One of today's posts comes to us from Jim Fasules, M.D., F.A.C.C., ACC's Senior Vice President of Advocacy. Prior to stepping up to the plate to lead the College's advocacy efforts during this tough practice environment, Jim was a pediatric interventional cardiologist at Arkansas Children's Hospital in Little Rock.

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At annual meetings like ACC.10 and AHA, cardiovascular professionals keep up with the newest and best science to make sure we’re providing patients with the right care. However, between the dwindling financial support from industry for these events and the even more dwindling reimbursement for CV services, maintaining this commitment to being knowledgeable about the most recent advances is becoming increasingly challenging.

The worst example of this is, of course, the Centers for Medicare and Medicaid Services’ final 2010 Physician Fee Schedule. Although many of the cuts included in the rule are phased in over a four year period (giving us time to fight their implementation), major cuts for 2010 include: 

• SPECT Myocardial Perfusion Imaging (78452): 36 percent cut
• Transthoracic echo with spectral and color flow Doppler (93306): 11 percent cut
• Coronary Stent (92980): 4 percent cut
• EKG (93000): 5 percent cut

ACC.org has a more detailed summary, but even this very brief overview highlights the grave situation cardiology is in right now. These cuts are deep enough over four years to threaten the survival of private practice cardiology. Indeed, many practices have already or are strongly considering selling their practice to hospitals. We are concerned this could have a major effect on access of rural and disadvantaged patients to timely cardiac care.

Our fight against these cuts has just begun. The ACC is working closely with cardiology practices through the Cardiology Advocacy Alliance (CAA) and with the cardiovascular subspecialty societies to mitigate the impact of the cuts. Though we obtained a four-year phase in, it is not enough. We’re continuing to fight on several fronts – regulatory, legislative and legal – to limit the effects of these cuts on you and your practice.

The road is steep though, and we’ll need your involvement more than ever. Visit www.acc.org/CAN to take action and to access the ACC resources available to help you survive these times. More tools will be coming in the next few months -- your feedback on the tools and resources you’d like to see is appreciated. Please email advocate@acc.org with your thoughts.

We’re doing all we can to help you and your practice get through these challenging times for cardiology, while we find a real solution to payment reform. We need to find a solution that reduces the cuts so we can focus on what we do best – providing high-quality cardiovascular care to patients.

-- Jim Fasules, M.D., F.A.C.C.

* Dr. Fasules' 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!

*** Image from Flickr (Suviko). *** 

Health system reform continues to march forward while we’re struggling with this aforementioned nightmare Medicare Rule. We once were fully engaged in reform -- until we were diverted. Nonetheless, we’re still keeping our voice at the table in the reform process. WE MUST. There’s more damage possible if we’re not engaged.

The first big item of importance relates to the SGR. The House has pulled the SGR 10-year fix provision out of their now unified bill to allow it to be merged eventually with a unified Senate bill. The SGR is in a parallel vehicle that can be potentially conferenced with the Senate bill (S 1776), which at this point lacks the 60 votes needed to move forward.

Both Chambers need to make sure the $245 billion SGR fix is not included in the cost of reform -- the President can’t sign that bill if it contributes to the deficit, which it would if it contained the SGR. However, Zeke Emanuel made clear that the White House does support the separate and parallel approach of fixing the SGR by adding the $245 billion to the $10 trillion national debt. That said, I think the SGR 10-year fix effort will nonetheless fail unless there is a way to get it approved by a simple majority in the U.S. Senate. That looks difficult. So, we might not want to tie our Medicare Rule fix to that wagon. One way or the other, however, the SGR 21% cut will not occur in January -- if the fix effort fails (which I predict it will), they will put a one- or two-year patch on as usual. 

Other Actions
In other reform actions, Sen. Reid made big news by insisting that a public option be in the Senate bill that merges the Finance and Health, Education, Labor and Pensions Committee proposals. The Majority Leader does not have 60 votes to support that decision, which he clearly made in defense of his own threatened Senate re-election race in Nevada. You see, he comes from a heavily union-dominated district, and he is facing stiff primary opposition supported by labor. So he needed to do this, even though he knows it can’t pass as crafted. Sen. Snowe could always bring back her trigger mechanism in the final bill in the Senate if need be, but I don’t see this version of a public option in what they ultimately produce.

The House will have a public option, but even Speaker Pelosi is having to accommodate the Democratic moderates and Blue Dogs in the provisions she ultimately will include. Only the Senate thus far is committed to an Independent Medicare Advisory Commission (IMAC) to replace MedPAC, but the all-important details of the IMAC -- if it proceeds -- will relate to who is on it, how they get appointed and how broad the powers of cost containment will be. 

One of the big controversies looming relates to the extent to which young healthy people should have to subsidize the costs of care for older and sicker people in reform. AARP of course wants to see a ratio of not greater than 2:1 between insurance costs for young, healthy people as compared with premium costs for older people in federal coverage programs. The insurance industry (and those concerned that young people won’t buy into mandated insurance if they’re up-front premiums are too high) want to see a 4:1 ratio between premium costs of seniors and the young-immortals.

And finally, we’re still stuck between a rock and a hard place in the House and Senate regarding whether we will tax the rich to pay for reform (the House choice), or we will tax Cadillac insurance coverage (the Senate choice) to pay. 

The House has completed their bill and the president has praised them for getting a proposal ready to go to the floor soon, but their bill is really far from done. There will still be a lot of debate, attempts at amendment and horse trading behind the scenes with the Senate before we get to a House and Senate conference committee to produce one unified bill. It will be a busy and politically crazy November and December.

*** Image from Flickr (Cedric). *** 

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.

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 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.

 

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.

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). ***

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.

Earlier this week, I pointed out an editorial in the WSJ about the "War on Specialists." The article makes some great points about what's going on currently in the health care world, but I think it's important to remember that the ACC is supportive of President Obama's efforts. So for today's Friday Poll, I ask The Lewin Report readers: Is President Obama waging a war on specialists?

 

The President, despite all the vilification and misinformation surrounding his views on health reform, seems the voice of reason and moderation to me of late. Take a look at his “plan,” which I included below. There’s not much in there we couldn’t get behind, particularly as compared to all the controversies in the major bills. He goes mainly after insurers. He has made it clear he’s not 100% dependent on a public option; he’s open to discussion about the MedPAC idea. The main concern I have about his commitment to ‘no contribution to the deficit’ in funding reform is that Congress has to propose how to do that -- and they could go after us. But Nancy Ann DeParle, his Health Czar, seems very clearly unwilling to go after doctors further to finance reform.

AMA, ACP, AAFP, and AAP (pediatrics) have all been gravitating toward aligning with Obama, who has by far the most moderate and flexible approach here of the options before us. They’re not dummies in this. They plan to be at the table when the really tough decisions are being made in the next 2-3 months. I’m thinking we should be there too. We could offer more real insights on payment and delivery system reform than any of the aforementioned. We may also need some big time help from the Administration on the final deliberations on the Rule this year. After the HHS Secretary weighs in, the final decision on that must also go through the OMB (Office of Management and Budget—Mr. Orzsag). It wouldn’t be bad to have some friends in high places, folks.

Look at the President’s agenda carefully -- the Dems are in power and are going to get something through. Would we not want to find a way -- but of course without robotically agreeing to anything they want -- to align with this moderate approach for now, rather than with all the disturbing details in the other bills?  We need to be at the table when the really scary stuff starts to happen. We better think this through carefully. Obama’s got the most middle of the road strategy here so far…

Also, I'm including below a revised statement on the President's Rose Garden Address...

Public Statement from Jack Lewin, CEO, American College of Cardiology

"I am most inspired by the vision of President Obama with respect to health system reform, and his principles for effecting needed changes to America’s health care system.

I believe the principles he has provided to this conversation are in full alignment with the principles developed by the College during the past year.  I firmly believe the President has taken a pragmatic approach that will bring persons on both sides of the aisle together to get reform passed this year.  His concern and desire to address the flawed SGR payment formula and to work with Secretary Sebelius to reduce defensive medicine through achievable tort reforms is also most welcome to all physicians.  It is essential that the nation move forward in 2009 with a meaningful and historic health reform proposal.

We look forward to working with the President, Secretary Sebelius, and the Administration to help move legislation through Congress this year and then to work on the process of implementation over the coming years."

The Obama Plan_Full (2).pdf (86.72 kb)

*** Image from Flirckr (Swatzo). ***

The 2010 Medicare physician payment rule advocacy effort continues full steam. The letters from Congress to HHS now total about 25% of Congress, with many very prominent members. That is impressive. HHS has got to be feeling the pressure. Ex-CMS Administrators Gail Wilensky, Nancy Ann DeParle (now in the White House), and Mark McClellan have been briefed by me on the debacle, and are in my view genuinely concerned that this doesn’t make sense. Their conversations with the Administration will be felt.

I also had a chance to share our concerns with leaders of the investment banker world this week in NYC with Harvard economist David Cutler (Obama’s health advisor), Leslie Norwalk (former Deputy HHS Secretary), Dana Goldman (Rand health economist), and several consumer group leaders at a Warburg Pincus briefing. The briefing was about how health reform would affect the economic viability of the health system -- but it was amazing how the potential of a 27% cut for CV practices caused great consternation about how their investments (devices, pharma, hospitals) will fare. And look for more major coverage in the media in the next two weeks on how the Rule will hurt seniors and health care -- it is serious, and we have to prevail somehow. We’re working ALL fronts.

The Golden Rule
My hope is that CMS will delay the implementation of the Rule until they can fairly evaluate the practice cost data -- and validate that this proposed approach is absurd. But hope isn’t enough. ALL PRESSURE must be kept on. The AHA data that reveals the 27% reduction in morbidity and mortality over the past decade in CV care should not be reciprocated with a 27% cut in practice reimbursement that will literally KILL outpatient and community cardiology and access to care for 60% of non-urban patients. Instead of implementing this proposed Rule, the CMS needs to be reminded of the Golden Rule -- to do unto cardiology as has been done by us to improve the well being and survival of the American public during this past decade.

We sent several communications to the Congress, the White House, and to the AMA about our concerns on the proposed Rule last week. I sent a letter, and ACC SVP for Advocacy Jim Fasules, M.D., F.A.C.C., sent a thoughtful memo this week to cardiologist and AMA President Jim Rohack. The letter highlighted our concerns with AMA’s survey data, which of course was used to inform the proposed Physician Payment Rule.

Dr. Fasules emphasized in great detail our concerns about survey data irregularities, process problems and — ultimately — practice impact. He also underscored the College’s respect for the AMA and its leadership, as well as our understanding of the many competing pressures in regards to this process. He writes:

“In the long run, it is far better to have data reflect the true costs of caring for patients whether being seen for health maintenance or with complex problems. The ACC hopes we can work with the AMA and CMS to improve the process and data analysis allowing long term policy decisions based on precise realistic measurements.”

We will not relent on our advocacy on this issue until it is fixed.

Former ACC Presidents Jim Dove, M.D., M.A.C.C., and Doug Weaver, M.D., M.A.C.C., and I recently co-authored a piece for Cardiovascular Business magazine on a hot topic in health care reform: accountable care organizations (ACOs). We write:

The problem, however, is that outside already established integrated systems, government regulations have made it difficult or even illegal for practices and hospitals to coordinate care and quality. Since most of the care is delivered by small groups of physicians that are not connected, the challenge is to allow trials of ACOs that are not legal large partnerships or entities.

This is complicated, and the ACC believes clinicians, patients and payors should have input about the design and function of this new structure. The ACC, for example, believes an ACO should reward providers for reducing unnecessary and discretionary services but not denying necessary care. ACO members also should not be at risk for costs they can’t control.

For today's Friday Poll, I want to know what you think about ACOs and their role in delivery system reform.