Following Dr. Vince Bufalino’s post on the effects of the Proposed 2010 Physician Fee Schedule on quality and access, several members have written in to describe their reaction to the proposed rule. I wanted to highlight just a few because of their eloquence and passion.

From Thomas Cahill, Jr., M.D., F.A.C.C.:

Hooray for Dr. Bufalino.
I feel that not just cardiologists but that physicians as a whole are giving away the farm. We are the most important providers of health care in this world. There is no way we should stay unorganized and let a group of politicians take over health care. Certainly, there is waste in any system. But when I was on call two nights ago, no patient I was asked to see questioned my arrival at 10 p.m. to evaluate their chest pain or felt that this was an issue of inappropriate healthcare; this only applies to other people, not these patients or their loved ones. Who else was there in the ER that night? Besides the dedicated ER staff, a cardiologist from our friendly in-town competitor; not a trace of a single congressman clamoring for health care reform. We work hard, respect and love and care for our patients; we do not get inappropriate tax cuts or post-retirement benefits including pension and health care that Congress appropriates for its own members.

There is no way we should shrink and pretend that we do not earn what we make honestly, which is what we do when our leaders announce in public forum that we back Obama's health care plan. As a society the ACC should be publicly making a very clear statement like Mayo Clinic did that we do not back the president's plan to put an eventual (or hasty if he really gets his way) end to the private practice of medicine, a noble profession. Stand tall, you are not the enemy of our nation. You are the leaders and must work even harder to get the patients to put grassroots pressure on Congress to prevent the decline of Medicine.

As far as the CMS cuts, this may be just a vanguard of the slicing and dicing by the political left of the payment to any health care provider who is not screaming, fighting, kicking until someone backs off. It is time we take off the white gloves and get our knuckles skinned in the battle for the health care dollar. If we do not, the tougher more organized competitors will be glad to take away another 10 -15%. And Congress will be glad to tax you out of 50 - 60% of your income.

From Jaime Gerber, M.D., F.A.C.C.:

The impact of the cuts in reimbursement that CMS proposes will devastate private practice cardiology across the country. In our area, access to care for Medicaid Tite 19 patients is already difficult. This will be the first casualty of cuts as we will no longer be able to service these patients. Following will be a restriction in the number of Medicare patients that we are able to enroll. Already our primary care colleagues have largely closed their practices to new Medicare patients.

Layoffs will then follow. These cuts will cause a huge job reduction adding to the worst recession since the 1930's. Nurses, techs, secretaries and assistants will lose their jobs as the private practice groups struggle to maintain financial viability. Plans to buy new EMR's and upgrade technology will be shelved and capital spending frozen. As in any business, operating costs will be cut to meet revenue. And like most businesses, people are the most costly budget items.

The net effect of planned physician cuts will be to worsen the recession, further shift costs to the hospital emergency rooms and to reduce quality of care and access to care for all.

From Gloria Hui, M.D., F.A.C.C. (her comment is in response to my first call for comments):

I believe the public should be educated on the difficulty of practicing medicine as it stands now, even before the proposed Medicare cuts. In April 2008, we moved our practice from Building 1 to Building 4 within the same medical center complex. We filed the address change with Medicare immediately. However, it took Trail Blazer, the Texas carrier for Medicare, nearly 6 months, before we were reimbursed for services rendered for our patients. Reimbursement sent to our old address was not allowed to be forwarded. Trail Blazer never returned mail, e-mail, nor phone calls. We exhausted our line of credit from the bank. Approximately 80% of our patients are Medicare. Our practice nearly collapsed. The more patients we saw, the deeper we were in debt. Not until having this experience did I realize why some of our colleagues would restrict the number of Medicare patients they see. I can fully empathize with them now. We need to collectively stop this type of physician abuse.

The responses are varied but the message is the same: These cuts CANNOT go through. Quality cardiovascular is at stake.

Keep the comments coming! Leave your thoughts below on the proposed cuts.

Rep. Anthony Weiner (D-NY) and Bruce Braley (D-IA) introduced an imaging amendment last week in the House Energy Commerce (E&C) Committee that would eliminate the ability of physicians to provide advanced diagnostic imaging services in their offices beginning in 2013. Bad idea. We all know that its passage would increase inefficiencies and present significant barriers to appropriate screenings and treatments. Support for this amendment -- mainly from radiologists -- is about money and not what’s best for patients. With the E&C Committee resuming talks on HR 3200 later today, this means that the Weiner amendment also could be discussed as early as today.

But, we’re fighting this bad strategy by organizing an effort with 23 other medical professional societies who sent a letter to Rep. Henry Waxman (D-CA), chair of the E&C Committee, opposing the amendment. We also talked to Majority Leader Hoyer about it. ACC staff and leaders also continue to meet regularly with Congressional staff about the benefits of appropriate use criteria and clinical guidelines to ensure that the right tests are delivered at the right time to the right patients. Appropriate use criteria and guidelines can reduce costs and limit unwarranted imaging, while at the same time ensure that patients that need it have access to appropriate care. The ACC also supports mandatory imaging laboratory accreditation to improve the quality of imaging. It’s time to use science and evidence to eliminate unnecessary tests, rather than price controls and turf wars that can only limit access to services to patients on the lower end of the economic spectrum.

In other imaging news, the ACC is working with the Access to Medical Imaging coalition (AMIC) and our partner cardiovascular societies to fight the changes in equipment utilization rates that are in both House and Senate reform bills. Stay tuned for more information. 

*** Image from Flickr (MacRonin47). ***

The ACC closely monitored this week the rumors that the Obama Administration and Blue Dog Democrats have proposed the creation of a new body, the Independent Medicare Advisory Council, as part of House health reform legislation. It’s true, but not likely to be approved without a lot of careful consideration. This new council could have expansive authority to set Medicare payment policy.  Sen. Rockefeller has been a proponent of this idea for many years -- his logical view is that Congress has no idea how to oversee health care and Medicare (I agree there). The major components of the current draft legislation that would be part of the health reform package to add tort reform according to the Blue Dogs could include:

• Effective in 2014, the revised ‘MedPAC’ Council would be comprised of 5 members (physicians or others with medicine or policy experience) appointed by the President;
• The new body would have authority to recommend to the President budget neutral payments for physicians, outpatient Part B services, home health, DME, clinical labs, ambulance services, ESRD, and FTE resident amounts. This includes updates to hospitals, SNFs, inpatient rehab, hospice and LTCFs;
• It would also have broader authority to recommend (1) Medicare's financing authority; (2) areas where the Secretary currently has discretion; and (3) certain specified program administration procedures; and
• Then, following the President's approval of the recommendations, Congress would have 30 days to disapprove recommendations by a simple majority.

The Administration believes this would "bend the cost curve" to growth in Medicare services and it is an appealing concept to many conservative Democrats in both chambers. But many more Democrats and Republicans have hesitancy about vesting this kind of broad authority to an unelected body. Congress is doing a great job of this right now, right? A number of physician groups, including osteopaths and surgeons, have already weighed-in opposing the inclusion of this proposal and have gone so far as to threaten to oppose the bill if it is included in the final package. Until we would see an actual proposal, I don’t know why they would do that. Having a physician oversight panel wouldn’t necessary be worse than what we have now.

As you can imagine, hospitals (and I suspect other health care organizations) are also waging strong opposition to the proposal. They would have no reps. We are currently subject to the well-intentioned but chaotic policy development of the Congress, and a new approach could hardly be much worse; that is,  DEPENDING on how it is designed. MedPAC has NO practicing physicians at present. The current situation really sucks. Before we knee jerk that a new approach is bad, let’s think it through and decide how we might influence a better way to make national health policy. The ACC will work with other stakeholders to monitor this idea as it proceeds to be discussed as part of the broader bill.

But, get this clear: NONE of the current House or Senate health committee chairs favor it. Therefore, this seems dead on arrival to me, unless medicine tries to save it. But, well designed, a new entity to deal with details of payment issues, benefits, and quality measures, for example, could be a big improvement over the current craziness. The problem is, the current well intentioned but often misguided Congress has to design and approve the new thing. That’s a big impediment.

Praise without end for the go-ahead zeal
Of whoever it was who invented the wheel
But never a word for the poor soul’s sake
That thought ahead and invented the brake

---Howard Nemerov, former US Poet Laureate

Give Me a Brake
President Obama really ramped up his health care reform efforts this week, but the Senate isn’t buying it, and neither is a significant contingent of the public in general. I predict we have August off with neither the House nor Senate getting a bill on the table before the recess.  Today, E & C Chairman Henry Waxman is alleged to have stomped out of a meeting in the Speakers’ office madder that heck about the growing disagreements among the tri-comm committee chairs, and threats of mutiny from the Blue Dogs. Aaaarrrrff! Congress has applied the brakes to health reform until some major problems can be addressed. This is tough -- we need reform, but...

Obama’s press conference got pretty good reviews all in all. He effectively made the point for me that it’s not just about the uninsured -- it’s more about the entire ‘house of cards’ of rising costs that needs to be addressed. We need to focus on slowing cost increases if we plan to spend over $1 trillion in new or reallocated dollars, or we’re just plum crazy. But, geeze. We’re not yet bending the cost curve with the current proposals -- which must happen. Then too, the House bill has some nasty provisions in there (nixing specialty hospitals; prohibiting opting out of any public coverage participation for docs; an undefined public option; imaging EU cuts; etc.).

These concerns and more are why ACC did not endorse HR 3200.  Rather, we've praised the SGR fix in their bill (and that the Senate seems to be willing to sacrifice!), along with the other positive things they proposed. But we had to reserve the right to fight against the things we don’t like in there—which is why we couldn’t endorse. As I said last week, AMA made a tough strategic decision to support the bill. You have to give them some credit for carrying the water for us all on getting the SGR fix to happen when the House bill goes to conference in the Senate. They sure got slammed by the Wall Street Journal for that, and I know that many AMA members are pretty hot about that decision, as are a good number of state societies. Dermatology, some of the primaries, and a small number of other associations also endorsed. I’m sure glad we decided not to. The Congress is certainly not “there” yet with what’s currently on the table. And, there’s no agreement on how to pay for reform yet.

New Timeline
Obama’s meetings at Children’s Hospital in DC, his prime-time press conference on Wednesday, and then a town hall forum in Cleveland, Ohio, on Thursday contained a few significant messages of change: he’s talking about 'we have to get this done by the end of this year, rather than get the bills introduced before the August recess.' That slow down is a big deal -- there’s no way either chamber will now introduce a bill this week. The House could. But I can’t believe they will. The Senate Finance Committee and Harry Reid (and the Blue Dogs in the House) have said very emphatically, ‘we’re moving too fast -- slow it down, damn it, until we get it right. Good thinking, gang. Sen. Baucus is still working on getting his Republican colleagues on Finance to agree to a strategy -- and they want more time. The problems to solve: how to ‘bend the cost curve;’ and how to pay for the expanded access. More...

Electronic health records (EHRs) do not offer complete data to gauge performance, according to a new study in the Agency for Healthcare Research and Quality's Research Activities by Jeffrey Linder, M.D., of Harvard. Linder's research showed that EHRs were often inaccurate in determining the actual cause of a patient visit (688 encounters were billed as pneumonia, but chart reviewers found only 198 actual visits for pneumonia). A large portion of the data in the EHRs was not coded, which makes data extraction for care measures difficult.

This says to me that we’re on the right track with our NCDR registries, with their validated data elements, and with our advice that EHRs be integrated with data registries where possible.

In other registry-related news, the IC3 Program is growing by leaps and bounds! We added a whopping 100,000 patient records this week alone. Amazing. This kind of patient data in our ambulatory registry will really move the needle on quality of care.

Meanwhile, the IMPACT Registry Pilot is on schedule to launch in August for six months to test the usefulness of data elements and the feasibility for data collection. The official launch of the registry is slated for 2010. The IMPACT Registry will be the first national registry to provide data about the demographics, acute management and in-hospital outcomes for a comprehensive selection of patients undergoing diagnostic catheterization or catheter-based interventions for congenital heart disease.

Little is known about the population of patients with congenital heart disease, particularly with respect to the use and outcomes of catheterization and interventional procedures.  To date, most resources have been applied towards increasing the understanding of the anatomy and physiology of congenital heart disease, as well as the natural history of common defects.  National guidelines have been published which provide recommendations for the appropriate use of diagnostic catheterization, interventional catheterization and surgical treatments.  However, because studies performed in congenital heart disease are generally small in number, and because prior registries of congenital heart disease have been limited in scope, there is a paucity of data relating to the use of diagnostic catheterization and catheter-based interventions, and to the morbidity and mortality associated with these procedures.  Current national guidelines were derived primarily from expert opinion, and there is a strong need for data to allow optimization and refinement of the guideline recommendations.

"Forty years ago this week, man first stepped onto the moon. It was an undertaking that took vision, commitment and sacrifice. It will take the same vision, commitment and sacrifice for this nation to meaningfully reform our health care system.

"President Obama has called on Congress to undertake this enormous task which is just as daunting as putting a man on the moon. We applaud President Obama’s leadership and we share his goal of health care reform, but we can’t settle for legislation that lacks the teeth to deliver real and necessary quality and payment reforms.

"The American people need health care reform that addresses the causes of our health care problems and not the symptoms. Hacking blindly away at costs and then claiming to have saved the system money is dangerous and punishes the very people that our health care system is meant to serve: the patients. When talking about reducing overall costs to the Federal budget during the campaign, then candidate Obama suggested taking a scalpel instead of an axe to reform, and that’s precisely how we should be reforming the health care system now.

"We must look at how we pay physicians and other care givers, and develop a payment system that incentivizes quality and positive patient outcomes. Until we completely change the way the U.S. payment system is structured, we’ll never be able to bend the cost curve of health care spending.

"Without payment reform that leads to quality improvement, health information technology adoption, and reduced disparity and variation, we will produce a noble increase in access, but without slowing cost increases. That is a formula for disaster.

"Some have proposed as a way to save money is to cut Medicare Part B reimbursements to specialists such as oncologists and cardiologists. Not only does that not achieve enough savings to be of any use, cutting reimbursement will lead to less access to vital services for people in rural areas and in underserved communities. But it really just shifts costs as the cuts to specialists will be offset by increases to primary care physicians.

"What we need are reforms that allow for the adoption of health information technology, coordination of care so that we can reduce heart failure related hospital readmissions, and the use of evidenced-based guidelines and appropriate use criteria to stop unnecessary medical procedures. And we need incentives to promote partnerships between primary care and specialists in order to better coordinate care for most expensive and complicated chronically ill patients.

"This is, as then candidate Obama suggested, a targeted approach that can achieve real reform with real results and measurable outcomes." 

Today's post comes to us from ACC's Advocacy Committee Chair Vincent Bufalino, M.D., F.A.C.C. In this position, Dr. Bufalino leads ACC efforts at advocating for changes to the health care system, in particular the payment system. When he isn't busy lobbying Congress, Dr. Bufalino is president and CEO of Midwest Heart Specialists in Naperville, Ill.

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The cardiology community is in frenzy over the latest insult offered by CMS. As well we should be – CMS has proposed reducing overall Medicare payments to cardiology by 11 percent. That overall figure is misleading – the proposed cuts to core cardiology services range from 10 to 40 percent. It also doesn’t include the regularly scheduled SGR cuts of more than 20 percent. The total result? Cardiology practices could see cuts at little 25 percent (ha!) to as much as nearly 50 percent. In just one year.

This is insanity. Cuts as massive as these will have enormous effects on the practice of cardiology – not just for the practices, but more importantly, for the patients. Here’s what the cuts could mean for patients:

1. Reduced access. Practices won’t be able to afford to provide certain services to patients, which means that they’ll need to go to the hospital to receive the care. This will require them to take extra time off work and pay higher copays. In low-access areas, the nearest hospital could be hours away. This just isn’t feasible for everyone. CMS may not have intended to reduce access to much-needed cardiovascular services, but that’s just what they’ll be doing if these cuts go through.
   
   
2. Staff lay-offs. With drastically reduced incomes, cardiology practices are going to have difficulty maintaining current staffing levels. This will have negative effects on the customer service offered to patients, as offices try to do more with less.
   
   
3. Reduced quality. Cardiologists have led the way in improving quality. Morbidity and mortality for heart disease have dropped 29 percent over the last eight years. This is because cardiologists are committed to quality. We’re a leader in our creation of clinical documents. Not to mention our incredibly well-developed group of registries that improves patient care. Large numbers of us participate in the Physician Quality Report Initiative. We use electronic health records at higher rates than other specialties. We are specialty committed to improvement. That said, our participation in quality improvement activities – which often require a heavy administrative burden – is threatened because we won’t have the funds to maintain the staff needed to submit the proper paperwork or the time to complete it. As fellow ACC member Patrick Anonick, M.D., commented on this blog: “We are rapidly approaching a point where we cannot afford the overhead to focus on these issues.”

This is serious. In my practice, we have a group of 50 physicians covering much of suburban Chicago.  If these cuts go into place it will put undue hardship on our practice. We would have to stop hiring new physicians and begin to shrink our staff base to maintain a stable fiscal base. It would clearly affect on our service and stop us from doing the free community work that we have become known for in the area. As we decrease our staff, the added extras that have become a part of our service will just go away. Many of our smaller counterparts will possibly have dire consequences to their longevity.

Here’s what the ACC is asking us to do:

1. Call, e-mail or visit with your lawmakers to point out the serious consequences of the proposed rule. The ACC has talking points, patient materials and a sample letter available on www.acc.org/can. Advocacy staff (Molly Nichelson and Justin Beland) can help you schedule appointments with your lawmakers, which will be especially effective if you visit during the August recess when they are back in their districts.
   
   
2. Take part in the ACC's "Cut the Cuts Roadshow" and volunteer to give your own or facilitate an ACC-taped presentation on the implications of the cuts on cardiology to your hospital or practice group. Email qualityfirst@acc.org for more information.
   
   
3. Now is also the time to give to the ACC Political Action Committee if you have not already done so. 
   
   
4. Attend this year’s Legislative Conference, Sept. 13-15 in Washington, D.C. This is a great opportunity to help educate Congress about these effects of these cuts. Registration is available here.

More than ever, Congress needs to hear from us. Please leave a comment below to say what you think would be the effects on your practice if the cuts were to go through, but make sure you also do one of the four things listed above. As Jack said earlier this month, “It’s time to roll.”

-- Vincent Bufalino, M.D., F.A.C.C.

* Dr. Bufalino’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!

*** Image from Flickr (Sir Twilight King). ***

There is no tort reform in the currently emerging bills. So, we signed on with a host of other societies and the AMA on a joint letter to Henry Waxman (D-Calif.), Chair of the Energy and Commerce Committee, urging Congress to include meaningful medical liability reform as a critical component of any health care reform legislation.

The letter highlighted the inefficiencies of our current medical liability system, escalating and unpredictable awards, and the high cost of defending against lawsuits. We are referring to recent data from Ohio on their malpractice statistics that underscore the changing med-mal issues. It underscored that as insurance becomes unaffordable or unavailable, physicians must make tough decisions including altering or limiting their services because of the following liability concerns:

• Most Cases Result In No Payment. The overwhelming majority of medical malpractice cases in Ohio continue to be resolved without any indemnity payment being made to the claimant. Nearly 80 percent of claims have no indemnity payments.
  
  
• Total Claims Are Down Significantly. The total number of claims has decreased significantly. Data from 2007 show 3,451 claims, compared to 4,004 claims in 2006 and 5,051 claims in 2005.  This 31 percent decrease relative to 2005 data is heartening.
  
  
• Average Indemnity Is Up. Though volume has decreased, other indicators have trended sharply in the other direction. Average indemnity, which was $269,374 in 2005, is now $315,635 in the latest report — a 17 percent increase since the first data point. Overall, these data suggest that only the more serious malpractice allegations are being pursued, but that providers and insurance companies are having to defend themselves more aggressively in instances where patients choose to take action.
  
  
• Legal Costs are on the Rise. Even when an indemnity payment is not made, there are significant investigation and legal costs related to the claim. In Ohio, the total allocated loss adjustment expenses (ALAE) for 2007 was $103,033,668. ALAE averaged $35,603, up over 45 percent since 2005.
  
  
• Age of Claim Matters. There is a significant correlation between the age of the claim and the size of the indemnity payout, if paid. Of the claims that closed with an indemnity payment, 186 closed within one year of being reported and had average paid indemnity of $67,146. That figure rose to $297,935 for 202 claims closing in their second year. Nine claims closed seven or more years after being reported, having average paid indemnity of $2,785,326.

The ACC is working to create a specialty society coalition to come together to get tort reform language inserted this fall into whatever bill finally emerges from  Congress. While we realize getting caps on non-economic damages is not politically possible at this time, real reform could gain traction. Why not get language that would require standards of merit for the tort pleading, and standards of merit for "expert" witnesses (facilitated by societies). What about periodic payments, collateral damages provisions, protections related to adherence to evidence-based care, and other such provisions to reduce frequency and severity of legitimate claims, and to greatly reduce illegitimate claims? We plan to try to organize a new effort in these regards.

I got called to appear live and unexpectedly yesterday morning on national Fox & Friends to explain ACC concerns about imaging cuts, after being quoted last week in USA Today on protecting access to imaging -- so, we are making an impact on the issue. But, it’s tough because hospitals and some others want to close down outpatient imaging altogether for their own self interest, which would devastate access to these services for many communities, and increase disparities in poorer populations.

As I discussed briefly last week, the Energy & Commerce, Education & Labor, and Ways & Means committees introduced their tri-comm health care reform bill, America’s Affordable Health Choice Act of 2009 (HR 3200, hyperlinked here for your reading pleasure). The President and others celebrated it as a landmark bill at the White House, while the Congressional Budget Office (CBO) Director, economist Doug Elmendorf, ruined their party by proclaiming the bill as an unsustainably expensive instrument that will destabilize the economy unless modified to reduce costs over time. CBO has always been the "skunk at the garden party" or worse, but this time they made House leaders and the President quite upset.  

What's In It
We strongly support access for all. But the CBO concerns are legitimate. Congress has espoused a set of worthy visions to improve quality and care coordination and efficiency, but the teeth for getting that done -- other than with the same old ineffective price controls -- aren’t yet there. A reform bill that works is certainly still possible after the debate gets going more openly. But, beyond the unspecified vision, the implementation strategies are not there. And, there are a lot of provisions in HR 3200 (many inspired by organized labor) that will alarm many of you if you read all the detail -- just understand this is a political process, and the House knows that most of that won’t survive the Senate’s scrutiny. One real concern for us is that there is no tort reform in this House version, and there probably won’t be anything to start with in the Senate health or finance versions either. 

We applaud the House for its commitment to provide access to health care to basically all US citizens, and in particular for eliminating the SGRrrr for the next 10 years. That’s huge -- $230 billion worth of what would otherwise be cuts to physicians. We praise their huge Medicaid coverage expansion, combined with taking the payment of that program away from states (which have paid on the CHEAP), and providing better payment to physicians. They put a good deal of new money into prevention and primary care, and they add money to offset physician workforce shortages. We also appreciate their establishment of a positive future Medicare physician payment updates (MEI) and favorable spending targets for updates in the future. We’re also well positioned with NCDR and the IC3 Program for their significant payment and delivery reform models, such as incentives for physicians and their expansion and improvements to the Physician Quality Reporting Initiative (although this program still lacks sufficient payment incentives ... a 2% "incentive" is close to useless for most practices). 

ACC President Fred Bove has expressed our praise of these positive elements to the three committees (that would infuse almost $300 billion of new dollars to delivery of patient care), but without praising or referring at this point to the elements of the plan that are undefined (the public option, for example), or to those we must work to amend because they are just plain bad policy (the imaging cuts, their attempt to undermine specialty hospitals, and their attempt to prohibit opting out of public coverage programs). We will work with House and Senate members to eliminate those elements -- none of which should survive Senate Finance scrutiny thankfully. The Senate will not buy the House’s income tax funding approach for HR 3200 as currently configured either. More...