President Barack Obama is taking submissions from all over America for the most common questions about health care reform. Quality, costs, medical malpractice, reimbursement – this is your chance to ask the President whatever is on your mind.  You can submit questions online: either on Twitter (use the hashtag #WHHCQ), Facebook or by uploading a personal video on YouTube. Learn more at the White House blog. You also can follow the event by following ACC’s grassroots Twitter account (@Cardiology). On Thursday, we’ll post the video from the town hall here.

Here is ACC's question:

"In your video introduction [blog readers, see below], you discuss the importance of lowering costs. Ironically, the best quality care in this country also is often the most efficient and cost-effective care. Therefore, what are the administration's plans to ensure that incentives to improve quality are prominently embedded in these efforts?"

What's your question to the President? Share your question in the comment section below.

I think it’s fair to say, nobody knows how this health care reform process is going to come out after last week's disturbingly ambiguous week. Both the House tri-committee bill (at 838 pages and a CBO estimated cost of $1.6 trillion over 10 years) and the Senate Finance bill (also $1.6 trillion over 10 years) have gone back to the drawing boards, tails between legs, to try to cut a half trillion out of their perceived grandiosity. The Senate HELP bill was estimated to cost less at a little more than a trillion, but, at 600+ pages, only a few folks really read it. The HELP bill isn’t that much of a bargain because it doesn’t include the costs of Medicaid expansion to cover an additional 15% of the uninsured. The Medicaid expansion is included in the Senate Finance and House proposals.

Finance says they will soon have trimmed the $600 billion over their target out by reducing the benefits and cutting some hospital costs in their revised strategy. The details are not yet available. They still plan to include a cap on deductibility of employer sponsored health insurance; and they will tax employers up to 8% of wage to help fund the new insurance “exchanges” and to subsidize low income uninsured coverage if they do not insure their workers directly.

Does size matter?  Is 800 pages better law than 600? Or are there more things to dislike in the growing complexity of the discussion? Probably the latter. Skepticism has increased. And,  when the public -- seemingly polled to death -- was asked whether they wanted government to completely take over health care, contribute to a rising deficit, and take away their choice, they said, “duh, no.”

Polling Overload
Of course, when that same seeming deer-in-the-headlights public was asked in a different way whether they were supportive of a ‘public option’ insurance plan to compete with private insurance this week, they answered overwhelmingly YES. Since 100% of Republican members of Congress are opposed to the public option, they must have been both scarily surprised by this alleged public option support from their constituency, and are likely ready to re-poll the beleaguered and confused registered voters yet again with some better polling questions, like “would you still favor a public option if it was to cause flesh eating bacteria (MRSA) to become a greater risk to your family? It’s hard to trust these polls -- the questions can lead us to the responses we seek.

There were far too many editorials and op-eds on health reform this week to summarize here. Even reading them was tough. Common threads are hard to find, but there is at least one: people still think the status quo is not good, and some kind of reform is necessary. Phew!  Of course, that could change next week.

House Bill Details
House members this week were getting pretty bent out of shape at doctors who weren’t supportive of their bill, and unable to see that the House had been kind to the profession. They expected big physician support. More...

Tyler Cowen, professor of economics at George Mason University, put forth a modest suggestion for health care reform in a New York Times editorial earlier this month: Cowen advocates a U.K. NICE-style system that would take advantage of comparative effectiveness research to cut costs for less-effective treatments — essentially, limiting or ending reimbursement for less effective treatments.

NICE has considerable respect, even among British physicians, but most of the debate here now seems to suggest that we must separate the coverage decisions from comparative effectiveness. ACC's John Brush last month gave adifferent take on comparative effectiveness research in his post on this blog.

*** Image from Flickr (SqueakyMarmot). ***

Yesterday I was featured on CNN Video talking about quality health care, rising costs, the public insurance option and employer coverage. Check it out.

Embedded video from CNN Video.

This month’s post comes to us from Robert Hendel, M.D., F.A.C.C., chair of the Cardiac Radionuclide Imaging Writing Group, member of the Appropriate Use Criteria Task Force AND chair of the Evaluation and Implementation of Appropriate Use Criteria. As you can see, Dr. Hendel has quite the interest in improving quality. He also led the way in demonstrating the effectiveness of appropriate use criteria to reduce inappropriate testing when he released the results of a pilot with UnitedHealthCare on SPECT MPI.

**********************************************

President Obama’s speech to the American Medical Association last week has been the topic of much discussion within the health care community. While outlining many components of his vision for health care reform, his emphasis on quality care resonated with me, largely due to the ACC’s continuing focus on this area. As the President stated, “…the bulk of our costs is the nature of our health care system itself – a system where we spend vast amounts of money on things that aren't making our people any healthier; a system that automatically equates more expensive care with better care.”

Unfortunately, cardiology was specifically mentioned in a less than flattering fashion, when he cited the recent JAMA publication that found only half of all cardiac guidelines are based on scientific evidence.

Improving Care through Clinical Documents
However, this conclusion is misleading with regards to the value of practice guidelines and the overall aim of providing the best care. Not every clinical scenario has robust literature support and in its absence, expert consensus opinion must fill the void to assist cardiologists in decision-making. The ACC, in conjunction with the American Heart Association and many subspecialty organizations, has been a leader in the medical world in developing documents to guide clinicians. Through practice guidelines, performance measures and appropriate use criteria, the College has been instrumental in improving cardiovascular care.

Beyond documents that define optimal, “must do” therapeutics, such as performance measures, clinicians need guidance in selecting the right test for the right patient at the right time. Since the inception of appropriate use criteria, which seek to define what test or procedure would be reasonable to perform for a given clinical situation, there has been a growing acceptance of this approach. The appropriate use criteria movement has been carefully followed by the Centers for Medicare and Medicaid Services (CMS) and private health plans, receiving almost universal praise.

Because of their basis on a strict, well-accepted methodology and that they are continually modified to provide contemporary application for resource utilization and reimbursement, appropriate use criteria have been recognized by national quality organizations. The most recent criteria, which are a revision of the radionuclide imaging criteria originally published in 2005, now have closed many of the gaps in the criteria’s application and are based largely on patient care flow diagrams. Other appropriate use criteria documents are now being revised and a multimodality approach to imaging criteria is underway in conjunction with the American College of Radiology.

Implementation, Evaluation
While creating these documents is very important, the ACC also is committed to the implementation and evaluation of appropriate use criteria, a critical component to actually affecting health care. In March, I presented the results of the multicenter pilot examination of the SPECT [Single Photon Emission Computed Tomography] Appropriate Use Criteria done in partnership with United HealthCare, which revealed the feasibility of applying the criteria to improve care. The pilot also was helpful in identifying areas of improvement in the use of SPECT.

CMS now has begun planning for a $10 million demonstration project testing appropriate use criteria and has involved ACC directly in the dialog. Furthermore, appropriateness is now a key focus of national medical quality organization, like the National Committee on Quality Assurance, AQA Alliance and others.

Physicians as Quality Drivers
We, as cardiologists, along with our representative organization, the ACC, must not lose momentum. We have to continue to drive the process from the physician perspective, with emphasis on quality and patient access. If we lose our focus, we risk having external forces, such as radiology benefits management companies, dictate the practice of cardiology. While the realigning of incentives to encourage quality is clearly needed, we must also do all we can right now to ensure that our patients receive the highest quality of cardiovascular care by using clinical documents to guide care choices.

- By Robert Hendel, M.D., F.A.C.C.

* Dr. Hendel'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 ACC was in Chicago last week for the AMA House of Delegates — and the President did not disappoint a considerably skeptical audience in his historic address there. The media way over-emphasized the one, little (almost good natured) boo expressed by the House over his reluctance to supporting caps on medical malpractice damages -- notwithstanding that the rest of his remarks were punctuated by frequent standing ovations. He’s good. And this was no easy crowd. But, his big principles and ideas about reform resonated surprisingly well it seemed. That said, the details (mostly not mentioned) will be where the devils are. So, while the docs there were flattered and impressed that he came, and he clearly performed very well, there was a lot of head scratching later based on confusion about "what did that really mean for me and my practice?"  

ACC Message
Our ACC message on this topic (which I touched on briefly last week) is that we must address payment reform as part of overall reform to drive down the cost curve by incentivizing systematic improvement in quality and evidenced based outcomes. That wasn't a big theme in Obama’s message -- or in the messages coming out of Congress this week. Quality improvement is mentioned always, but I'm worried that the beef (details) aren’t there (we DON’T want to hear later that PQRI will be our de facto payment reform for now... yikes). Without payment reform that leads to quality improvement, health IT adoption, and reduced disparity and variation, we will produce another noble Massachusetts-like increase in access, but without slowing cost increases. That is a formula for disaster.

The ACC has proposed a payment reform option pilot through the development of voluntary, multi-specialty, quality-based physician networks organized around participation in CMS-approved registries. Under this proposal, physicians would be paid by a combination of budget neutral fee-for-service and virtual bundled bonus payments that reward quality improvement and improved patient outcomes. In a way our approach is a kind of glide path for non-integrated practices toward virtual and then perhaps real integration -- this is the only path I see toward substantial future payment improvement.

The Oh-So-Controversial Public Plan
The most controversial thing mentioned in POTUS' address was the need for a new public plan. I think that could get traded off as reform proceeds to appease the Republicans. But AMA and others have expressed concerns about a public plan. The House committees want to make sure the 'public plan' pays doctors better than typical private insurance -- if they could guarantee that, a lot of physicians might be interested. Regardless, the nation must move forward and expand access and coverage to all Americans, to fix the flawed SGR, to improve quality, and to institute payment reforms that promote better outcomes and value. But this public plan issue is very heated -- many Dems passionately want to see it included; and many Republicans are just as passionate that it must be killed. To derail reform over the controversies surrounding a public plan as a single provision is irresponsible.

So maybe Senator Conrad’s alternative suggestion to create purchasing 'co-ops' rather than a public plan might solve this dispute ultimately. The idea is that states might form federally sanctioned public private insurance 'cooperatives' to improve access to special populations (as already exist in some states as alternatives to traditional Medicaid). This alternative might be the 'fig leaf' the Senate Dems need to get around this issue. But, the House Dems are NOT going to let go of it on their own. This week I visited the influential Dem House leaders Xavier Becerra of Ways and Means and Lois Capps of Energy and Commerce last week, and they are insistent that the public plan must be in the final bill.

*** Official Barack Obama portrait (Wikimedia Commons). ***

The Brookings Institution recently held a panel discussion of key questions around comparative effectiveness research.  Senate Finance Committee Chair Max Baucus (D-Mont.) and Office of Management and Budget (OMB) Director Peter Orszag offered opening comments. Participants discussed the importance of comparative effectiveness research to overall health care reform for lowering costs, eliminating variation in spending and quality of care, and promoting measurement and benchmarking.

Citing the recent JAMA article underscoring our desire and need to enlarge the evidence base for ACC/AHA guidelines, panelists noted that comparative effectiveness research could help develop more robust guideline evidence in the future.

Meanwhile, ACC’s new policy position on comparative effectiveness and clinical effectiveness research is due to be disseminated and published soon!

*** Image from Flickr (Leo Reynolds). ***

The New America Foundation's Health CEO for Health Reform produced and widely publicized last week a white paper on payment reform written by some very prominent health sector CEOs, as well as by Len Nichols, Ph.D., New America Foundation health economist, who incidentally spoke at ACC.09 in Orlando and at ACC’s 2009 Health System Reform Summit. Len has been one of the most central and respected policy leaders in how payment reform might best proceed. He and a power-packed group of health system CEOs have prophesied that fee-for-service payment must and will die within the next decade, albeit on a painfully gradual basis.

However, the authors believe new alternative payment reforms will be much fairer and less hassling to physicians, and will eliminate the administrative absurdities and costs of the current fee-for-service system, putting physicians back more in the leadership of directing patient care and aligning incentives around quality and effectiveness.

While any change of this magnitude will be scary to those of us whetted to fear of change (clinging to a failing status quo), I’m not so sure this kind of real reform is going to happen for most doctors. The current model is certainly going to kill us, and no amount of tweaking will save it. But change comes painfully slow.  

*** Image from Flickr (pot noodle). ***

Payment reform gets a lot of lip service in the new New York (Washington, D.C.) as a key to reform and cost containment. But will it really happen? The Avalere health policy think tank and ACC co-sponsored a major meeting in Washington last week for policy wonks and government types on payment reform as a key element of health care reform. It was called Raising the Bar—Payment Reform in System Reform. Some physician attendees were likely more ready to "visit the bar" than "raise it" after hearing what may be coming in these regards.

Interestingly, while all the Senate and House reform proposals seem to be heavily engaged in payment reform strategy, payment reform of the kind that will be needed to “bend the cost curve” has been prosaic rather than specific, and the CBO refuses to score any savings due to payment reform without years of evidence. So will payment reform be more than rhetoric?

The "Have" and "Have-Nots"?
Our intelligence suggests that the administration may try to assuage physician angst and anger over the decade of SGRrrr flat payments (with rising business costs) by offering a 5 percent boost in Medicare fee-for-service payments for everybody in 2010. Congress may not agree. But, this could be a carrot to get physician support for health care reform, and to swallow the bitter pill that the SGRrrr may not be permanently fixed this year (AMA still thinks it will happen, but don’t hold the breath). A different source says that the integrated systems (a.k.a. in reform lingo “accountable care organizations”) could get much bigger potential increases of perhaps 15 – 20%. 

In other words, payment reform may create “have” and “have-not” classes of physicians based on willingness to be in physician-hospital integrated systems. For many independent smaller practices that remain in fee-for-service that will mean flat pay, or becoming employed by or sublimated to hospitals, a notion that many cardiologists may find unattractive or even alarming for the long term. More...

The House put out a preview of its vision for reform — Henry Waxman’s hand looms heavy in the authoring this tri-committee health care reform collaboration among Waxman (Energy and Commerce), Charles Rangel (Ways and Means) and George Miller (Education and Labor). House Speaker Nancy Pelosi’s hand is also in there somewhere. Pete Stark (Ways and Means Health Subcommittee Chair) is baaaaaack from medical leave. He’s engaged in SGRrrr relief this week. The House has not tried to create a radical departure from how the Senate proposals are shaping up, which bodes well for something to ultimately pass Congress this summer.

Comparing and Contrasting with the Senate
There are a few differences between House and Senate versions, but the similarities are what’s more striking:

• Insurance reform to eliminate underwriting and excessive profits
• Universal coverage/access via both continued employer coverage and an individual mandate with subsidies for low-income families not covered by employers
• A public insurance plan to compete with private insurers
• Purchasing cooperatives
  
• Loosely defined strategies for reducing costs of care and improving quality
• A notion of “accountable care organizations” to go along with payment reforms
• Promotion of the "medical home"
  
• Primary care, nurses, and team practice and workforce scholarships.

Employers that don’t provide coverage would get taxed (pay or play); and Medicare Advantage insurance plans get cuts. But, the payment reforms and big payment increases may not be for everybody — likely only for the integrated system types.

The House proposes to pay for reform with the same menu of options discussed by the Senate and the White House already. Taxing fat cat health insurance premiums above a median average premium cost is still on the table. The House also acknowledges there need to be more cuts  ($300 Billion worth) from health care somewhere to actually finance expanded access, which could put physicians at risk (imaging is again being discussed as a place to cut).

Senate, White House Updates
The Senate HELP Committee got its language out. We outlined that last week and will give you a link to that if you’re interested as well. It’s only 600 pages long. A great book to read, but a lot of folks may be waiting for the movie. The Senate Finance Committee is still working on its language details, but it’s getting closer to being published before “mark-up,” and will come out in a week or so.

The White House has been involved with all these committees to make sure things keep moving in parallel with them. The President’s having meetings every day with committee chairs and various constituency leaders to move the issue forward. His Wisconsin town hall promoted keeping the ‘public plan’ in the mix to keep insurers competitively priced. Obama also spoke earlier today at the AMA's meeting about the need for reform and why doctors should support his efforts. See an AP video on the meeting below, and check out ACC's statement.

Next steps
All Senate and House committees are on track to mark up their bills during July, and we appear to be heading for the introduction of both Senate and House bills before the August recess. The Conference Committees would then begin to deliberate a final bill in September. We need to start educating members about what the implications of these bills will be on cardiology -- that is, once we’ve got all the proposed language in front of us. But things could get stalled too -- like over the public plan.

The (Divisive) Public Plan
We were asked this week by four major media sources what ACC thinks about the ‘public plan,’ particularly since AMA allegedly trashed it (I don’t think they really did, but that’s how their comments were interpreted). Not having explicit policy, what we’ve been saying is:

The public plan is a legitimate issue to consider, with pros and cons; but, given that the specifics are unspecified, we have no position yet. However, ACC wants the nation to move forward and expand access and coverage to all Americans, and also use the momentum of reform to fix the SGR, to improve quality of care, and to institute payment reforms that promote quality and effectiveness. These are the key things Americans need. To derail reform over the controversies surrounding public plan as a single provision is irresponsible. If that issue that takes longer to resolve, so be it. But let’s not let one divisive issue otherwise hold back major needed reforms.

I'll be talking about these new developments in greater detail in coming weeks. Try to stay tuned.