This just in ... A new ACC member survey provides insight into just what the impacts of the cuts on practices will be. The practices surveyed said staff layoffs (42%), elimination of service lines (33%), limiting office hours (14%) or not accepting Medicare (13%) were options they were considering as a result of the cuts. Only one-quarter reported no action and those which will not change practice patterns tended to be in academia or work in hospitals. That being said, even academic institutions and hospitals are not untouched by the rule.

Patients seeing solo practitioners (100 patients seen on a weekly basis) will be hit the hardest with anticipated cuts across the board in staff, service lines, Medicare payment and office hours. Medicare patients will also be extremely inconvenienced as 13% of practices (17% of private practices) anticipate a need to reduce the number of Medicare patients or stop accepting Medicare payment. Cardiovascular practices report that about 50-60% of their patient volume is Medicare patients. Taking that into account, calculations reveal that at least 14% of the Medicare population receiving cardiovascular care (or 7% of all cardiovascular patients) would be directly impacted by the anticipated cuts.

The survey also shows a clear trend toward hospital migration. Almost one-in-five (18%) of active, practicing cardiologists in the U.S. have already migrated to another practice or hospital and 28% say that a practice merge is on the horizon. When you look at practice type, private practices which expect to be hit the hardest by the recent ruling are more likely to consider integration into a hospital system (39%).

Last week former ACC President Jim Dove, MACC, led a fantastic meeting at Heart House, the Evolving Models of Cardiovascular Practice Symposium. The symposium was designed to help CV practices understand better their options for hospital employment or integration, versus creating independent/individual practice associations (IPA) or larger groups -- and/or trying to figure out how to survive business-wise in the changing marketplace. Physician and administrator representatives of 110 practices attended -- but over 200 were turned away!

The event was standing-room only, indicating just how relevant this topic is right now. According to a pre-event survey of attendees, 43 percent had integrated their practices with hospitals, or were seriously considering it, or were in the process of doing so. Dr. Dove rightly noted that it is disturbing to see the sense of hopelessness in cardiology today -- a specialty that has been at the summit of medicine for decades and has reduced morbidity and mortality from heart disease by 27 percent in the last decade alone. Regardless of the outcome of negotiations around the Rule, however, this symposium clearly hit a nerve with members. It’s just another example of the ACC providing the tools members will need in the coming months to ensure their continued ability to successfully practice cardiovascular medicine. ACC members Mike Valentine, Bo Walpole, George Rogers, Chuck McKay and others helped envision and organize this meeting with Dr. Dove. MedAxiom and the Cardiology Advocacy Alliance also participated in making it a successful program. We’re going to have to take it on the road. During the meeting, CVN recorded two great discussions about pratice viability with ACC leaders. Check out both segments: "Fighting for Patient Access: Part 1 and Part 2". 

From my own point of view -- one I expressed to the attendees -- the most important trend we’re NOT seeing, but need to promote is that of getting more exemplary physician leadership for group practices, IPAs, integrated system boards, and very importantly for hospital boards. As a profession, we have delegated and abrogated our former leadership of hospitals, insurers, and health systems. Such physician leadership is the best way to protect patient care and improve quality of care. If we’re going to be increasingly selling practices to hospitals, we also need to be populating the hospital boards to a much greater extent and impact. Good partnerships between administrators and dedicated physician leaders make the most successful practices -- but we need to help generate new generations of physician leaders for the best future for CV medicine and cardiology.

So, it’s an evolving profession (I know, some say devolving, but they’re wrong).

GREAT editorial in today's Wall Street Journal on "Obama's War on Specialists." I highly recommend you check it out. Here's a teaser:

From Senate Finance Chairman Max Baucus's health-care bill to changes the Administration is pushing in Medicare, Democrats are systematically attacking specific medical fields like cardiology and oncology. With almost no scrutiny, they're trying to engineer a "cheaper" system so that government can afford to buy health care for all—even if the price is fewer and less innovative ways of extending and improving lives.

The Journal continues: "We have nothing against primary care physicians, and clearly the country could use more of them. But then, it could probably use a lot more doctors, including specialists, as the boomers age and the prevalence of obesity, diabetes and other chronic diseases rises. The increase in specialists has tracked advances over 50 years in medical science and technology. Democrats look at these advancements and see only the costs, not the benefits." 

*** H1N1 Virus, from CDC.gov. ***

ACC Board of Trustees' Work Force Taskforce Chair George Rodgers recently blogged on The Lewin Report about an impending cardiologist work force shortage and what we could do to stop it. I want to know what you think -- what will be the effects of a shortage?

To kick off our 2009 Legislative Conference coverage, former ACC Texas Chapter Governor and current ACC Board of Trustees member George Rodgers, M.D., F.A.C.C. will discuss a recently released study on the impending cardiovascular professional workforce shortage, which appears in the Sept. 22 issue of Journal of the American College of Cardiology. Dr. Rodgers is president and chief medical officer of Biophysical Corporation, a company dedicated to advancing clinical knowledge through its research in the field of biomarkers, and a practicing cardiologist in Austin. As part of the release of the study, Dr. Rodgers and ACC SVP of Science and Quality Janet Wright, M.D., F.A.C.C., conducted a phone conference with reporters, which is available at the end of this post.

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

There are many issues that cardiovascular professionals need to talk to lawmakers about to better inform health care policy and improve the health care system. As Margo Minissian, CCA, said in her post last month: Cardiovascular professionals are the “experts on health care and our lawmakers need us to get up-to-date on the different issues.” My commitment to advocacy is why I’m here in Washington, D.C., for the ACC’s 2009 Legislative Conference.

At this moment, two of the hot topics are payment reform and health care reform. However, an underappreciated advocacy topic for cardiologists, but one I feel is highly important, is addressing the cardiology workforce crisis. My colleagues on the ACC Board of Trustees Workforce Task Force and I on Thursday published in JACC the results of a survey finding that an inadequate supply of cardiovascular specialists will be available to treat the projected 20 million more Americans that will have heart disease by 2020.

Some of the study's findings:

• Currently there is a significant shortage of over 3,000 cardiologists in the workforce.  Only approximately 800 new cardiologists complete fellowships every year in the U.S.
  
• Forty-three percent of cardiologists in the current workforce are over the age of 55 – nearing the point in their careers that they might consider retirement. 
  
• There are going to be much greater demands in the next 20 years for cardiology services based on such drivers as population (baby boomers), the epidemic of obesity and the anticipated increase in prevalence of diabetes and concomitant cardiovascular diseases.
  
• Health care reform may further drive demands for more cardiovascular specialists.

Disparities
Not surprisingly, the report also found significant disparities in representation of women and minorities. Women represent about 12 percent of general cardiologists, 10 percent of interventional cardiologists and EPs and 30 percent of pediatric cardiologists; however, compare these rates to the rate of female medical students – 50 percent – and it’s clear how much room for improvement there is in encouraging women to pursue cardiology. Meanwhile, Hispanics and African Americans represent only 6 percent of the current cardiovascular workforce, compared to 25 percent of the general U.S. population.

What To Do About It
What does this all mean? In order to meet the growing demand for cardiovascular services, more is going to have to be done to recruit cardiologists and other nonphysician practitioners to the cardiovascular world. Part of this can be done through advocacy: we need more government funding for fellowship training positions in general cardiology. The government needs to help promote practice efficiency, such as subsidies for EHRs, a reduction in administrative burden and tort reform. Advocacy also will be needed to create more opportunities for under represented minorities, including shorter fellowship training and increased mentorship. We’re also able to meet the growing demand through increased use of team-based care, which will require more funding to train nurses and physician assistants on cardiovascular-specific care.

The shortage of cardiovascular professionals is a significant problem that will only get worse if no action is taken. Read more about the workforce study, and additional ways to reduce the shortage, in the most recent issue of JACC.

* Dr. Rodgers' 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!

Senate Finance Committee released last week their first draft of health care delivery system reforms. It’s not the bold agenda they had been ruminating about, but in their comments they allude to many of the payment reform innovations that are necessary to improve patient care and quality and help doctors succeed. Some of the key provisions are:

• SGRrrr reform: Rather than fix the SGR formula, the Committee opts for a two-year patch. This is disturbing, because three years from now, there’s not likely to be a half trillion dollars lying around to fix the rapidly compounding problem. They should find a way to get this nightmare off the table, which we will strongly recommend. Speaker Pelosi, House leaders AND Senate Finance Chair Max Baucus (D-Mont.) do say there is approximately $200 Billion tucked away to significantly wipe out the SGRrr debt. But it’s not apparent in this Senate Finance proposal. AMA and ACC talked this week about working to get the whole thing fixed and behind us.
  
  
• The Finance Committee's proposal provides a 5 percent bonus for primary care doctors, without asking for any particular behavioral response. They also would offer general surgeons a similar bonus if they’re located in to-be-defined surgical shortage areas. CV surgeons are in just as short a supply as general surgeons and should certainly be included. However, if these bonuses are financed by reducing payments to all other doctors as it appears, a lot of tension and infighting is likely among physician specialties. Not good. The ACC wants to help Congress identify new dollars to bolster primary care and increase general reimbursement through reduced readmissions and other efficiencies.
  
  
• Some imaging cuts seem very likely, with good news and bad news. The good news is that appropriate use criteria are referenced in the language as a way to address rising costs; the bad news is that RBMs (radiology benefit managers) are also mentioned.
  
  
• The Finance committee envisions quality of care pilots, “accountable care organizations,” use of registries and clinical decision support tools to improve quality as well as reduce readmission costs, but the details on the innovation recommendations -- including financing -- are not provided.

The Senate Health, Education, Labor and Pensions Committee and the House of Representatives are yet to weigh in. This first view from Senate Finance looks very much like the same concepts we saw in previous years. We will encourage them to be a bit bolder.

*** Sen. Baucus. Image from Wikimedia Commons. ***

I see physician payment reform as the biggest threat and opportunity of the year. There is growing consensus among policy wonks, members of Congress, and others that fee-for-service (FFS) medicine has to be replaced with something better. But what?

One thing for sure -- that most physicians do not understand -- is that non E & M FFS payments are being “nickel and dime’d” downward slowly-but-surely to make FFS payment less attractive and less viable. It is a plot. The recent and likely future actions of the RUC in these regards to inexorably whittle down procedure and diagnostic services payments under pressure from CMS contribute to this. The entire RBRVS readjustment processes are undermining gradually FFS, although there have been some modest increases in E & M payments, but not enough to make primary care viable.

Since most of the waste in health care costs is still in unnecessary or avoidable inpatient care, if there was a way to ‘gainshare’ with hospitals when physicians reduce unnecessary spending or admissions, there would be resources for significant pay increases in a reformed payment system in which both society and patients win, and real savings are achieved. But, the hospitals are the losers in that scenario, making it tough to get going. More...

Advisers to House Speaker Nancy Pelosi (D-Calif.) suggested last week that the best way to encourage widespread HIT adoption is to withhold Medicare payment for physicians who refuse to adopt health information technology. These kinds of penalties likely will be included in legislation to be taken up by the next Congress. Not a good approach, Madam Speaker. We might have a wee physician supply problem with this approach.

A new report by Paul Ginsburg at the Center for Studying Health System Change concludes medical technology is significantly the culprit for soaring health care costs. AdvaMed and advocates for technology advances strongly disagree.

New technology does contribute to higher costs, and physicians should be careful about how they use it. But that doesn’t mean we shouldn’t use it. Technology, properly used, can avoid more expensive inpatient care and medical complications due to delayed diagnoses. This is where the ACC’s Appropriate Use Criteria and evidence-based guidelines come in. Using advanced technologies appropriately will help save dollars and lives. But, given the growing financial crisis, there will only be more calls to reduce costs, and some of them will be shortsighted in terms of longer term cost savings.

With physician supply problems in cardiovascular care looming, having likely new cuts in Medicare and Medicaid could actually reverse progress in CV morbidity and mortality in the near future. We can’t let that happen.

We need more doctors! A recent article in Health Affairs predicts population growth and aging will increase internists’ workload by 29 percent by 2025. Based on the current supply of generalists for adult care, the authors anticipate we’ll have a deficit of 35,000 – 44,000 adult primary care doctors. This is serious — we need to get creative about meeting our workforce needs (unless the current financial crisis prevents people who intended to retire from doing so?)

One of the most visionary things the ACC Board has done in its history was to add CCA nursing, PA, and PharmD members, noting that teams of care in CV medicine could help address an undersupply of cardiologists, and improve coordination and quality. Thanks goodness we have that opportunity to consider and develop. But, if we also have to absorb primary care in the absence of sufficient internists and family practitioners, we may be up a metaphoric creek.  

The world’s biggest super-collider in Switzerland, activated several weeks ago, successfully smashed subatomic particles together as designed to recreate a mini-Big Bang, and seemingly without creating a black hole, an unintended consequence that some observers feared could potentially form and swallow up our planet. Unfortunately, the black hole did manifest — not near the collider in Europe — but instead on Wall Street.

The still unresolved fiscal crisis will likely suck up a great deal of the resources needed for health system reform. ACC President Doug Weaver and I talked further about this issue on Cardiosource Video Network this week. One unexpected effect of this crisis might be that the predicted physician/cardiologist supply shortage may be less severe — people won’t be able to retire.

The black hole is also affecting the candidates’ outlook on health care. Although it was only touched upon in last night's VP debate, Sen. Obama has acknowledged some of his health and environmental priorities may have to be funded in a multi-year sequential fashion as a result of the financial crisis. Sen. McCain’s campaign has thus far said they still plan to proceed full steam ahead with their health priorities. If so, it would involve funding their way by making cuts in existing Medicare costs. That would be scary for physicians and high-cost services like imaging. Deferring big spending right now might be a good idea — both campaigns need more work on their ideas. In fact, I think perhaps 2009 should be devoted to a national ‘conversation’ about what reforms should look like, given that there won’t be much money for real implementation, and all the big strategies need work. More...