Yesterday morning ACC staff and I pulled together this video outlining what happened in the final 2010 Medicare Physician Fee Schedule, along with how the ACC plans to fight the rule with a four-pronged approach. Check it out.

For the past several months I awaken each morning hoping the CMS 2010 Physician Payment Rule issue is merely a nightmare, and I can get up and help the College once again focus on constructive engagement in health care reform. No such luck. It is a nightmare, but one that is part of our reality.

Friday at 4:30 PM -- 30 minutes before the issuance deadline, the CMS (Centers for Medicare and Medicaid Services or See-a-Mess) dropped a bomb.  In a call from Jon Blum, the top political insider in CMS, he said I have “good news and bad news.”

The BAD news: the Rule adopts the AMA-collected practice costs survey data, meaning cardiology gets an average practice cut of 27-40% in private practices. (Note that academic, hospital, and integrated system salaried cardiology is largely insulated from the cuts initially, but the effects could eventually reach everywhere through market forces).

The allegedly GOOD news: CMS will phase in the cuts over four years, meaning they will impose an average of 5-7% cuts in 2010. But, what he told us is not accurate in the language we see that nuclear codes (SPECT) will be cut as much as 36% in 2010. We are working to analyze the language in the final rule, but this isn’t good news, and the Secretary and the White House have signed off on it.

Bottom line: The Four-Year-Phase-In is far better than having the full impact hit in 2010, because it will allow us to survive to get valid data and reverse the cuts completely in 2010 if necessary. BUT WE NEED TO FIGHT THIS DECISION NOW, NOT WAIT UNTIL NEXT YEAR. We need to mount a strategy to prevent even the 5-7% average cut in January and in particular reverse the nuclear/stress cuts.

Next steps
After all the hard work and excellent advocacy we’ve witnessed from all of you these past months, I regret telling you we’re not through. But, please don’t allow discouragement to cause you or others to give up. We’re not done here.

*** Image from morgueFile (jdurham). ***

As expected, CMS released its final 2010 Medicare Physician Fee Schedule at just a little before 5 today. I'll have more later this weekend, but here's the quick and dirty summary for now...

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Final Rule Includes Phased In Cuts for Cardiology

The Centers for Medicare and Medicaid Services (CMS) today released its 2010 Medicare Physician Fee Schedule final rule, which includes policy proposals that will significantly reduce payments for cardiovascular-related services. While CMS has attempted to mitigate the impacts of the cuts by spreading them out over a four-year period, the impact of the cuts is still enormous both for 2010 and beyond. Cuts of this magnitude—whether enacted this year or spread over four—cannot be absorbed and we will continue to fight the implementation of this data until a rigorous review is conducted.

The ACC understands the very real impacts these cuts will have on your practices, your staff and your patients. The College is exploring all options and staff and leaders are working together to help you understand all of your options. Below is a high-level summary of the policy changes finalized in the rule. In addition, we’ve also provided links to the tools and resources available to you now.

More information over the coming weeks will be provided in Cardiology magazine, ACC News and The ACC Advocate. Please also plan to join ACC CEO Jack Lewin and President Alfred Bove, M.D., F.A.C.C., for an all-member call on Nov. 12 from 4:00 to 5:30 p.m. (EST) to discuss the 2010 rule. To RSVP for the call, click here.

RULE HIGHLIGHTS:

Practice Expense: Despite the hundreds of calls and letters from you, members of Congress and patients, CMS has chosen to incorporate the results of the American Medical Association’s Physician Practice Information Survey into its formula for calculating practice expense relative value units (RVUs). In a slight change from the proposed rule, the agency has said the cuts will be phased in over a four-year period versus all at once. With the exception of evaluation and management services, nearly all services that cardiologists perform will see cuts ranging from 10 percent to more than 40 percent for individual services phased in over 4 years. A few key examples for 2010 alone:

• SPECT Myocardial Perfusion Imaging (78452) – 36 percent cut
• Transthoracic echo with spectral and color flow Doppler (93306)--10 percent cut
• Coronary Stent (92980) - 4 percent cut
• EKG (93000 )-- 5 percent cut
• Level 4 established patient office visit (99214) -- 7 percent increase

As mentioned above, the ACC is exploring several options for stopping the implementation of these cuts. CMS’ decision to phase-in the cuts, while not what we would have hoped, is due in large part to your tremendous efforts over the last few months. Your actions clearly had an impact and we strongly encourage you to continue to email your congressional representatives and CMS detailing the ramifications of these cuts as we move into the next phase of challenging these cuts.

Bundled codes for myocardial perfusion/SPECT imaging
CMS’s continued pressure to bundled together imaging services reported with multiple codes has now hit myocardial perfusion imaging. In 2010 myocardial perfusion imaging/SPECT studies including wall motion and ejection fraction will now be reported with a single code. CMS decided to substantially reduce the payment for myocardial perfusion imaging as part of this rule by reducing both the physician work value and the practice expense value. To make matters worse, because there is a new code for the service, CMS apparently is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value. The result is a 36% cut in payment for 2010. This change alone accounts for more than one-third of the projected payment cut to cardiology. ACC will begin immediately to pursue strategies to mitigate this cut. Specifics on the new codes and tips on how to work with health plans to transition to the new codes will be emailed to you next week and also included in the November issue of Cardiology magazine.

Consultations: Payments for consultations provided in office and hospital settings are eliminated under the final rule. The RVUs assigned to these codes will be redistributed to office and hospital visits and services now billed as consultations will be billed as hospital or office visits. This will reduce payments to varying degrees for consultation services.

Malpractice: CMS has chosen to update the malpractice RVUs with data from a new survey of specialty-level malpractice premiums. In addition, CMS has proposed a new method for determining malpractice RVUs for technical component services. The proposed new malpractice RVUs would reduce cardiology payments by 1 percent. However, the impact will vary depending on the mix of services provided.

Equipment utilization: CMS has finalized its proposal to change the agency’s formula for calculating the per-procedure cost of diagnostic medical equipment worth more than $1 million. The proposal would assume that all diagnostic equipment with an acquisition cost greater than $1 million is used 90 percent of the time an office is open, thus driving down the practice expense RVUs for services using that equipment. Within cardiology, cardiac MR and cardiac CT services will be subject to payments set based on this utilization assumption. CMS did agree not to apply this cut to equipment for non-hospital cardiac catheterization services.

SGR: As required by current law, the final rule includes a 21.5 percent reduction in Medicare Physician Payment as of Jan. 1, 2010. This cut is in addition to the payment reductions that result from the proposed policy changes described above. In short, there could be as high as a 30 percent cut in Medicare payments for cardiology. However, as in previous years, Congress is expected to pass a one to two year fix this fall. CMS did finalize its proposal to remove physician-administered drugs from the accumulated SGR debt, which makes a fix to SGR less expensive.

WHAT’S NEXT
Taken together with the payment cuts cardiology has already experienced, CMS’ final rule represents a grave threat to cardiology practices and to patient access. The consequences, whether intentional or not, are already being felt. The ACC and its partners in the cardiology community are prepared to help you and your practice navigate these challenging times, while also pulling out all the stops to stop the practice expense cuts and find real solutions to payment. The following resources are available to you now. Your feedback on the tools and resources you’d like to see in the coming months is also appreciated. Please email advocate@acc.org with your thoughts.

• Practice Management Toolkit: This newly updated site contains information designed to help you best manage your practice. While continually being updated, you’ll find information on practice solutions, health IT, coding and billing, working with health plans, quality and educational tools, and more.
  
  
• Medicare Provider Enrollment Website: This CMS site provides you information about Medicare enrollment. The ACC will provide information to members on options in future communications.
  
  
• ACC CardioAdvocacy Network / ACC Political Action Committee: The ACC’s CardioAdvocacy Network (CAN) keeps you up to date on ACC’s grassroots efforts and ways you can get involved. Currently the site contains links to a sample congressional letter regarding the final rule. The ACC Political Action Committee (PAC) is another way to ensure the cardiovascular voice is heard on Capitol Hill. There’s no better time to get involved with either or both of these key advocacy programs.

I talked a little bit earlier this week about comparative effectiveness research (CER) and the role of cost effectiveness in this research. At ACC's Medical Directors' Institute, a variety of views on the topic were given. Tell me what you think below (and check out what others have said in previous posts on the topic).

 

In yet another attempt to reach the president and administration officials about the proposed 2010 Medicare Physician Fee Schedule, the ACC tomorrow will run an ad in four different major newspapers -- Washington Post, New York Times, Chicago Tribune and USA Today -- decrying the cuts. We're just a couple of days away from the release of the final rule; we must pull out all the stops in preventing these cuts from being finalized.

President Bove, SVP for Advocacy Jim Fasules FACC, and I met with the top brass at CMS last week to try to ascertain what’s going to happen.  We met with CMS Acting Administrator Charlene Frizzera, Deputy Jonathan Blum and several CMS physician division chiefs for a long discussion on the implications of the Rule if it proceeds as proposed. 

The CMS principals had not considered the likelihood that this rule would devastate private practice of cardiology as it will (they have been considering those predictions merely exaggerations of the effects by us). In essence, they continue to see this is an 11 percent cut (bad enough!), not wanting to connect that to the cuts in support staff, support services (echo and stress testing, etc.) that create the actual 27 percent average reduction in practice revenues. CMS leaders did cringe at the contemplation of a 27 percent cut, and I believe they are now going to have to look squarely at the implications of it for the Obama administration; this will cause a number of problems on their watch that they have not anticipated, including:

• About two-thirds of CV patient care access will be threatened as practices close — the worst effects will be in rural states, suburbs and away from large academic centers and integrated systems. Seniors will scream bloody murder.
• The same hospital-based cardiology clinic and diagnostic services cost two to four times more than equivalent payments to private practices in the outpatient setting — this will drastically increase Medicare costs at a time when “bending the cost curve” is the big goal. We must not forget that CV care is 43 percent of Medicare, and this will have an impact they have not anticipated. It’s dumb.
• The shift of cardiologists to hospital employment and other employment venues will have significant repercussions for chronic disease management. Such has occurred in parallel when a large number of general internists were forced for financial reasons to close their practices and become hospitalists.
• Medicare beneficiaries will suffer a Part B premium increase as the costs of lab services, etc., rise. It’s a veritable tax on seniors as well.

CMS wants to continue to message that the survey reflects the current environment of practice expenses fairly (perhaps with a few inevitable glitches), and that their processing of the AMA survey data was not done with any political purpose or manipulation. I believe they are sincere in this. But, one could tell they were disturbed as they confronted a 27 percent cut as reflecting accurately the actual practice costs of cardiology over the past year -- and then they weren’t thinking about implications. It just doesn’t make sense. 

Next Steps
So, what now? The secretary still has not opined on the staff submission of the Final Rule, nor apparently has OMB (Office of Management and Budget) in the White House. I would think the attendees at this meeting will probably be making a few phone calls to ask what should be done -- if anything. They were pretty frank in asking us a recurring question: “What can we tell the Secretary or the President that would explain why we shouldn’t follow our regulations and put the rule out as prescribed?” We gave them plenty of things they could say, like, “You did not validate the data;” “AMA did not validate the data;” “The data for CV practices is not valid;” “The implications on the adverse effects to private practice of cardiology will be horrific;” and “I don’t want to be here when this happens.” Neither do we. 

It is possible that some heroic measure will be attempted. But we need to start developing our legislative, legal and other contingencies because this was not an encouraging meeting. But, we’re doing a lot more than meeting again with CMS:

First -- On the Congressional front, the ACC is keeping up the pressure on Capitol Hill. More than one-third of Congress has registered concerns about the proposed rule with either by letters or calls to CMS and Health and Human Services Secretary Kathleen Sebelius. We continue to hear from members of Congress that your individual calls, letters and visits are making a difference. In several cases, the personal stories about the impacts of the cuts on patients and practices have made such a difference that members are prepared to support emergency legislation should it be necessary. 

Second -- I have met directly with Obama administration officials to highlight the gravity of the cuts, particularly at a time when the administration is looking to increase access to care as part of its health care reform agenda.

Third -- While I can fully assure you that we are at the table and working to stop the cuts, we are also working to mitigate the impacts of smaller cuts on your patients and practices, including those related to new nuclear codes slated for Jan. 1. In an effort to help your practice plan for these changes, the ACC has developed a practice expense calculator that you can use to gauge the impacts on your practice. (This is also a useful tool when talking to members of Congress about the specific affects of the proposed rule.)

Further -- See the ad mentioned above. 

Finally -- ACC President Fred Bove, FACC, and I will be hosting an all-member call on Nov. 12 from 4 p.m. to 5:30 p.m. (EST) to discuss the 2010 rule. RSVP for the call now. I strongly encourage you to attend this call, where we will provide an overview of the final rule, as well as answer your questions about next steps.

If this rule goes through as is, it will literally devastate the private practice of cardiology and outpatient access to cardiovascular care. We can’t let this happen.

The ACC annual Medical Directors’ Institute (MDI) was held this week at the Park Hyatt and Heart House in Washington. The topic was comparative effectiveness research and implementation. It was a terrific policy discussion which included dynamite presentations from AHRQ Director Carolyn Clancy, the UK’s CER agency NICE, Canada’s similar entity, the US Veterans’ Administration, the CMS, the National Health Council, and many other stakeholders in addition to ACC senior leaders, governors, and staff. We strongly support CER, and also want to make sure it proceeds along the lines of a patient-centered, socially responsible, and scientifically excellent path through some difficult political minefields.

The timing for this MDI was perfect in that ACC had just published our own CER policies and principles, called “ACC 2009 Advocacy Position Statement: Principles for CER.” The position statement offers nine principles for CER, outlined in brief below:

• The ACC strongly supports CER as a way of having informed decision-making.
• CER priorities should be set by a multi-stakeholder group to ensure that the research agenda reflects the needs of the country. The research agenda should be based the burden of the disease being considered, mainly morbidity and mortality.
• The ACC recognizes that the research on comparative effectiveness is “only the first step in improving the quality, equity and efficiency of medical care,” and stresses that improving quality must be the primary aim of CER.
• CER should be distinct from entities that create coverage and benefit programs, and requires close monitoring to avoid adverse consequences on access, quality or safety.
• The ACC recognizes that CER will require substantial and long-term financial support.

The paper then goes on to outline how the ACC can participate in the CER process, including informing priorities through our clinical documents, like guidelines and appropriate use criteria, as well as our registries (NCDR) and providing standardized data elements and definitions. In addition, the ACC has the ability to disseminate CER findings to patients through our large membership. The policy statement concludes: “The ACC believes CER research, when conducted correctly, is a useful tool that assists physicians and other providers in delivering high-quality, equitable and effective health care to patients.”

Comparative effectiveness is a frequent topic on this blog (see the post from John Brush, M.D., F.A.C.C.), and clearly has the potential for good – improved quality – and, if done poorly, a potential for evil – reduced access to needed treatments. Because of its potential for evil, I strongly believe that comparative effectiveness needs to happen separately from any cost comparison. This is necessary to maintain physician and patient (consumer) trust that CER is untainted scientifically from societal/government pressure to reduce costs.

Those are my thoughts on CER ... but there have certainly been some spirited discussion by our CER experts here at MDI that disagree with me. We’ve had some great speakers, including a senior scholar at the Institute of Medicine Michael McGinnis, M.D., M.P.P., Myrl Weinberg, president of the National Health Council, panels that include representatives from the Canadian Agency for Drugs and Technology in Health and U.K.’s NICE, and Carolyn Clancy, M.D., of AHRQ representing the U.S., and a briefing from Michael Rapp, M.D., of CMS, among many others.

UPDATED 10/28: New CVN video on "Perspectives on CER" with an introduction from SVP of Science & Quality Janet Wright, M.D., F.A.C.C., and thoughts on CER from attendees of MDI.

BIG news this morning from the ACC. After learning some lessons from our pilot program IC³, the ACC is launching the first-ever registry-based network for cardiology practices, called the PINNACLE Network. Its goal is to give practices the tools they need to be both innovative and high quality.  Learn more from the press release below or watch the CVN video.

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AMERICAN COLLEGE OF CARDIOLOGY LAUNCHES THE NATION’S FIRST
REGISTRY-BASED CARDIOVASCULAR PRACTICE NETWORK

Washington, DC – The American College of Cardiology today announced the launch of the PINNACLE Network, the first-ever registry-based cardiovascular network to link thousands of cardiology practices to each other and to the ACC’s National Cardiovascular Data Registry (NCDR), the preeminent cardiovascular data repository in the United States.

The PINNACLE Network™ immediately addresses the rapidly shifting business environment that private cardiovascular practices face with a wealth of practice management and financial management tools. The PINNACLE Network™ also builds a foundation for innovative, registry-based systems to reward practices for the high quality care that they provide.

“With the legislative and regulatory threats to traditional payment systems and the emergence of value-based payment programs, the ACC is in a unique position to develop and offer the PINNACLE Network™ with its suite of practice management tools to help practices not only survive but thrive,” said Alfred A. Bove, M.D., Ph.D., president of the ACC.

A comprehensive practice management system, the PINNACLE Network™ provides financial management tools to help practices thrive; workforce strategies to enable physicians to meet the increasing demand for cardiovascular care; guidance for the adoption of health information technology; and risk management education and strategies to lower the cost of liability premiums.

The PINNACLE Network™ will provide access to data management systems that translate data into clinical insights and leverages the power of the ACC’s national data registries to give practices negotiating power with payers for value-based payment systems.

“Embedding quality improvement and value-based payment in the natural flow of practice operations will be the foundation for a practice’s success clinically, financially and professionally,” said Janet Wright, M.D., the ACC’s senior vice president for Science and Quality. “By creating health information technology solutions for using ACC Guidelines and Appropriate Use Criteria at the point of care, the PINNACLE Network™ will show patients, colleagues and the health care community that we are delivering the right care for the right patient at the right time.”

The PINNACLE Network™ is powered by the PINNACLE Registry™, the nation’s first operational office-based data registry and will provide a centralized system for clinical practices to promote practice innovations and achieve clinical excellence.

The PINNACLE Registry™, designed by cardiologists, benefits from its two-year pilot phase as the IC3 Program and now will be integrated into the NCDR® to provide participants with access to both hospital and ambulatory patient-focused data. As one of the largest practice-level scientific efforts undertaken in the United States, the IC³ Program®, now the PINNACLE Registry™, contains hundreds of thousands of clinical patient records focusing on four common cardiac conditions -- coronary artery disease, hypertension, heart failure and atrial fibrillation.

For more information on the ACC’s PINNACLE Network™ visit www.pinnaclenetwork.org.

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.

 

Kaiser Permanente’s CEO George Halvorson called for a celebration this month for the successes of a program launched decades ago they call Archimedes. It is a computerized artificial intelligence system that creates models of the human body and then projects the probable impact of care and treatment approaches. Archimedes has been used to do a couple of clinical trials and ended up with results that matched the actual clinical trials done on live patients. They routinely use it to improve care. And it works.

One of their primo researchers, David Eddy, M.D., just did a large scale test of Archimedes relative to the prevention of heart attacks and strokes. One of the scenarios that the researchers ran through Archimedes looked at what might happen when a mixture of prescriptions that science has suggested are helpful in CAD was combined to prevent heart attacks and strokes. (The drugs considered were aspirin, Lisinopril, and a statin). There was no tool to do that study. So they used Archimedes and ran a computer experiment with their own patient database.

Archimedes predicted that a "bundled" prescription of heart protective medications would reduce the risk of heart attack and stroke for the Kaiser Permanente high-risk populations by 71 percent. They missed by a bit. Over the course of three years, the three drug program actually prevented 1,271 heart attacks and strokes. That reduced the occurrence of heart attacks and strokes for the covered population by 60 percent instead of the 71 percent projected by the system.

300 media outlets have picked up this story. The world now knows that the simple combination of medications in KP's Aspirin-Lisinopril-Lovastatin (A-L-L) initiative -- this will have a potentially greater impact on emerging nations that can’t afford interventions I suspect. It’s very interesting stuff. And, they’re spreading the option to participate across their entire population, and 250,000 have signed up to try it with disease management and/or early risk factors.

It’s impressive -- they’re using predictive modeling, targeted member outreach, and computer-supported care to get real results. Hats off to KP and Archimedes.

*** Image info: http://www.flickr.com/photos/gi/ / CC BY-SA 2.

The tension related to the Medicare 2010 Physician Payment Rule is mounting. CMS must already have some idea what it plans to do on Nov. 1 when it must give public notice of its proposed final rule (which still has to be signed off by the OMB and the White House). But, we have no idea where CMS is going with it. There are lots of rumors.

The best thing would be for CMS to amend this before they issue it. I believe I impressed the White House last week on the importance of this, and I further know the WSJ editorial has had an impact. If primary care were to have a guaranteed payment update through another mechanism to take the pressure off this issue, CMS might be willing to hold up the Rule for all specialties until the validation of the data could be undertaken more responsibly.

ACC has always been a solid supporter of helping out our beleaguered primary care colleagues. As such, we are considering sponsoring a parallel bill to health care reform that would give primary care a needed boost directly as part of reform, and without the unintended but very bad consequences of trying to reallocate payment and reimbursement from specialties to primary care in a zero sum game. In CV medicine, we will face serious shortages as the tsunami of obesity and diabetes-related CV morbidity crashes toward us. If the Rule proceeds, a cardiology access crisis will immediately follow.

So, if such primary care legislation were to succeed, the Rule might more palatably be delayed with respect to non-primary physician specialties until the obviously unrepresentative data could be validated and a fair, amended rule could be issued. But this would be a very difficult maneuver to create. It’s our aim that CMS undertake to remedy the situation NOW on its own. Given the catastrophic consequences of its implementation otherwise, all of our energy and resources are focused on amending or delaying the Rule. ACC President Alfred Bove, M.D., F.A.C.C., and I will host an ACC all-member call on Nov. 12 from 4:00-5:30 p.m. (EST) to discuss the 2010 rule. To RSVP for the call, click here.

There's just two days left before the official launch of Hospital to Home, ACC's quality initiative to reduce 30-day all-cause, risk-adjusted readmission rates for heart failure or AMI by 20 percent nationally by 2012. Check out this video with Harlan Krumholz (following his blog post here). Also, don't forget to enroll in the initiative and register for Thursday's launch Webinar (1 p.m. EDT) at http://www.H2HQuality.org.

Senator Debbie Stabenow (D-Mich.) produced what could turn into a major miracle in Congress this week with the introduction of S. 1776. The bill would eliminate the (un)Sustainable Growth Rate (SGRrrr*) formula for the next 10 years, without creating the budgetary impact of $245 billion of accumulated debt associated with the formula that the Congressional Budget Office (CBO) requires to ‘pay for it.’ In essence, Stabenow would consider paying off the SGRrrr debt by making it a contribution to the multi-trillion national debt, not a 2010-2020 budget cost. The bill thus would eliminate the Pay-Go rule. Although Congress has taken similar actions for the Stimulus and to pay off part of the Alternative Minimum Tax hit, recognize that this is done VERY rarely.

The House attempted to do something similar to get rid of the SGRrrr in HR 3200, which prompted the AMA and American Academy of Family Physicians to support the entire bill; but including the SGR elimination as part of health care reform causes the CBO to chalk up the debt cost as part of the cost of reform. S. 1776 is a better and parallel approach.

ACC was called by Sens. Reid and Baucus this week and asked to support this radical move, which Mr. Reid (D-NV.), Mr. Dodd (D-CT.) and Mr. Baucus (D-MT) also believe is necessary. No problem getting our support -- we’ve been trying to get rid of this nightmare for 10 years. Action on S. 1776 will of necessity have to move with lightening speed. It will move fast, or die fast. Getting this albatross off our necks would be a major plus for all of medicine.

If S. 1776 doesn’t pass, Congress will definitely kick the SGRrrr can down the road and propose another one-year band aid patch on it as they do every year.

Again, the AMA deserves great credit for delivering on this SGRrrr issue if it happens. To underscore how much momentum is behind it, AARP is teaming up with AMA to get S. 1776 enacted and is contributing 50 percent of the advertising cost to a major multi-million national TV campaign. We need our constituency to call your Senate office and ask them to vote YES on S. 1776 this coming week to promote security and stability in seniors’ access to Medicare physician services.

(* note  --“SGRrrr,” for those of you new to the Blog, just adds a ‘growl’ to SGR)

*** Image from Flickr (YardSale). ***

We still have no responses from HHS or CMS (Medicare) to the strong letters of concern we sent to them from an impressive number of more than 25% of the members of Congress regarding the impending and flawed 2010 Medicare Physician Payment Rule. Our campaign on this issue has been and continues to be powerful. This silence is both frustrating and unnerving.

We are hopeful the White House and HHS will be motivated to meet with us and to modify the Rule at this point. I did have a chance to meet with Health Czar Nancy Ann DeParle and her team about our concerns with the Rule in the White House this week. They are all aware it is a mess.

What are our options at this point? As we draw ever closer to the Nov. 1 deadline for the issuance of CMS' final rule, many of us are hearing conflicting reports about our options and what CMS may or may not do now.

Here’s the story: CMS by law must have a rule publicly issued by Nov. 1 (that’s a Sunday, so we’re expecting news by close of business Friday, Oct. 30).  That rule, of course, needn't be the current proposed rule. CMS can:

1. Place a moratorium on implementation until it can analyze the data and recommend changes;
2. Use the 2005 data with or without inflation adjustment;
3. Blend the 2005 and Physician Practice Information Survey (PPIS) data;
4. Phase in new recommendations as outlined above in No. 2 and No. 3; or
5. Let the rule stand.

We are urging the first possibility. We would have to evaluate the details of the following three bullets, if proposed. We would vigorously oppose letting the Rule stand, of course. While CMS can change the PROPOSED rule, only Congress could change or prevent the FINAL rule. One other important point: The Secretary of HHS signs off on the Rule, but must have the review and approval of the White House OMB (Mr. Orszag) as well -- so advocacy there may be important going forward if HHS isn’t communicating a workable option to prevent the demise of outpatient and community cardiovascular practices.

In any case, even with the temporary reprieve resulting from option 1, there would likely still be modest cuts to payment for cardiologists -- just not as draconian as those that would result if the proposed Rule went into effect. 

Continue your calls to your lawmakers about this critical issue. This battle is not about preventing the cuts; it's about saving the private practice of cardiology, and preserving access to care for the vast majority of CV patients who rely on these practices.

*** Image from Flickr (Suviko). ***

Today’s post comes to us from Harlan Krumholz, M.D., F.A.C.C., the Harold H. Hines, Jr., professor of medicine at the Yale University School of Medicine. Harlan is a well-known leader in advocating for improvements in cardiovascular quality. Not only did he lead ACC’s successful quality improvement program “D2B: An Alliance for Quality,” he currently serves as the co-chair of the Hospital to Home (H2H) steering committee. Outside of his work with the ACC, Harlan is also heavily involved in the Centers for Medicare and Medicaid Services’ efforts to develop national measures for public reporting of hospital performance.

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Over the last several decades, the cardiology community has led our profession in generating new knowledge and seeing it applied for the benefit of our patients. Recently, we dramatically improved door-to-balloon times – moving in rapid progression from an era where only one-in-three patients were treated within the guideline-recommended 90-minute timeframe to now, where almost 90 percent of our patients are treated within that benchmark. Remarkable.

Another chance to lead lies before us. On Oct. 22, the ACC, in partnership with the Institute for Healthcare Improvement, will launch a major quality improvement initiative called Hospital to Home (H2H)… this time focusing our quality efforts on readmission rates. Currently, about 20-25 percent of our patients hospitalized with an acute myocardial infarction (AMI) or heart failure are back in the hospital within 30 days. Many of these admissions are preventable through improvements in the transition from inpatient to outpatient status. Unfortunately, we have often neglected this vulnerable transition period for patients.

Gaps in Care
We have many obvious gaps in care – patients often leave without information about the hospitalization being transmitted to other caregivers in a timely way; without access to medications; without appointments being set; and without an emergency plan for if their condition suddenly worsens. Studies have shown since the 1990s that improving the handoff between the hospital and the “home” can lead to a reduction in readmissions by addressing these gaps. Our fragmented health care system places many barriers in front of health care providers in putting known methods into practice. To reduce readmission rates, we’ll need to make special efforts to focus on transitions and most importantly – to focus on the patient, specifically, making efforts to ensure that the patient is ready and knowledgeable enough to manage their care – and that the system is poised to provide the support they need.

H2H Goals – Just the Beginning
H2H will assist providers in overcoming the systemic barriers to improving readmission rates. The initiative is committed to reducing 30-day all-cause, risk-adjusted readmission rates for patients with a diagnosis of heart failure or AMI by 20 percent nationally by 2012. In HF, that would take the rate from about 25 percent to about 20 percent. This goal is ambitious – but we aspire to produce a substantial benefit for patients.

H2H will leverage other national initiatives contributing to a reduction in readmission rates and will harness the collective knowledge, creativity and energy of its key strategic partners -- Kaiser, the Veterans Administration, the American Hospital Association, The Joint Commission, PREMIER, HCA -- and others to reach this goal. In my opinion, the 20 percent reduction is just the beginning of what we can achieve through our collaborative efforts. The path is more challenging than ever because of our goal of actually affecting patient outcomes, but we are bringing together expertise, resources, tools and a mechanism for us to learn from each other to meet this goal.

For those of you who want to be part of this effort, you will not be alone. We already have more than 250 facilities (e.g., hospitals and medical practices) that have joined us. Teams will be anchored at hospitals but will stretch across the continuum of care. We will track progress and, ultimately, assess whether we decreased preventable readmissions through improved care. We want this effort to equip teams for success.

Join Us in Reducing Preventable Readmissions
For more information, visit: http://www.h2hquality.org/, or email hospital2home@acc.org. H2H officially launches Oct. 22 with a Webinar explaining the initiative in greater detail. To join the Webinar, please register in advance online. If you are unable to attend on Oct. 22, you will be able to access the Webinar archive through our Web site.

We want to again show the nation that the cardiovascular community knows how to get results for our patients. We hope you’ll join us for this exciting initiative.

* Dr. Krumholz'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!

The Senate Finance Committee voted earlier today 14-9 to approve the America's Healthy Future Act. All the Dems voted for it, and Sen. Snowe was the only Republican who voted for it. The committee's approval allows the process to proceed to merger with the Senate HELP bill and then to the floor. The Congressional Budget Office (CBO) has estimated that the bill would cost $829 billion over the next decade and reduce the deficit by more than $80 billion. One reason it's less costly than the House bill is that it doesn’t fix the SGRrrr.

The CBO has slowed activity in the House as they analyze costs and debate whether the House SGR fix must be added to the cost of HR 3200. So, floor action there is unlikely in the next two to three weeks; and the Senate will take some time to sort through their issues as well as they try to merge the Finance and the HELP Committees bills. In terms of more details about the activities on the bills:

First, on the House side:

• The caucus considered several options for reducing the gross cost of their bill to $900 billion, none of which had great appeal to House members.  But that does seem to be an agreed-upon goal. And CBO is watching.
  
  
• The conversation regarding the public option revolved around a version that would use Medicare +5% rates, negotiated rates, or “some combination thereof.”  The last reference appears to suggest a trigger-like mechanism for starting with negotiated rates but moving to Medicare-like rates if savings targets are not achieved – an idea discussed in some of this morning’s press reports.  In sum, a “robust” public option appears likely in the House.  Leadership’s strategy is that is the best means of producing the left-most version in conference, although with the Senate heading for 60 or 61 votes at most, how far that issue can shift in conference is dubious at best.
  
  
• One means of lowering the cost of the bill that’s being considered in the House is to raise the Medicaid eligibility threshold from 133% of poverty to 150%, with the federal government absorbing most, if not all, of those incremental costs.
  
  
• The high-end insurance plan tax is unlikely to be included in the first House-passed bill, although many caucus members acknowledged some version of it is likely to come out of conference with the Senate.

Then, on the Senate side:

• “Rule 28”, which prohibits extraneous provisions from being included in House-Senate conference negotiations, will apply to the HELP-Finance merger process.  Staff for both committees have been adamant that provisions not included in either the final HELP or Senate bills will not be considered at this stage.  We predict that “rule” (more of a “guideline,” as Dr. Peter Venkman would say) will get broken at least once, but it is an added barrier to new issues being introduced to the process in the near term.  The “Manager’s Amendment” laid down once the Senate has moved to the reform bill could include new provisions, and there will likely be extensive consideration of amendments on the floor.
  
  
• Due to the fact that the $81B “surplus” in the Finance bill is “off budget” – because it is derived from new payroll/Social Security tax revenues – we think it is unlikely that the provider “fees” and other offsets and revenue raisers in the bill will change meaningfully during the merger process with HELP.
  
  
• Many Senate Democrats do not consider this the final word on, or even as necessarily relevant to, the public plan debate in that chamber.  Sens. Carper and Snowe continue to push their approaches to a fallback public plan, with the key distinction being Carper’s is almost exclusively state-managed, while Snowe’s would entail a single, federally-chartered corporation that would administer the state-based plans where the trigger has been pulled.  Neither appears to have made significant concessions to the other at this point, but inclusion of some compromise version looks probable via an amendment on the Senate floor.

Every day these and other issues are being debated and debated. We’re in there, pushing for the SGR fix, tort reform, and protection of the physician right of ownership, among other issues. And, we’re always reminding everyone about the 2010 Payment Rule debacle -- and asking they do something about so we can turn our attention to reform.