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

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

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

I’m back in D.C. today after a whirlwind couple of days at AHA. It was an exciting trip, reminding me how much I look forward to ACC’s own scientific session in March (not to be missed!).

That said, there’s still one major item left to discuss from AHA’s meeting: the release of ACC Foundation/AHA/Society for Cardiovascular Angiography and Interventions focused updates on the management of patients with ST-elevation myocardial infarction (STEMI) and the management of patients undergoing percutaneous coronary intervention (PCI). It’s only fitting that the document was released during AHA – the update takes into account many of the major trials conducted recently for cardiology and released at AHA and ACC’s meetings. The update makes new recommendations to ensure patients reach lifesaving therapy for STEMI as quickly as possible. 

The update recommends that each community develop a STEMI system for triage and transfer of patients that complies with the standards set forth by Mission Lifeline. The system should include destination protocols to STEMI Receiving Centers and transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates and/or are fibrinolytic ineligible and/or in cardiogenic shock.

Another significant change recommended in the update is greater acceptance of PCI of the left main coronary artery. The update suggests it may be considered based on favorable anatomic condition and an increased risk of adverse surgical outcomes.

UPDATED: 11/19 with CVN video, as promised.

I stopped by the Expo floor and couldn’t help but notice the decline in the number of industry exhibitors. We had similar declines in our exhibitors last year, which causes me to think this is representative of the new nature of our relationships with industry. Our relationships with industry are becoming increasingly sparse, which some would argue is how it should be. Or they would argue that the relationships shouldn’t exist at all.

That’s not the College’s view, though. We believe that although there must be firewall for relationships with industry, done correctly, they can be positive and constructive relationships. These relationships shouldn’t be seen as inherently bad, they just must be effectively and ethically managed, and breaches in ethics should NOT be tolerated.

The ACC handles our relationships by creating a firewall between the funding and the program it supports. The funding is solicited for specific new or ongoing programs/initiatives. The money is dedicated exclusively to an objective – but the industry supporter has no say in how the funds are used for the program/initiative. By using this process, the ACC can still get the valuable financial support it needs to continue to make available quality programming and education.

The College has taken a leadership role in this debate, building consensus on the issue among medical professional societies. (For more on ACC’s stance on relationships with industry, see a post from ACC.09.) We must continue to move toward responsible, transparent relationships that will allow us to maintain quality education and research in cardiovascular medicine.

What do you think?

Some good trials came out yesterday at AHA. Here's the wrap up.

Here is Sunday's daily wrap up from CVN of LBCTs at AHA.

Today I’m traveling back again to Orlando (feels like ACC.09 was just yesterday!) for the American Heart Association’s Scientific Sessions2009. The event promises to be exciting ... more than 30 late-breaking clinicaltrials will be released and more than 4,000 presentations made. You’ve got tolove the suspense of wondering which LBCT is going to be the hot one of theconference. I have a jam-packed schedule while I’m here – I’ll be attendingseveral of the plenary and special sessions, and meeting with 10+cardiovascular societies.

Thesebig CV meetings are my opportunity to connect with the other societies andexplore ways we can work together. Given the drastic Medicare payments cuts facingcardiology over the next four years and the rapid pace of health care reform,working together is going to be key to our success.

Just like the European Society of Cardiology’s meeting in August, the ACC has heavy presence at AHA’s meeting. We have a booth down inthe exhibit hall (booth #2023) to give ACC members at the meeting the opportunityto mix and mingle with ACC colleagues and ACC staff (or become an ACC member ifyou’re not already). If you’ve got questions about what the ACC is up to thesedays, you can come down to the booth to find the answers directly from staff.We’ll also have our products available for purchase, along with registrationfor other cutting-edge CV educational programs.

If you’re looking for more coverage of the meeting, visit http://cardiosource.com or follow @Cardiosource on Twitter for up-to-the-minute summaries,presentation slides and videos from the meeting’s LBCTs. 

I'm heading down tomorrow to Orlando for AHA's 2009 Scientific Sessions. Are you joining?

Janet Wright, FACC, was recently asked to be a guest blogger on the Disruptive Women in Health Care blog for an ongoing series on medication adherence (soon to be an e-book!). She writes,

Over decades of practice in cardiology, I had a first-hand view of the challenges patients face in adherence – an inability to afford the prescription to an incomplete understanding of a med’s value or benefit to overestimating the risk to unclear directions or complex instructions on how and when to take the drugs. ... Successful medication adherence is not a failure on the part of the patient to take their medication, but rather a failure on the part of the health system – including patients, their providers, the reimbursement structure, the insurance companies, etc. – to make it easy and worthwhile for the patient to take his or her medicines. 

She concludes:

Successful patient medication adherence is not just about the patient taking his or her medication – it’s about the health system working together to allow the conditions to exist to enable the patient to take his or her medication.

Check out her full post on the Disruptive Women blog and leave your thoughts on Rx adherence below. 

*** Image from Flickr (DawnVGilmorePhotography). *** 

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

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

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

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

Cardiovascular Business magazine yesterday came out with an interesting article on the rule: "CMS cuts could make hospitalists out of cardiologists." I was interviewed for the article, which says: "This lack of practice sustainability will lead cardiologists, according to Lewin, to become 'employees of hospitals, causing the closure of individual and group cardiology practices.'" What do you think?

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.

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.

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 Australian Medical Association sent out an amazing message to physicians last week recommending members consume six cups of coffee per day. Apparently folks had been noticeably nodding off during surgery and patient consultations. I guess they're willing to trade off napping for tremors. But, I'm taking the advice seriously for the attitudinal benefits (Dr. Jackyl and Mr. Coffee?).