Out of Pocket Spending (OOPs) is increasing faster than people can accommodate it. According to the Wall Street Journal, a recent survey by the National Association of Insurance Commissioners shows 22% of respondents are seeing their health care providers less often because of the economic downturn — this was reported last month (not after last week’s debacle). A smaller percentage of respondents also said they were economizing by not taking their prescription drugs.

A Chicago Tribune article reported another disturbing trend: Average premium and out-of-pocket costs for health insurance for an individual will climb 9 percent to $3,826 in 2009.

Meanwhile, Karen Davis, president of the Commonwealth Fund, testified before the House Ways and Means Subcommittee on Health last week that the rising cost of health care has coincided with eroding insurance coverage and more responsibility for costs for the American family.

Davis recommended the following steps:

• Providing health insurance premium assistance to low-income and modest-income families who cannot afford family premiums (where’s the $$$?).
• Strengthening employer coverage (the opposite of what everybody else is doing).
• Setting national rules for the operation of individual health insurance markets or creating a national insurance connector that makes affordable health insurance policies available to those without access to employer coverage (like Wyden tries to do in his bill).

This is serious. An economic downturn, combined with rising costs for health care and insurance means more patients with chronic conditions like cardiovascular disease will end up uninsured and economizing on their care. Is this a perfect storm, or what?

Last week was a very busy week at the ACC! But what’s new? In addition to a Hill briefing on realigning payment and quality, the College played a prominent role in the following events:

I spoke on a panel at a CME and Industry Conflicts Forum targeted at senior congressional staff and major medical reporters on conflicts of interest — and how to avoid them while maintaining funding for key activities. My premise followed William Mayo’s sage advice: “The best interest of the patient is the only interest to be considered.” But that shouldn’t mean that industry doesn’t have a responsibility to contribute significantly to education, quality and research. Our job is to make sure such contributions in our purview are managed to be bias-free, science focused, and patient-centered. 

We also discussed conflicts of interest at the AdvaMed (Advanced Medical Technology Association) Med Tech Conference. AdvaMed is about to publish their new professional conflicts policies, which, like PhRMA’s new policy, will prohibit lots of direct gifts to doctors and funding to sham speakers’ bureaus. This will actually be a good thing in my view. It won’t mean an end to CME funding (carefully managed), though.

I also shared the College’s views on reforming the health care system at the National Congress on the Un- and Under-Insured. Our principles were well received, and our Quality First ideas were very much praised by consumer groups there.

Finally, I discussed the physician’s critical role in health system reform with the Kaiser Family Foundation in an interview posted online.

Wow. What a busy week.

Even more coverage related to yesterday's post:

• McCain And Obama Health Plans: An Authors’ Roundtable [transcript from a call between the three authors – Wharton economist Mark Pauly, Harvard economist Katherine Swartz, and economist Gail Wilensky, senior fellow at Project HOPE and a volunteer adviser to the McCain campaign – who wrote the third paper about combining the McCain and Obama health plans]
• Health Plan Scoring That Runs Out Of Bounds [a rebuttal to the Health Affairs critique of McCain's plan by volunteer McCain advisor Thomas Miller]
  

 

Health Affairs last week published independent analyses of Sens. McCain and Obama’s health plans [and also a third paper on how the plans could best be combined]. According to the analyses, 20 million Americans would lose coverage through their employers under Sen. John McCain’s health care plan, but Sen. Barack Obama’s plan would sport a $100 million price tag. Watch for coverage of the two candidates’ health care proposals in the October issue of Cardiology.

I hope every ACC member becomes engaged in the campaign of whichever candidate you support (it could help us later). I would offer the observation that neither party platform does much for physicians — we would likely be either harmed or ignored by both parties (harmed in different but equally frustrating ways). After this week’s interactions, I can offer you the following predictions for the future:

• The US economy is in big trouble. The just-announced $700 billion financial institution bailout is a very troubling sign for all national priorities, and health care will still be second to national defense and military efforts. We will have to pay back China or whoever else underwrites these “loans” from the Treasury. It is disturbing that we appear to be privatizing profit, but nationalizing debt. We will all have to pay off the cost of the $700 billion and its interest. Meanwhile, while the Treasury Department is spinning it otherwise, we have all recently assumed the debt holdings of Fannie and Freddie. Our national debt has increased this past two weeks by an estimated $5 trillion of taxpayer risk. That doesn’t bode well for the need for massive health care expenditures, even though the health care sector has provided most of the new jobs and growth of the economy over the past eight years!
• Even without being able to finance universal access to care or big reforms, the nation is moving with certainty toward measuring quality (and value) of care,  and towards increasingly paying physicians in terms of their (our) performance on quality and value.
• We need to help our members understand these issues and prepare for them — not hide from them. We (at least ACC and STS) are enough ahead of this game to be able to lead the way for medical professionals to responsibly oversee quality and measurement on behalf of patients and society. No other constituency really can. It’s our challenge. And it won’t be anywhere near as expensive as achieving universal access or bailing out Medicare. We can do it.

More coverage:

McCain, Obama Health Plans Critiqued [Health Affairs Blog]
The McCain Critique: Out Of Touch And Short Of Ideas [Health Affairs Blog ... a rebuttal to the critique of the Obama plan]
McCain’s Radical Agenda [Bob Herbert, New York Times columnist]

Today we held a briefing on Capitol Hill with Bob Berenson, M.D., of the Urban Institute, and Project HOPE’s Gail Wilensky, Ph.D., on the topic of “Realigning Payment to Improve the Quality of Patient Care.” During the briefing I discussed the difficulties that will ensue trying to change the current system. For one, the continuing government bail-out of financial companies is taking the billions of dollars needed for health care reform. It's not encouraging. Despite that, there are concrete steps we can take in the interim to improve quality and reduce waste, such as better utilizing legitimate clinical data (like the data found in NCDR) to improve outcomes and adherence to guidelines. Small but powerful steps can be taken between now and when major reform is finally put in place.

Wilensky offered two solutions during the briefing for fixing the SGRrrrr. Her preferred solution to fix incentives is episode-bundling, where hospitals and practices would receive one payment for one episode of care. It’s a little messy, but it’s still better than the present system, Wilensky said. Dr. Berenson countered that episodic bundling doesn’t provide incentives for appropriate, evidence-based care, which is crucial. He offered an improved version of capitation as a potential solution. If offices receive a per patient payment in addition to a lower fee schedule payment, this could encourage providers to offer higher quality of care, while potentially expanding to services such as e-mail or phone consultations.

The ACC is promoting a pilot that would move away from volume-focused payment and would instead focus on improved outcomes and better patient care, and to provide a business case for HIT adoption and e-adherence to guidelines. We hope to work with Congress in the future on it. To succeed in improving the health care system, all its players must come together to work on solutions. But, we're not 'there' yet.

Other coverage:

Health reform prospects in the wake of Black Sunday [The Health Care Blog]
Health care expansion? Forget about it [The Health Care Blog]
The Chance for Major Health Care Reform in Either 2009 or 2010 Is Now Zero [Health Care Policy and Marketplace Review]
The Chances for Health Care Reform? [Disease Management Care Blog]

The House Energy and Commerce Committee was hot on health care last week. The committee approved 11 health-related measures that they are now pushing to move through Congress. Committee members Monday unveiled a bill designed to increase adoption of HIT among providers over the next decade.  The legislation would incentivize adoption of HIT and penalize those who don’t take advantage of it. 

Rep. Nathan Deal (R-Ga.), ranking member of the Energy and Commerce Subcommittee on Health, meanwhile is pressing for physician transparency on pricing to prevent providers from “gouging” patients for their services.

And, House Ways and Means Health Chair Pete Stark (D-Calif.) floated his own HIT bill this week. He would similarly provide big payment incentives for those who invest (or have invested) in “accredited” EMRs (a government entity would be assigned to accredit products that would meet certain standards and be interoperable with all other accredited products). The incentives would taper down over five years and then become payment disincentives or reductions thereafter. 

In conjunction with the Legislative Conference, the ACC this week launched its Quality First campaign to the public with a print and online advertising campaign. The print ads ran in CongressDailyAM, CQ Today and Roll Call. An online version of the ad was featured on the Web sites of National Journal, Politico and The Hill. Take a look at the print ad if you missed it in the policy pubs.

Over 250 ACC members gathered in Washington, D.C., last week to educate Congress about the ACC’s important work in improving quality and promoting evidence-based care. President Doug Weaver kicked off the meeting and attended many Hill visits, along with other officers. Our Legislative Conference participants held nearly 250 meetings with their national representatives to discuss the need for health system reform and incentives to encourage the adoption of HIT. In addition, participants communicated the importance of long-term reform to the Medicare physician payment system. I myself was able to meet with Rep Pete Stark (D-Calif.), Rep. Nathan Deal (R-Ga.), Sen. Jim Bunning (R-Ky.), Rep. John Dingell (D-Mich.), Rep. Joe Barton (R-Texas), Sen. Arlen Specter (R-Pa.), Sen. Ken Salazar (D-Colo.), Rep. Lois Capps (D-Calif.), Rep. Dan Lundgren (R-Calif.), and Sen. Chuck Grassley (R-Iowa).

What’s apparent to Dr. Weaver, the ACC officers, the attendees and me is that Congress is poised to really try to eliminate the SGR in ’09. How they will do that is uncertain, but getting that albatross from around our necks is essential. Secondly, we are approaching having a critical mass of congressional members who understand and support our quality of care ideas and goals — and might therefore fund some projects to make these ideas tangible using the NCDR. These reflections were NOT characteristic of what we heard last year. We are having an impact.

During the meeting, Doug Weaver kicked off an ACC press conference and panel with Reps. Barton and Capps to discuss how better to integrate quality into the health system reform priorities. During this press conference, the ACC released the results of a health care reform public opinion survey we conducted recently using prominent DC pollster Frank Luntz. Modern Healthcare published a great story covering the findings. View the survey results.

But, in essence, members of Congress don’t yet support having the profession lead the way in measuring and promoting quality (we are definitely turning that around for ACC and STS). However, the public would support us to do that, and in particular if we partner with trusted consumer entities like AARP and Consumers’ Union. The public doesn’t trust Congress or insurers to lead the way. The public is beginning to get a sense of what quality of care means (not just great magazines in the waiting room), and in valuing quality measurement as part of what is needed.

The College has a set of bold plans to take health system reform challenges/opportunities and develop actionable plans to protect members and promote patient centered, evidence-based solutions. Our Health System Reform priorities and the Quality First campaign are central to that.

Dr. Weaver and a delegation of respected ACC speakers participated in a very successful joint educational symposium as part of the annual Congress of the Sociedade Brasileira de Cardiologia (SBC) in Curitiba, Brazil — and what a meeting it was. There was a very lively debate about the need for more physician-directed quality of care initiatives after my session discussing our Quality First campaign, including the status of our NCDR efforts.

Six thousand cardiologists attended the Congress, mostly coming from Brazil, where there are about 11,000 physicians who consider themselves cardiologists. However, most of these are primary care doctors who do a considerable amount of cardiology care. Only about 1,700 of the total have had the equivalent of a full US internal medicine and cardiology fellowship training, and would thus be eligible to become an FACC. Brazil is one of the few nations worldwide outside the US that has and requires a certification exam that most of the aforementioned 1,700 have presumably completed. There are about 80 F.A.C.C.s there now, and that number is almost certain to grow to beyond 100 within the coming year. In addition, over 400 SBC members attended ACC.08 and will also be at ACC.09. Cardiosource has also been successful in Brazil, with an impressively increasing number of hits. 

I highly recommend visiting their “virtual meeting” which will be posted in about two weeks on the SBC society’s sophisticated Web site, where you will be able to view any of our presentations. You won’t have to be fluent in Portuguese to appreciate what an innovative job they do recapping their sessions and activities from the annual meeting.