Wow. The President’s ultra-visionary speech -- and then the $3.5 Trillion budget proposal -- add up to a breathtaking agenda. On the other hand, if the economic crisis is worse than expected, or if anything else goes wrong in the world (like a Pakistan implosion, or worsened Mideast crisis, or deepening war in Afghanistan, etc), the economics of Mr. Obama’s proposals could be in the tank. That’s why it’s a bit like rolling the dice — there are big risks in the agenda, and in the budget proposal.

But, that said, why would the country not aspire again to a truly first class education system here for all citizens to build a powerful future economic base; or to a first class health system that covers everybody but doesn’t bankrupt the economy; or to a new green energy industry transformation that could further fuel a more entrepreneurial economy? This is a big vision, but a very appealing one.

The POTUS (President of the United States) certainly reiterated his support for health care reform last Tuesday night; and then he did so again Wednesday when put his money where his mouth is with the 10-year, $634 billion “reserve fund” to pay for 50 percent of the expected cost of a vastly reformed U.S. health care system. But, where does the other half of the health reform budgetary goal come from? That’s not clear, and is up to Congress to seek. This $634 billion fund will come largely from Medicare Advantage plans cuts; higher co-pays for wealthier seniors; cuts in home care; and other unspecified cuts to providers (along with new incentives for quality). Believe me, there will be devils in those details. But, we should all recognize that the present non-system IS unsustainable.

Speaking of unsustainable, what happens to the SGRrrr? That will cost over $400 billion to pay off over ten years (thereby eliminating the coming 40% cuts over that time; but by the way not increasing physician pay at all!). If we take injectable drugs costs out of Part B Medicare, the SGR pay off could be less -- supposedly about $329 billion. This amount is supposedly to be included somewhere in the budget -- but must be funded by cuts elsewhere.

This is for sure -- the SGR fix is NOT part of the $634 billion -- that’s to expand coverage to all Americans. President of AMA, Nancy Nielson, said this week that AMA believes the SGR fix is, however, in the budget. I can’t see HOW it will be paid for yet, but Kennedy, Baucus, Obama, they all say they want it to go away. Maybe it’s buried in the $1.75 trillion deficit somewhere? But since we don’t yet know how it will be paid for, I think it’s still to be determined. Ulp. Maybe not gone yet. 

The proposed budget is comprehensive and looks at prevention; chronic disease, incentives for reduced hospital readmissions (we’re ready to step up here); improved patient safety, quality of care and program integrity (and here); and private sector ideas to ensure appropriate use of technologies including imaging (and here).  The proposed budget also encourages implementation of health information technology which is crucial to substantive reform (but most of health IT is Stimulus $$$). By making healthy patients the goal of any reform efforts, we create less of a financial burden on our health care system that is already 17 percent of the nation’s GDP — due to be 20% in 5 years or less.

If we decide to do so, Cardiology can not only help out with this effort — we can show how to make it happen. The trick will be to do that and come also to the rescue of the private CV practices that are getting hit by huge insurance cuts this year on top of Medicare’s flat pay for a decade. But, ACC can use our registries -- and the new IC3 quality networks to create pilot programs that save money and provide better quality care to patients -- and share some of the savings with the practices. Based on the discussions of those at our recent Health System Reform Summit, many of the attendees believe -- if Medicare and Congress will help create the business case -- we could go on record with these kinds of accountabilities to “fix health care from the inside out:” 

1. We could reduce heart failure readmissions by 20 percent in two years (through IC3, NCDR, and new “quality first networks of members incentivized to participate).
2. We could use appropriate use criteria (AUC) to reduce the numbers (and thus costs) of inappropriate cardiovascular imaging by 15 percent in two years (again using web-based AUC decision support tools in ‘quality first voluntary incentivized networks’).
3. We could also use our AUC for revascularization to reduce variations in stenting and angioplasty (same approach).
4. We can also volunteer to test out new payment concepts, and to test out Medical Home ideas that could apply to heart failure, or CHD, or geriatric cardiology practices.

Note that in all of the above focuses, there are also many patients who appropriately need these services and who aren’t getting them. So, while applying science to the point of care will reduce some services that are perhaps over-provided now in some geographies, expanded access to care will bring in millions of new dollars and patients who lacked coverage before -- this will offset declining revenues due to reduced variation.

I am confidant our Board and Blue Ribbon Panel will strongly support President Obama’s 10-year commitment to reforming and bettering our nation’s health care system. President Obama’s proposed budget is an impressive step in that direction, and the nation cannot let Congress get sidetracked and bogged down in political maneuvering around it. This reform effort could put a lot more money in health care over the next ten years -- where very little has been added for the last 10 in the delivery side. But, there will be winners and losers in reform, and ACC needs to help members get ready to succeed here.

We need to be at the table all the way. The President is having a System Reform Summit in DC this week with 75-100 people invited. Nobody knows who’s invited yet. We obviously hope to be there to add ideas, but so does everybody else. It looks like after members of Congress, business and consumer leaders, and attendees from the administration itself are counted, there aren’t many seats left. But we could be there to suggest real solutions with tools we have already developed. “Shovel-ready” projects?

However, I sincerely hope this isn’t a repeat of 1992, when “conflicted” doctors, nurses, and patients were afterthoughts in the reform discussions. Everybody is conflicted here.

We are definitely getting our message of willingness to work out with Mr. Obama, Mr. Orzag (OMB Director), and Congressional leaders to help them find ways to achieve their bold goals. 

*** Image from Flickr (Darwin Bell) ***