Canada’s medical schools this week endorsed a report from the Association of American Medical Colleges calling for medical schools and teaching hospitals to prohibit industry gifts and services and to curtail the involvement of industry in educational activities.

The head of the Association of Faculties of Medicine of Canada says endorsing the report, "Industry Funding of Medical Education," ensures that industry support of education does not lead to real or perceived conflicts of interest.

We walk a fine line with our partners in industry. The ACC, of course, has strict policies in place to ensure industry never influences our educational content, and we’re incredibly transparent about our funding. On the other hand, without industry support, we — and other CME providers — could not offer the quality education our members trust.

American College of Physicians has launched a campaign to use proposed “stimulus” dollars to finance an 18 month 10% payment increase in Medicare for FPs and internists. This is surely needed to protect the viability of primary care. It is tricky, however, because many specialties also treat chronically ill patients as their primary providers. ACP has asked ACC for our support of this effort on their part, along with American Academy of Family Physicians. The stimulus spending will be time limited to 18 months. ACP must assume that once such an increase is granted, it will not be rescinded later. If this is created, I would think it should apply to all E & M code patient-centered chronic disease management in other specialties.

We should talk with the primaries about also applying stimulus dollars toward a 10% increase for electronic reporting for quality measurement in a more effective “version 2” of the currently frustrating PQRI. This could provide specialists such as cardiologists a parallel positive update that could foster health IT adoption, IC3 activities, and improved care for patients, perhaps in association with low interest loans and grants for health IT.

Last week I paid another visit to Kavita Patel, MD, deputy staff director for health on the Senate Health, Education, Labor and Pensions (HELP) Committee to discuss "delivery system reform and physician payment options for the future." Patel is a wonderful resource and terrific contributor. She has the charge of designing the changes for delivery and payment for Senator Kennedy’s proposal, due in late January. Dr. Patel believes the Committee will use Senator Baucus’ white paper as their starting point. That means the idea of a ‘national health board’ is on their table; purchasing coalitions like Federal Employee Health Benefits Plan, payment reform, the medical home concept, health IT investment and quality measurement will be in their proposal in some form.

The behind the scenes banter last week has a number of features of interest:

• Congressman Stark (D-CA; Health Subcommittee Chair, House Ways and Means) has publicly stated we don’t have the money in ’09 to do major health system reform, and we need to think realistically about postponing big ticket items until 2010. He did emphasize we need to reauthorize sCHIP and fix or patch the SGR physician payment formula in ’09 no matter what we decide for later -- which is good  to hear. Stark is first in the line in terms of seniority to replace WAM big Chairman Rangel, who has serious problems -- he can’t survive as Chairman in the view of most pundits. But, Congressman Xavier Becerra (D-CA) is also a top contender. Becerra turned down becoming Obama’s chief trade negotiator to stay in the House lineup for leadership. We are friends with both of these folks.
• Hilda Solis (D-CA), another friend, left the Energy and Commerce Committee to become Secretary-designee of Labor. We hate to see her leave E & C, but the Secretary of Labor will play a role in system reform. This isn’t all bad for us.
• The CBO (Congressional Budget Office) put out some powerful recommendations on 2 key topics of interest to Obama and Congress on reform: insurance reforms promoting expanded access to care; and payment strategies for funding reform. Keep in mind that CBO Director Peter Orzag just left the agency to join the Obama Transition Team two weeks ago, enroute to being his Director of OMB (Office of Management and Budget). These reports are now to be considered Obama-speak in my view. I will summarize those voluminous reports after the holidays. They might be fun reading for many of you over the holidays -- if you’re sick. But, I’ll get to it for you.
• HHS Secretary Michael Leavitt is not out of office yet, and he has put out recommendations for his successors on “value based purchasing” in health care. ACC is working on a detailed response that reflects the deliberations of QSDC, PAR4, the Advocacy Committee, and the BOT.
• ACC is commenting this week on CMS’ proposed rule on e-prescribing. It’s not very bold -- doesn’t require that we be able to see the previous prescriptions for the patient in front of us, even though this information is generally available. Progress is progress; but a gradually declining 2% incentive is not going to move this agenda too fast!
• Stimulus planning is the biggest message on the Hill last week in health care. The buzz is that Daschle (Secretary-designee) has nailed down a promise for $50 Billion (yes, a B) for health IT in the Obama stimulus plan. They are thinking of massive loans and grants. That’s nice. But, we want then to also consider real payment incentives -- you know, like a 10% payment increase -- for health IT adoption and reporting. This is what our IC3 plans anticipate -- and we will eventually get there. But loans and grants -- while welcome -- won’t of themselves transform HIT adoption, which will require changing practice workflows to promote true quality improvement. Hopefully that should be the goal!

The ACC’s delegation to the Cardiological Society of India’s meeting earlier this month made big news in India — see the story at right, including a photo of Jagat Narula, M.D., F.A.C.C., Pratap Reddy, M.D., F.A.C.C., and me. Reddy owns many CV hospitals in India. Although the media there aren’t the best fact-checkers (I’m Dr. Levin, chief cardiologist from the American Heart Association in one article), they did a great job disseminating our basic message, which was that, while the recent terrorist killings of 170 people in Mumbai were truly tragic (and which have had non-stop 24-hour media coverage there for weeks), multiples of that number of Indians die needlessly each hour of every day of preventable CV disease. CV disease is already the number one killer in India, but it is increasing alarmingly with recent dietary and lifestyle changes.  India must do more to decrease their risk factors for CV disease.

The CSI (Indian Society of Cardiology) is very interested in working more with us in these regards in helping them develop PR capacities to better reach out to the public on prevention issues, and to include more on prevention in our joint education efforts.

When Thomson Reuters published its list of Top 100 CV Hospitals last month, it got me thinking about how richly our National Cardiovascular Data Registry (NCDR) contributes to quality care. Consider the following statistics:

• 100% of hospitals on the U.S. News & World Report Best Hospitals Honor Roll 2008 participate in the NCDR
• 100% of hospitals on the 100 Top Hospitals(R) Performance Improvement Leaders 2007 - Large Community Hospitals participate in the NCDR
• 98% of hospitals on the U.S. News & World Report 50 Best Hospitals Heart & Heart Surgery 2008 participate in the NCDR
• 97.5% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Teaching Hospitals without Cardiovascular Residencies participate in the NCDR
• 96.7% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Teaching Hospitals with Cardiovascular Residencies participate in the NCDR
• 96% of hospitals on HealthGrades® America's 50 Best Hospitals – 2008 participate in the NCDR
• 95% of hospitals on the 100 Top Hospitals® 2007 National Benchmarks for Success - Large Community Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals® 2007 National Benchmarks for Success - Major Teaching Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals® Performance Improvement Leaders 2007 - Major Teaching Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Community Hospitals participate in the NCDR

Wow. Now we just have to get the word out to the hospitals not on the lists about how to get there: Participate in the NCDR.

The Obama administration has asked that interested parties set up neighborhood town-hall kinds of meetings to discuss health system reform priorities and needs to be collated and shared with Secretary-designee Daschle and President-Elect Obama. We at ACC will offer assistance of information to any of you out there who might be willing to hold one of these meetings. ACC may hold one at Heart House and at a private home in Washington. Mr. Daschle has promised to try to attend a few of these personally, and to send some of their team out to others. I encourage you to sign up to host your own meeting -- but don't forget to let us know if you do! E-mail qualityfirst@acc.org. 

ACC President Doug Weaver was featured in this month's Cardiovascular Business Magazine as an "ACC Corner" columnist discussing relationships with industry. Dr. Weaver writes:

We depend on industry support to help carry out our mission. Without such funding, our efforts to provide meaningful unbiased education and to improve quality would be crippled. Rather than restricting industry funding for such activities, we should instead focus on actively managing relationships with industry and the potential for conflicts of interest in our relationships.

He concludes: "Our job is to make sure that any relationship is managed in a way that ensures unbiased, evidence-based, patient-centered and balanced reviews of science, regardless of funding sources."

What do you think? Is managing -- rather than restricting -- relationships the best way?

A couple of weeks ago, I talked about offsetting the decrease in payment from the Medicare 2009 Physician Payment Schedule by participating in the PQRI (in the future through the IC3 quality improvement program affiliated with NCDR). Ganpat Thakker, M.D., F.A.C.C., governor of the ACC West Virginia chapter, commented on the post: “Most of us who reported PQRI measures for 2007 did not get [an] incentive payment. CMS did not have necessary setup, and there is no appeal option. I am almost positive that we will not receive any reward for 2008 either.” The reality is that CMS lacks the capacities to run PQRI effectively -- it is a crude beginning of a quality monitoring and incentive program. A few of our larger practices got some actual reward from PQRI, but not many.

My message to all of you exasperated physicians on this topic is: Think of PQRI as an awkward baby step in the potentially good direction of substantially increasing payment for improved quality and risk-adjusted outcomes. I emphasize potentially. We are advocating to Congress and the payers for real "value" and quality-improvement reward programs with significant incentives (at least 7 – 10 percent payment increase). We are further working on Congress and insurers to appreciate the value in using our NCDR systems and the new IC3 quality improvement program to members and primary care practices to collect and populate CV performance data. If we, as the profession, are not engaged in designing and helping to implement quality improvement and reporting programs, they won’t work.

The ACC applauds all of you who made the effort to participate in the PQRI, realizing full well that it was as frustrating for most of you as the Blagojavich Senate seat selection process has been for the people of Illinois. But, since quality reporting is coming for certain, at least those of you who tried to participate are getting ready for the inevitable, and a future program that will hopefully offer real value to patients and doctors.

Please join the conversation on the topic of quality reporting and tell us what you think. Don’t use any four letter words though -- please -- if you’re a PQRI participant. We’re going to make it better.

This week marked our 41^st annual New York Cardiovascular Symposium managed incredibly well by Valentin Fuster, who will receive ACC’s coveted Teacher of the Year award at ACC.09. The NY Symposium had record attendance (2,000) and record international participation (61 percent). The program and the faculty are exceptional — but no doubt part of the attraction (for families of attendees) may be that the EURO-dollar exchange rates has transformed the Big Apple into the shopping equivalent of a European Wal-Mart. But these attendance numbers buck all the trends. People are still willing to travel for quality education.

This meeting offered President Weaver and me additional opportunities to me with international CV leaders, NY-based industry representatives and academic leaders. But the real opportunity was the excellence of the program content, as evidenced by the packed room through all of the sessions.

There was a great article last month from Slate about Web sites that claim to offer consumers in-depth reviews of their doctors. Kent Sepkowitz, M.D., visits checkMD.com, HealthGrades.com, RateMDs.com, Suggestadoctor.com, DrScore.com, CompareHealthCare.com, RatePoint.com, Wellness.com, and Vitals.com with a list of a dozen doctors. He finds that all the sites offered information on licensure and history of disciplinary action, as well as reviews from previous patients. The reviews are decidedly sparse, however (only 5,709 on one site featuring 137,832 physicians) and skew negative … because patients happy with their care generally don’t go online to grade their doc. Needless to say, Dr. Sepkowitz is skeptical about the value of these online rating sites, as patients should be.

ACC SVP Janet Wright, F.A.C.C., and her Clinical Quality Committee believe we need to develop our own systems of recognizing excellence based on valid clinical data sources, and on legitimate proficiency achievements that all our members could aspire to reach -- a system patients and members could trust.