On Monday I attended a plenary about managing patient expectations in the face of the current cost-savings-focused environment. As doctors, we sometimes find that patients want the most expensive care or the most tests as part of their treatment because they view it as the “best” care they can receive. However, this usually isn’t true. The best care is the care that’s been validated by science – and high quality science at that. This can be difficult to come by, even in the field of cardiology, which compared to other specialties, has some of the best research available.

Why does cardiology have some of the best, most comprehensive research? Because cardiology has registries, and we use them to collect data in real-life, which we then turn into the research that informs the clinical documents that guide everyday practice. The ACC has a suite of six registries (NCDR) that together pull research from nearly 2,000 hospitals and 180 practices (yes, one of those registries is an ambulatory registry – the PINNACLE Registry -- formerly called the IC3 Program).

At AHA, research from the NCDR is making quite an appearance. There’s a total of 14 abstracts from the NCDR out at AHA, which hopefully you had the opportunity to check out: five abstracts from the CathPCI Registry; four from the ICD Registry, one from the CARE Registry, two from ACTION®-GWTG™ and two from the IC³ Program (now the PINNACLE Registry).

Of particular excitement are the two abstracts from ACC’s IC³ Program/PINNACLE Registry. The first is an oral presentation by Paul S. Chan, M.D., M.P.H., on “A Report of the First 10,000+ Patients.” The study found nearly three in five enrolled patients had coronary artery disease (CAD) and all the outpatient performance measures (PMs) could reliably be assessed. Adherence to the CAD PMs was often suboptimal, suggesting substantial opportunity for improving the quality of outpatient care.

The second (a poster presentation by ACC staff members Kristi Mitchell, M.P.H., and Sunil Gupte, Ph.D.) is “Electronic Medical Record Adoption in Cardiology Practices: A 2009 Snapshot.” This study found EMR adoption within PINNACLE Registry (then the IC³ Program) is slightly greater than that reported in the literature and may be due to the greater number of large practices enrolled. The PINNACLE Registry provides a foundation to analyze EMR adoption and implementation rates in U.S. cardiology practices and to observe trends associated with reducing some of the financial barriers due to the recent provision of federal funding. As such, the PINNACLE Registry will be positioned to determine the impact of EMR usage on clinical quality and patient outcomes.

The large number of abstracts presented at the meeting is a testament to the rich evidence coming from these groundbreaking registries. We need to keep moving forward with our efforts so that ALL clinical decisions can be made on the basis of the strongest level of evidence.

UPDATED: 11/19 with video.

AHA kicked off its meeting with an opening session featuring AHA President and ACC member Clyde Yancy. Yancy helps lead the Coalition to Reduce Racial & Ethnic Disparities in CV Outcomes (CREDO), a joint society effort that stresses research (how accurately can we describe the present disparities?) and action (once identified, how can we target the areas to improve care?). Learn more about it from an interview I conducted with Clyde back in July.

Also speaking during the opening session was Thomas Frieden, M.D., M.P.H., director of the CDC. Dr. Frieden has been a friend to cardiology over the years through his efforts as commissioner of the New York City Health Department, where under his watch, the city cut smoking rates in teens and adults, eliminated trans-fats from restaurants, rigorously monitored the diabetes epidemic, and required certain restaurants to post calorie information prominently.

Another interesting bit on Frieden’s resume: As NYC commissioner, his department ran the largest community EHR project in the country, following a request from Mayor Bloomberg (another friend to cardiology). The project focused on getting EHRs into community health clinics to improve quality and now includes more than half of the doctors caring for patients in Harlem, the South Bronx and Bedford-Stuyvesant – low-income areas that would typically be the last to have access to such technology.

Dr. Frieden’s is an interesting approach – providing low-cost EHR and implementation support – to making sure that practice are able to implement technology. Outside of this program, you find that many offices, particularly those in small practices of one to three practitioners, face significant barriers to adopting technology. Even though the federal government is offering significant funds to help urge adoption, practices face high upfront implementation costs for health IT (we’re talking $124,000 over five years, with only $44,000 in incentives to offset the costs). That’s daunting – and many may not be enticed by the incentives knowing the cost of implementation.

However, our challenge is in reaching out to these docs to communicate the bigger picture: reduced costs and gained efficiencies—not to mention higher quality care for our patients. Getting engaged in health IT will provide the best chance of keeping smaller practices viable in the coming era of payment reform. (If you’re interested in health IT, you should come to ACC.10, where we’ll have a day-long spotlight session on the topic.) The ACC also has great resources online at www.acc.org/healthit.

***Image from Flickr (Prasan Naik)***

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.

Yesterday I arrived in San Francisco for the TCT (Transcatheter Cardiovascular Therapeutics) conference, a yearly interventional cardiology meeting. Meetings like TCT provide an opportunity for interventional cardiovascular professionals to stay up-to-date on the latest science, technology and procedures. When it comes to cardiovascular education, the traditional paradigm is under attack and a new -- and more relevant -- platform is emerging. Not only are there new tools linking education and quality, but CMS, Congress and others are increasingly focused on education linked to licensing, certification and credentialing.

The ACC is actively addressing these issues by providing an integrated approach to life long learning. This includes developing opportunities for cardiovascular professionals to measure, track, and improve their performance, and, thus the quality of care they provide to patients. We are planning to help members meet and excel in the face of these new requirements. I like to think we’re leading the revolution in cardiovascular life long learning.

Meanwhile, we’re leveraging ACC’s quality resources like our registries, guidelines, performance criteria and expert faculty to facilitate this revolution. A great example of a new tool is our IC3 Program – our pioneering registry focused on the ambulatory setting. IC3 allows participants to benchmark their clinical performance, compare with others, and make adjustments where necessary -- and to participate easily in various new payment incentive models. 

All this talk of education and measurement isn’t going away anytime soon. We’ve got to adjust and take steps to thrive in a changing environment -- by directing and leading the change.

That said, if the frustratingly ill-crafted proposed CMS 2010 Physician Payment Rule is not taken off the table for cardiology, we’ll be diverted away from leading in the health reform charge in order to deal with a vestigial example of what's very wrong with the current environment and payment system. The proposed Rule would reduce practice revenues in outpatient cardiology by 20-40 percent, essentially devastating community cardiology practice. This is occurring in parallel to an opportuntiy for real and positive system change. What tragic timing -- and what a painful example of the problems and archaic nature of the current HHS and CMS systems (see my last post for more of my views on this). 

*** Image from Flickr (Paraflyer). ***

ACC Senior Vice President of Science and Quality Janet Wright, M.D., F.A.C.C., and I were invited to attend a special meeting sponsored by NQF (National Quality Forum) on “enhancing physician performance.” The forum, which included ABIM (American Board of Internal Medicine) and the sister boards of family practice, surgery, pediatrics, internal medicine, ophthalmology, consumer groups, insurers, and business and consumer leaders, focused on primary care, prevention, new forms of payment, quality measurement, patient engagement, comparative effectiveness research and workforce issues. Key themes that came out of forum were the need for a quality-centered environment, patient-centeredness, a resurgence of professionalism and the need to reduce waste and ineffectiveness.

That all sounds familiar. But, the meeting was a refreshing conversation about how to actually improve performance. MOC is one way -- and that’s what this meeting was mainly about. But, ACC believes that registries (NCDR and IC3) could create an MOC environment where doctors demonstrate on a continuous basis quality competence and more desirable outcomes.

*** Image from Flickr (a.drian). ***

The ill-crafted Weiner-Braley amendment to HR 3200 (which would eliminate the ability of physicians to provide advanced diagnostic imaging services in their offices beginning in 2013) was not heard last week before the historic vote. But it has not gone away. Chair Henry Waxman will hold a special session of Energy and Commerce, with participation of Ways and Means and Education and Labor representatives, to hear more than 60 proposed amendments to the bill, including potentially the Weiner amendment. This will happen as soon as the House is back in September.

So we need everybody mobilized this month to meet with their members of Congress during this recess, and to be eloquent and emphatic about how damaging to access and patients this amendment would be if included (the House members are already mostly home in their Districts; the Senate will stay in session for a few more days, but will be on recess by the end of this week). We need for Congress to understand the importance of making the leap to REAL reform -- which would make this amendment and the whole self-referral debate moot. We need therefore to frame our conversation with members of Congress in terms of our support for true payment reform to promote patient-centered and evidence-based care leading to improved quality, outcomes, and efficiency.

Leading By Example
ACC Chapter Gov. George Crossley, M.D., F.A.C.C., is an example of how to do just that. He was featured in an opinion piece on health care reform in the Tennessean on July 28. Dr. Crossley writes, “There is a right way and a wrong way to reform our health care system. And while opinions clearly differ on right and wrong in the halls of government and at our nation's kitchen tables, one aspect of reform cannot be overlooked: doctors.” Crossley also addresses the payment cuts that would result from the proposed 2010 Physician Fee Schedule when he writes that the “large-scale arbitrary cuts” will inhibit cardiovascular professionals’ ability “to make great strides in how patients with heart disease and other illnesses are treated.”

Electronic health records (EHRs) do not offer complete data to gauge performance, according to a new study in the Agency for Healthcare Research and Quality's Research Activities by Jeffrey Linder, M.D., of Harvard. Linder's research showed that EHRs were often inaccurate in determining the actual cause of a patient visit (688 encounters were billed as pneumonia, but chart reviewers found only 198 actual visits for pneumonia). A large portion of the data in the EHRs was not coded, which makes data extraction for care measures difficult.

This says to me that we’re on the right track with our NCDR registries, with their validated data elements, and with our advice that EHRs be integrated with data registries where possible.

In other registry-related news, the IC3 Program is growing by leaps and bounds! We added a whopping 100,000 patient records this week alone. Amazing. This kind of patient data in our ambulatory registry will really move the needle on quality of care.

Meanwhile, the IMPACT Registry Pilot is on schedule to launch in August for six months to test the usefulness of data elements and the feasibility for data collection. The official launch of the registry is slated for 2010. The IMPACT Registry will be the first national registry to provide data about the demographics, acute management and in-hospital outcomes for a comprehensive selection of patients undergoing diagnostic catheterization or catheter-based interventions for congenital heart disease.

Little is known about the population of patients with congenital heart disease, particularly with respect to the use and outcomes of catheterization and interventional procedures.  To date, most resources have been applied towards increasing the understanding of the anatomy and physiology of congenital heart disease, as well as the natural history of common defects.  National guidelines have been published which provide recommendations for the appropriate use of diagnostic catheterization, interventional catheterization and surgical treatments.  However, because studies performed in congenital heart disease are generally small in number, and because prior registries of congenital heart disease have been limited in scope, there is a paucity of data relating to the use of diagnostic catheterization and catheter-based interventions, and to the morbidity and mortality associated with these procedures.  Current national guidelines were derived primarily from expert opinion, and there is a strong need for data to allow optimization and refinement of the guideline recommendations.

A group of ACC leaders and staff met this week to develop a bold agenda for maximizing the appropriate use of cardiac imaging. This new initiative, called FOCUS (Formation of Optimal Cardiovascular Utilization Strategies), aims to minimize geographic variations in cardiovascular imaging and reduce unnecessary imaging by 15 percent through the development of educational programs and data collection and measurement tools that help put appropriate use criteria directly at the point of care.

While still in the development phase, this initiative is critical, particularly as the debate over health care reform continues and lawmakers and others look to imaging as an area to cut costs. The ACC strongly believes that the use of appropriate use criteria at the point of care is a viable alternative to unilateral cost cuts that don't take into account appropriate use of imaging.

But, given the entries that preceded this one, get the IRONY: Here we are diligently working on reducing unnecessary or inappropriate imaging, while Congress continues to apply blunt instrument price cuts that will not truly reduce costs, and will result in disparities by which lower income families will not have access to appropriate and needed images. This is nuts.

A paper published in the May 19 issue of the British Medical Journal found delay in door-to-balloon (D2B) time is associated with higher mortality rates in patients undergoing PCI. (Surprise!) The study was based on data from the ACC's National Cardiovascular Data Registry (NCDR). Median D2B time was 83 minutes. The adjusted mortality rate for PCI by 30 minutes was 3.0 percent, while those with D2B times of 240 minutes had a mortality rate of 10.3 percent. The goal of the D2B Alliance for Quality (90 minutes) yielded a mortality rate of 4.3 percent.

The authors state that "their data support calls for an 'as soon as possible' standard for patients undergoing primary percutaneous coronary intervention." But how fast is too fast? Share your thoughts ...

There’s been a lot of talk about a surprisingly high degree of bipartisan collaboration on the Senate congressional committees working on health reform, despite the lack of similar collaboration in other debates. But, now, as the HELP Committee and the Senate Finance Committee work in private to complete their reform proposals this month, there’s quite a bit of nail-biting about whether the Republican principals on the committees will defect or stay with the team. In Senate Finance, Chairman Baucus (D-Mont.) has always been very collegial with ranking member Sen. Grassley (R-Iowa), as well as with member Sen. Hatch (R-Utah). After all, they’re all from relatively similar rural state environments. Nonetheless, Hatch and Grassley have a list of complaints (the biggest one being the “public plan” concept) and we are beginning to hear rumblings of their desire to strike a different course. In the HELP Committee, ranking member Sen. Enzi (R-Wyo.) has heretofore been pretty chummy with Chairman Kennedy (D-Mass.), but he’s under pressure from his Republican colleagues to run for cover.

Meanwhile, Sen. Coburn (R-Okla.), a physician, has developed an alternative Republican bill based on tax credits and voluntary expansion of access, rather than expansion of entitlement public coverage — this is the concept Congressman Paul Ryan (R-Wis.) praised last week. To please fellow physicians, and differentiating his measure from the Dem bills this far, Coburn also has a medical malpractice section in his bill, albeit it is focused on health courts and a few other nice provisions—but far short of a cap on non-economic damages (what we really need). If a split occurs along partisan lines to support Coburn, even though it has no chance of passing, the Senate will have to resort to a max of 60 votes to get a reform bill passed, and adopt a strategy that could break into pieces if just one defector among the Dems emerges. So, there’s a lot of nervousness about what compromises will be needed to keep everybody together, aiming for the support of 70 senators on a bill that would constitute a real mandate for reform.

The House is typically much more partisan—and the Republicanss there complain that aren’t even being consulted on the Democratic plans. However, I hear from the White House that there is a surprisingly strong collaboration among the three relevant and traditionally argumentative House committees — Ways and Means (WAM), Energy and Commerce (E&C), and Education and Labor (E&L). Californians Henry Waxman (D) (E&C) and George Miller (D) (E&L) are working closely with Charlie Rangel (D-N.Y.), Chair of WAM, on a bill that might not even need to get individually marked up by the three committees. If they achieve that kind of unity, they could catch up with the momentum and lead the Senate has had thus far. Interestingly, Pete Stark (D-Calif.) has had health problems preventing him from his expected leadership role as the WAM Health Subcommittee chair for the past few months. Stark historically has favored a single-payer or “Medicare for all” plan, so a lot of observers may be somewhat relieved that he is not a strong voice in these discussions at this point. He does know a lot about health care, however, and is a valuable person on the details of many issues, including protecting the patient-physician relationship against insurance intrusion, and on his recognition that PQRI thus far has been a joke. Congress is a complex beast.

Everyone believes the process is still on track for passage of reform legislation — even if there’s a partisan split — and that two parallel bills will be on the table by July to be marked up and ready to be introduced officially on the floor of the House and Senate before the August and Labor Day recess. But if the Bipartisan vision in the Senate gets smashed, even all the king’s horses and all the king’s men will be struggling to get that back together for passage of a comprehensive bill later this year.

On Friday, the Centers for Medicare and Medicaid Services (CMS) released to all U.S. hospitals their performance on six key measures, in preparation for public announcement of these measures this summer.  The measures: 30-day mortality and 30-day readmissions for heart failure; acute myocardial infarction; and community-acquired pneumonia.

Hospital to Home
"Hospital to Home" -- a new partnership between the ACC and Institute for Healthcare Improvement -- is moving along swiftly, as a way to help our members reduce CV hospital readmissions. CV hospital readmissions are currently at 25% of discharges within 30 days. 

Though our Hospital to Home (H2H) project, we aim to reduce 30-day all-cause readmissions for heart failure and AMI by 20% nationally by December 2012.  The project will officially launch when the CMS measures are publicly released this summer.  Watch the video below for more info.

I did an unhealthy red-eye and 24 hour total stay in Paris this week to make a keynote presentation on our vision for health IT and on how registries could greatly improve quality here in the US and internationally at an invitation-only meeting organized by Sanofi and others in Paris.

Europe and other countries are behind our progress in these regards. I imparted a lot and also learned a great deal from other presenters, including about the growing interest of consumer groups in our activities, and about the growing interest in improving medication adherence everywhere. Some of the best results in that latter category seem related to pilots where health insurers pay for the outpatient drugs 100% if adherence is measured and tracked. 

Everybody, however, interprets the recent JAMA article on relationships with industry as potentially spoiling any genuine partnerships that might otherwise develop to improve patient care via registries and professional societies.

Merck and other companies are also hard at work on researching how to improve adherence. We have learned a lot from their sharing of their research, along with ideas from the Veterans Association, MedCo, and others -- who like us, know that in addition to improved prevention strategies, adherence has to be a critical priority if we intend to reduce morbidity significantly in the near future. This will important in preventing readmissions as well.

*** Image from Flickr (macwagen). *** 

Check out this CVN interview with health care economist Len Nichols at ACC.09. Nichols gave the Bishop Lecture earlier today -- he said that ACC members should contribute to health care reform by participating in quality measurement, appropriately using technologies and engaging policy makers.

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). ***