpractice relief could save a lot of money in reducing defensive medicine. If, for example, tort reform was able to save $50 billion per year in defensive medicine, it would add up to $500 billion over 10 years -- over half the projected costs of health care reform spending.

The ACC has long-held that caps on non-economic damages and other reforms, such as those contained in California’s MICRA, have the most significant impact on stabilizing malpractice premiums. However, realistically, there's a low likelihood such reforms would make it through the legislative process. Other options that could be included in reform or for demonstration projects:

• Health courts: Health courts are specialized administrative courts designed to handle medical injury disputes
  
  
• Certificate of Merit: Requirement to obtain a written statement by an appropriate licensed professional, certifying that there exists a reasonable probability that the treatment fell outside acceptable standards and that such conduct was a cause in bringing about the harm
  
  
• Collateral source rule: Eliminating the collateral source rule would allow juries to take into account payments from our sources when calculating awarded damages
  
  
• Periodic payments: Allows the defendant to make periodic payments of future damages over $50,000, if the court deems appropriate, instead of a single lump sum payment. It would ensure that funds continue to be available to the plaintiff to cover these future cost as they occur and avoiding the mismanagement of a lump sum payment
  
  
• Adherence to practice guidelines: This provision would offer limited liability protections to the physician or health care professional who offered care within nationally-accepted clinical guidelines
  
  
• Expert witness: Requirement that expert witnesses meet certain qualifications prior to testifying, such as must be a licensed physician and must be in the same or similar specialty as the defendant. Expert witnesses must also have been in practice within the past five years, which can include academic or clinical research programs.

The ACC supports the amendment offered by Rep. Bart Gordon (D-TN) to H.R. 3200 that would provide incentive payments to states for enacting certificate of merit requirements and early offers programs. There are many ways that we can begin to reform the malpractice system to reduce costs associated with defensive medicine. We just need to get started.

*** Image from Flickr (walknboston). *** 

ACC President Bove and ACC leadership have asked staff to get in the weeds a little bit more around some of the controversies swirling around health care reform, such as the public option, the "MedPAC on steroids notion," what the minimum benefits should be, how quality will be incentivized, and so on. We have very little time to get such ideas agreed upon and on the table, but we are committed to doing so. A few of the ideas that we believe ought to be incorporated could include:

• Payment and delivery system reform. While this critical need is a minefield of extraordinary complexity, we believe at least one new provision must be added that would create significant resources to fund pilot projects and experimental demonstrations around payment reform, bundled payments, accountable care organization concepts, the patient-centered medical home and other such ideas that will never come to fruition without significant funding and experimentation. We believe that new funding approximating 1.5 to 2 percent of Medicare spending for hospital, physician and other provider reimbursement should be made available to the secretary of HHS for such payment reform experimentation -- and with new dollars. That would provide about $4 billion out of a $450 Medicare billion overall program -- not even 1 percent of total spending. That money could not only fund a broad array of pilots that could extend to smaller practices and hospitals, but it would allow the CMS (Centers for Medicare and Medicaid Services) to expeditiously hire the kind of expertise and capacity-building resources it will need to help the nation make these transitions gracefully and effectively, and to work with the profession to make it happen sensibly.
  
  
• The SGRrrr needs to be obliterated. HR 3200 wipes it out for 10 years, but not completely. I think Mr. Baucus will just fund a one year fix -- that’s unacceptable. Let’s move on.
  
  
• Tort reform has to be included. The cost of defensive medicine is widely argued. HHS estimates it at $126 billion per year including almost $60 billion in Medicare and Medicaid, but Pricewaterhouse Coopers estimates it at $210 billion (I trust them more than HHS), and others claim it may even be higher. So, what’s to argue? It’s a lot of wasted money, not to mention the legal costs and hassles! What if we cut the defensive medicine estimates by 75% to, say, an estimate of $50 billion a year? Saving $50 billion annually would result in a $500 billion savings over the 10-year budget period for which expanded access to care is estimated to cost $1 trillion -- the cosmically sized number Congress has not yet decided how to pay for. Dang! Why not fund half the cost of reform by reducing the hemorrhaging of health care dollars into the legal system? While we know the U.S. Senate won’t vote for the most comprehensive reforms we would like to see, we believe the current pressure for bipartisan action could open the door for significant tort reform progress that would save that $50 billion of defensive medicine target I referred to. ACC is working on convening specialties, states, consumer groups and others to get this issue back on the table!
  
  
• Primary care: Nobody would disagree that primary care is more devastated than the rest of medicine, even though workforce shortages in cardiology, CT surgery and other specialties will also impair the system in the future in significant ways. But primary care really is a disaster in terms of supply. So, why not fund a renaissance of primary care as part of the $1 trillion investment, rather than the “robbing Peter to pay Paul,” nickel-and-dime approach currently before us? These approaches won’t work in terms of saving primary care; they divide the House of Medicine, and they will further impair access to specialty care. HR 3200 puts some new funding in for primary care, but it will be insufficient to even persuade one medical student to move in that direction.
  
  
• Benefits: If the cost of universal access exceeds what Congress is willing to spend, why not consider having the minimum benefits consist of USPHS-approved prevention services and high deductible coverage (perhaps over $2000) at minimum? People would still have to pay for some outpatient care, but nobody would be bankrupted by health care anymore, and any serious condition would be covered. This isn’t perfect, but it is so much better than we have now.

Weighing in on Other Controversies
We probably do need to help Congress find its way to work around the public option dilemma, the MedPAC on steroids idea, and other divisive issues. But if we were to succeed in getting the previously mentioned objectives moving, these controversial provisions might iron themselves out on their own, given the lack of consensus about them in the Congress. In other words, we might do better to be emphatic and clear about what we want to happen than to spend all of our energy on what we don’t want.

Regarding an empowered MedPAC, Sen. Rockefeller (D-W.V.) has introduced a separate bill on this topic. We will need to think about what we agree with. His bill would:

• Reform MedPAC as Executive Agency Modeled After the Federal Reserve Board
  
  
• Elevate MedPAC to be an independent, executive branch entity, like the Federal Reserve, with the power to implement recommendations that are more insulated from special interests, and more accountable to the American people
  
  
• Inform new research in health services to adequately address deficiencies in the evidence
  
  
• Test new and innovative payment models for provider reimbursement, and
  
  
• Expand the capacity to evaluate basic and health services research for reimbursement. 

President Obama tonight will address Congress on health care reform "in understandable, clear terms [with] what our administration wants to happen with regard to health care, and what we are going to push for specifically," according to Vice President Biden. Let's see if he addresses any of the items I've outlined here.

*** Image from Flickr (WilWheaton). ***

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

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

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

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

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

There is no tort reform in the currently emerging bills. So, we signed on with a host of other societies and the AMA on a joint letter to Henry Waxman (D-Calif.), Chair of the Energy and Commerce Committee, urging Congress to include meaningful medical liability reform as a critical component of any health care reform legislation.

The letter highlighted the inefficiencies of our current medical liability system, escalating and unpredictable awards, and the high cost of defending against lawsuits. We are referring to recent data from Ohio on their malpractice statistics that underscore the changing med-mal issues. It underscored that as insurance becomes unaffordable or unavailable, physicians must make tough decisions including altering or limiting their services because of the following liability concerns:

• Most Cases Result In No Payment. The overwhelming majority of medical malpractice cases in Ohio continue to be resolved without any indemnity payment being made to the claimant. Nearly 80 percent of claims have no indemnity payments.
  
  
• Total Claims Are Down Significantly. The total number of claims has decreased significantly. Data from 2007 show 3,451 claims, compared to 4,004 claims in 2006 and 5,051 claims in 2005.  This 31 percent decrease relative to 2005 data is heartening.
  
  
• Average Indemnity Is Up. Though volume has decreased, other indicators have trended sharply in the other direction. Average indemnity, which was $269,374 in 2005, is now $315,635 in the latest report — a 17 percent increase since the first data point. Overall, these data suggest that only the more serious malpractice allegations are being pursued, but that providers and insurance companies are having to defend themselves more aggressively in instances where patients choose to take action.
  
  
• Legal Costs are on the Rise. Even when an indemnity payment is not made, there are significant investigation and legal costs related to the claim. In Ohio, the total allocated loss adjustment expenses (ALAE) for 2007 was $103,033,668. ALAE averaged $35,603, up over 45 percent since 2005.
  
  
• Age of Claim Matters. There is a significant correlation between the age of the claim and the size of the indemnity payout, if paid. Of the claims that closed with an indemnity payment, 186 closed within one year of being reported and had average paid indemnity of $67,146. That figure rose to $297,935 for 202 claims closing in their second year. Nine claims closed seven or more years after being reported, having average paid indemnity of $2,785,326.

The ACC is working to create a specialty society coalition to come together to get tort reform language inserted this fall into whatever bill finally emerges from  Congress. While we realize getting caps on non-economic damages is not politically possible at this time, real reform could gain traction. Why not get language that would require standards of merit for the tort pleading, and standards of merit for "expert" witnesses (facilitated by societies). What about periodic payments, collateral damages provisions, protections related to adherence to evidence-based care, and other such provisions to reduce frequency and severity of legitimate claims, and to greatly reduce illegitimate claims? We plan to try to organize a new effort in these regards.

*** Image from Flickr (walknboston). ***

An opinion piece appearing in yesterday’s WSJ by law professor Richard Epstein reflects on President Obama’s “tantalizing” mention of professional liability reform in the U.S. Obama said he does not support “caps on malpractice awards” but does support the “need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines.”

International Solutions
Epstein discusses his support for caps on damages for non-economic damages (pain and suffering), and looks at how international health systems handle malpractice in ways that “attract far less controversy, and are far less expensive.” There are four features that increase costs, Epstein says:

1. Jury trials
2. The contingency fee system
3. The rule requiring each side to bear its own costs
4. Extensive pretrial discovery

Among many other reasons. He decides the proper reform is to replace the peer jury with “specialized commissions” like that of other countries, which he feels can “help reduce litigation expenses and promote uniformity in case outcomes across regions.”

A Better Idea
Although this idea isn’t new and is appealing in many ways, I don’t think it would have much effect on lowering premiums. Frankly, lowering caps on non-economic damages, without any caps on actual damages, medical costs, and work and lost income costs, is the only way that has demonstrating significant reductions in malpractice premiums. Pain and suffering damages typically wind up as the patient’s means of paying the contingency fees for legal costs where little of the dollars actually get back to the patient plaintiff. Where pain and suffering damages are uncapped, personal injury attorneys are going to continue to go after frivolous lawsuits in which juries feel sorry for the plaintiff, even if there’s no negligence. MICRA in California and Texas’ similar recent tort reform legislation clearly demonstrate the effectiveness of caps on pain and suffering. Too bad that can’t be on the agenda. Check out a previous discussion of professional liability reform options on this blog.

We may disagree on the “how,” but Epstein and I agree on the “why” we can’t let go of pushing for reform. Liability costs are a serious problem and add to the expense of both providing care and to the overall system costs. We can’t stop fighting until effective action is taken.

The Senate Committee on Health, Education, Labor and Pensions (HELP) last week outlined its broad goals for reforming the American health care system. Among the top goals: improving the delivery system; enhancing prevention and wellness; reducing fraud and abuse in public and private health systems; and establishing shared responsibility for financing of reform efforts. Nobody can argue with the goals, but how the heck do we get there? We’ll need more details and some HELP.

The Committee appropriately suggests that health care reform legislation should encourage adoption and use of health IT; promote evidence-based medicine; facilitate health literacy; and include strategies for tackling preventable medical errors and hospital readmissions. It also proposes better managing chronic conditions through care coordination, medical homes and community health teams. Again—we agree. I mean, duh.  But, how do we systematically do that? ACC is working with leaders in the Senate and House as they continue to flesh out these and other proposals and develop overarching health reform legislation. For the latest information on health reform, visit http://qualityfirst.acc.org.

Meanwhile, President Obama met this week with key Democratic Senators Baucus and Kennedy and reaffirmed his support for the creation of a government-sponsored “public plan” health insurance option — the issue that invokes the most angst and opposition from Republicans who might otherwise support some kind of overarching health reform legislation (as an alternative to national bankruptcy?). Read more in the New York Times and The Washington Post. 

For me, it’s what is not in these articles and stories that is most concerning. Consider the following:

IF the SGRrr payments are flat for ten years as projected, how do we prevent tens of thousands of doctors from just throwing in the towel, exacerbating the access problem? If we move the delivery system toward integrated groups, and transform payment from fee-for-service to bundling or episodes of care (or capitation) to align payment incentives with quality improvement, who receives and distributes the payment bundles?  Hospitals? New entities?  If the money goes to hospitals to dole out to doctors, should doctors all be employees of hospitals to be able to share in the huge profits hospitals make from? Or could bundles go directly to doctor groups? If so, how would they be organized if not already in integrated systems? And, if any of this is going to work in terms of payment incentives, gainsharing, and new potential relationships between physician specialties and hospitals, isn’t some anti-trust relief going to be needed? Is that part of the reform plan?

And, where is the med-mal relief plan that we will need to reduce defensive medicine costs? And, what if a new public plan is created that pays less than what it costs for some doctors to produce the required care? In the current Medicare program, it is illegal to balance bill patients to cover costs. Will a future potential Medicare-for-all concept of Medicaid, the new ‘public plan,’ and Medicare allow doctors to opt out--or will we be forced into a kind of pseudo-public employment? If the new public system were to become untenable and unfair in terms of reimbursement (let’s say the government has some budgetary problems in the future?), would doctors be prohibited from opting out of the program and still seeing patients who were willing to pay them directly?

And what about EMTALA? If health reform achieves universality, is EMTALA to be sunsetted? Do on-call stipends go away? Why or why not?

None of these ‘details,’ among many, many others, are currently included in the emerging principles of reform discussions. It’s a little scary. We really need to think about these details. It seems to me that after we pass whatever we pass this year, we’re going to have a year or two of very messy details and divisive issues to deal with.   

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. ***

A lot is going on in Washington around reform every day. I had a chance to talk with Speaker Nancy Pelosi (D-Calif.) last week, and she is truly eloquent in terms of her ability to summarize the various changes needed to improve the American health care non-system. She knows her stuff. From her point of view, the SGRrrr still has to be eliminated this year (encouraging). She believes universal coverage will be achieved, and she’s very excited about ACC’s proposals to reduce unnecessary readmissions and to use quality of care and the NCDR to reduce morbidity and mortality, increase evidence-based care, reduce disparities, and improve effectiveness.

ACC President Fred Bove and I talked with Rep. Nathan Deal (R-Ga.), House Energy and Commerce Minority Leader. He is also interested in quality and wants the Republicans to be players in delivery system reforms. He thinks the Democrats are trying to lock them out of the reform process. He’s also interested in malpractice reform and asked Fred Bove and me to get him more information, not only on our Quality First agenda, but also on how we might advance tort reform in the big system reform process. 

Physician, Health Plans: Can Agendas be Aligned?
Karen Ignagni, CEO of America’s Health Insurance Plans, and I talked last week about their concerns and key issues in reform, and how we might align our agendas. Obviously, AHIP doesn’t want to see a “public plan” that would compete head-to-head with private insurance as part of the solution. But she does understand the protective value of having insurers and physicians working together on payment reforms that would both improve quality and also improve the bottom line of beleaguered practices, noting that insurers have not very often been on the “good guy” list in these regards of late.

I do think there may be a lot more in common in the near future between physicians and health plans as reform progresses. We’re both targets for savings. The most viable kind of payment reform would result from gainsharing relationships where doctors get credit for improving the system. Patients are the primary beneficiaries, and insurers share in some of their resulting increased profits. As quality and effectiveness improve, so should the insurers’ bottom line. It could be different for hospitals in this regard.

*** Image from Flickr (cormac70). ***

The ACC on last week was featured in a Politico article that discussed whether medical malpractice reform will be included in any health care reform package that is released. Congress estimates the global costs of malpractice premiums, settlements and judgments to be about 2 – 3 percent of total health care costs (this estimate appears to be accurate). This is not seen by the Office of Management and Budget (OMB) and the Congressional Budget Office (CBO) as sufficiently expensive to rank as a top health care reform priority. However, Health Affairs and others have estimated that an additional $200 to $300 billion is spent on “defensive medicine” annually, and directly related to tort risks. Our members agree — fear of lawsuits is a major generator of unnecessary care, and thus, needs to be considered in reform.

Obama said last week that professional liability should be “on the table” in health care reform discussion, and so has Sen. Baucus (in his white paper, see here for more coverage). Here are some ideas for reforming medical malpractice:

• The Fair and Reliable Medical Justice Act, introduced in the 109^th and the 110^th Congress, includes ideas for ensuring safe and effective medical care, while working to limit malpractice insurance premiums.  This legislation would provide grants to states to create alternatives to current tort litigation.
  
  
• The early disclosure model offers health care providers tort liability immunity after an offer, in good faith, to pay compensation to any patient injured or harmed as a result of care. The compensation would have to include any economic loss to the patient, non-economic damages (as determined by the state) and reasonable attorney fees. Of course, the current malpractice legal standard is negligence. If this were changed to just injury (as in no fault), the costs would be huge, since many more patients could apply.
  
  
• The second approach, the administrative determination of compensation model, calls for the establishment of an administrative board to designate classes of avoidable injuries. Based on these classes, the board would determine the level of compensation awarded to the patient. Again, this would open up compensation to all adverse events, even when care provided was excellent. Very fair, but very expensive.
  
  
• Under the third alternative, specialized health courts would be established. The court would be presided over by judges with expertise in health care with the ability to hire outside experts. The judges’ decisions regarding compensation would be binding but subject to an appeals process. Personally, while appealing in many ways, I think this has very little effect on lowering premiums.
  
  
• Still, another alternative being floated by some Republican members is to link the determination of negligence to whether the physician followed approved clinical guidelines. This idea is still in its infancy and it remains to be seen how it would be legislated — but we should drive this one!

None of the above options would be as powerful as establishing caps on or elimination of non-economic damages (like California’s MICRA, and the new Texas law provide), but we can at least explore all options. Although hugely important in terms of reducing defensive medicine costs in particular, professional liability may need to be handled in parallel to comprehensive health care reform, since it remains divisive. ACC has developed a Tort Reform Action Plan, which is a part of our health reform strategy.  

ACC has been investigating how to improve quality and reduce med-mal premiums for CV doctors by analyzing malpractice claims history for cardiology, which is usually bundled in with other specialties. We are working with Michael Maglaras, an expert in the malpractice insurance business. We've talked about how the College is preparing to support members with malpractice insurance resources given the possible tightening of the market in the upcoming months. We'll just have to wait and see. But the College is poised and ready to respond if needed.

*** Image from Flickr (walknboston). ***

The pace of planning for health care reform in Washington is frenetic. The President wants action this summer. Democratic leaders want a bill to be ready to be marked up by June for debate over the summer. The Senate Health, Education, Labor and Pensions (HELP) Committee (Kennedy) is trying to get their first draft done, as is the Finance Committee (Baucus) in the Senate. Now, Representatives George Miller, (D-Calif., representing Speaker Pelosi), Henry Waxman, (D-Calif., Energy and Commerce chair) and Charles Rangel (D-N.Y., Ways and Means chair) have committed to developing a House strategy by June as well, vowing not be “rolled over” by the Senate. We all could be rolled over.

I was called to talk last week by the Senate HELP staff to provide ideas about quality of care pilot projects. We have them. HELP Committee is interested in reducing readmissions for heart failure and acute coronary syndrome, and they are very interested in how registries and clinical decision support systems could be accelerated in the outpatient arena toward improving quality and reducing costs (IC3 and Quality First! ACC has “shovel ready” projects). They also want a proposal on how the various cardiovascular registries could be made interoperable. It would cost several million $$$ to have the registries (we have several) on one interoperable platform, but the yield in terms of advancing comparative effectiveness and clinical quality would be terrific.

Our ‘Quality First Network’ idea can rather easily be extrapolated to include other specialties -- Congress wants to create pilots that all specialties can participate in if desired. Our proposal would be to pay a significant payment increase (perhaps 10%) to incentivize the costs of health IT adoption and workflow change to use clinical decision support to track guidelines, performance measures, and appropriate use criteria (AUC) across all outpatient care with reporting to CMS and insurers. Congress might require a “stretch goal” for each specialty -- something that would be negotiated by CMS and each willing specialty -- to be eligible for the full incentive. For cardiology, a stretch goal could be reducing hospital readmissions, or applying AUC for imaging, for example.

If Congress would actually help fund these kinds of ideas, we might really get somewhere in terms of reducing costs and improving quality. What ACC proposes as “quality first networks” fits with the Brookings Institution idea of “Accountable Care Organizations (ACOs).”

I also met last week with Senate Republican leaders and their staff. Senators Gregg (R-N.H.), Hatch (R-Utah), Enzi (R-Wyo.) and colleagues are curious about whether the profession is going to support the Democratic proposal for a new “public insurance plan.” As you may recall, the ‘public plan’ would be run by CMS as a choice for employed persons and those not eligible for Medicare or Medicaid, and would be designed to price-compete with private insurers to lower premiums over time. The Republicans understandably see this as a poorly disguised path to a single payer and want physicians to be forewarned that “if we think Medicaid payments are fair, wait until we see the payment model of the new plan.” I shared that we have similar concerns, but can’t really express them without seeing anything specific proposed as yet. Republican leaders also remain interested in tort reform, as do we; but unfortunately, nobody seems to be interested in truly substantive reform, such as putting MICRA-like caps on non-economic damages. Rather, they seem to be talking about health courts and other nice, but less powerful ideas.

*** Image from Flickr (Rob Shenk). ***