There were some exciting late-breaking clinical trials presented here today and yesterday, and ACC leaders were widely quoted in the media on the implications of what was discussed. 

I took a little time out yesterday from the international scene to hold a panel with the American Heart Association to examine AHA and ACC’s vision for the future of U.S. health care. The panel featured me, Fred Bove, Clyde Yancy and Robert Califf.  Part of the purpose was to help cardiologists and CV professionals understand better the differences and areas of collaboration between AHA and ACC. We focused on the positives, which are numerous, rather than on areas on competition. As I’ve said before, the future of health care should be rewarding for continuous outcome improvement and providing patient-centered care.

The ACC has a health care reform campaign, called Quality First, which, like the name suggests, advocates for payment incentives for quality care, along with increasing the focus on patient value (which we define as transparent, high quality, cost-effective, continuous care), better coordination across sources and site of care and emphasizing professionalism to increase partnerships with patients. Reform would also provide universal coverage through an expansion of public and private programs. (You can read more about Quality First and specific examples of how to make it a reality in ACC’s “Blueprint for Reform.”)

Of course, making sure all of this is included in health care reform is quite a tall order, which is why the ACC is working with lawmakers and the White House to make sure that they know what we feel is best and how best to achieve it. We’ll know soon enough if we’ve left an impact.

The science so far at ESC 09 has been quite impressive. Check out Sunday's daily wrap-up video from CVN, featuring RE LY, PLATO and CURRENT OASIS 7.

¡Saludos de Barcelona! The theme of this year’s ESC Congress is “Prevention of Cardiovascular Disease from Cell to Man to Society.” From the ESC 2009 program:

“Cardiovascular disease remains the main cause of mortality and morbidity [and] we felt that major advances in prevention and risk factor identification should be our scientific highlight.”

According to the World Health Organization, an estimated 17 million people die of cardiovascular disease – in particular heart attack and stroke – each year. In the U.S., over 860,000 people died in 2005 from cardiovascular disease, accounting for 35.3 percent of all deaths in the country. This is a very important topic, and ESC plans to address it through nearly 80 sessions focused on how to reduce the CVD burden.

At the ACC, one way we address prevention is through our patient education Web site, CardioSmart. CardioSmart is a place for people diagnosed with cardiovascular disease to learn more about their condition and how to improve their health. We like to consider it a “safe space” for patients to come online and look for more information. Not only can they find more information, they can also participate in their health through the CardioSmart Blood Pressure Tool, which gives visitors a simple, secure and easily accessible way to enter their daily blood pressure readings and see their process. They can then take to their readings to their next doctor’s visit. The format of the site and the tools that it offers helps to make the patient a PARTNER with their physician, which in turn can help increase compliance and improve outcomes.

*** Image from Wikimedia Commons (Metamario). ***

Beginning tomorrow, I’m off for several days to the beautiful city of Barcelona for ESC (European Society of Cardiology) Congress 2009. I’ll be covering the event daily, so check back for updates. Also, follow the ACC on Twitter for more scientific coverage (@Cardiosource) and general news (@ACCinTouch) from the meeting.

Check out this preview video from Cardiosource:

Sherif F. Nagueh, F.A.C.C., our ACC representative to the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) reported recently that during ICAEL’s July meeting, members debated the idea of a two-tier accreditation system in which there would be minimum accreditation requirements, as well as a higher level that offered recognition that a lab meets a higher level of quality. One benefit for labs achieving the higher tier of accreditation might be a longer period between accreditations. The ICAEL board has not made any decisions yet, but Dr. Nagueh encouraged us to share our thoughts.

The ACC leadership had strong consensus that this is a bad plan and lowers the standard for quality under the first tier. Bill Zoghbi, F.A.C.C., said, the two-tier system:

"Adds complexity to the process with little added benefit. Importantly it does not address the current situation: Although overall good, criteria for accreditation are still sub-par in some areas and with low penetration. The minimum standards for accreditation should indeed be minimum standards for good quality.”

Former ACC President Doug Weaver, M.A.C.C., adds that recently he heard of a dentist and a neurosurgeon opening a medical imaging center together. “This is what is wrong in American health care, and we need to support even higher standards than what exist today,” Doug said.

The Obama administration's team held a conference call last night for interested physicians to help get us up-to-speed on all that is happening in health care reform. They agreed to try to answer questions by e-mail. While the call was a great idea -- to get us engaged and accurately informed on their policy recommendations to Congress -- it's tough to pull this kind of communication off well. The reforms proposed are overdue. IF, that is, Congress enacts them.

There really is a lot of BS (Blatant Scare-tactics) out there, but there is also a lot of concern over the deals that insurance, hospitals, and others have cut with the Administration to be supposedly immune to further injury: the deals are in favor of those industries and won't create the "bending the cost curve" savings needed to pay for expanded access (emperor's clothes are missing).

Doctors may be the only low-hanging fruit left to prune. The WH staff are not into that tactic, but are they boxed in if Congress moves in that direction? I think those who didn't e-mail in their questions in time last night were shouting those kinds of futile concerns on the call. Nobody heard them.

However, I think that many physicians -- such as our members, and oncologists, nephrologists and other specialists who got the short straws in the absurdly unscientific 2010 Physician Fee Schedule proposal -- are so focused on protecting their practice viability by opposing the proposed rule that there’s no time or energy left over to focus on the critically important issues of health reform. That's worrisome. 

Think of my wistful but sincere Kennedy tribute. We're going to get something in a health reform bill -- and it is needed. But what will we get?

The insurance industry will come out OK, I suspect. We're generally helping them by our expressing with them our misgivings about a public plan. But is insurance helping us? Duh (they're very busy right now).

The semi-tragic reality is the President and his Administration really DOES want to empower us. They sincerely acknowledge how important the contributions of physicians and other health care practitioners are to meaningful reform. I believe them on this. They see why that IS important to patients and the future. But I don't see it happening in what's in the bills so far. And the massive donations to Congress of the other constituencies (we tend to be loud but cheap) bother me in terms of what Congress will actually do. The call was a nice gesture. But we still have our work to do! The fall will pass quickly and then the winter approaches. It's almost pruning time.

I accepted a very arduous travel arrangement requiring that I take a quickie 3-day trip to Hawaii last weekend to speak at a physician conference, and also attended a meeting with the fledgling Hawaii Chapter of the ACC. Finally, we may be able to add some ALOHA to the ACC agenda!

The meeting with the Hawaii Chapter was promising. Hawaii, where everything is more expensive than the mainland, EXCEPT for health care, is one of the per capita lowest cost health care spending states, despite also having better population-based outcomes at lower costs. Hawaii has a lot to teach us. Stay tuned folks. We can be mentored by our colleagues there. 

Even though health care in Hawaii, where ALL employed people have health insurance, is far from perfect, it’s a lot more perfect than the rest of the US. Some surmise this is because Hawaii is more generous in its treatment of those at the lower end of the economic totem pole (not a Hawaiian metaphor) than the rest of America. Others theorize that Hawaii is so successful because it has a population that is genetically superior. We think that is the case in Washington DC too (!), but there is absolutely no evidence for it here or in Hawaii, according to CDC, which notes that Polynesians have some of the most high risk genetic factors of any subpopulation in the country. Another theory about Hawaii’s lower health spending and lower morbidity and preventable mortality relates to the alleged superior lifestyle benefits of Hawaii, where the thinking is that all citizens spend most of their time surfing (this is again certainly not the case, and in fact obesity and sedentary lifestyles are very common there). Then there is the mysterious “Island Factor” not yet discovered by Manhattan, Puerto Rico, Nantucket, or the Caymans that might explain things? 

Well, the reality of Hawaii’s relative success is not that complicated: Hawaii’s benefit comes from 20 years of universal coverage of all working families who have had better access to good primary and specialty care. The reason Hawaii has the highest incidence of breast cancer of all 50 states, for example, along with the LOWEST death rates for breast cancer, is that Hawaii citizens have access to primary care prevention and surveillance generally. Our CV colleagues there will nonetheless share that they are just as frustrated with Medicare spending and payment cuts, and the impending Medicare Rule for 2010 as everybody on the mainland. They are clear the health care there, while better in many ways, is in trouble in the future like everywhere else. And it won’t get fixed by having another Mai Tai. 

That said, the lesson of the benefits of great access to both primary and specialty outpatient care in reducing preventable morbidity has been discovered not just in the 50^th State, but in all other developed nations except ours. Hello-Ha.

UPDATED: Check out this piece from the Honolulu Advertiser about my trip.

The American Medical Association (AMA) has asked us to help disseminate a message from Jim Rohack FACC, President of AMA, about their support for HR 3200. As I told you last week, I think the AMA has been unfairly treated based on misinformation on their position on H.R. 3200. They are trying to eliminate the SGR. This message is aimed to clarify their reasoning. According to the AMA:

• The original bill contained a core set of high-priority provisions that the AMA has long supported;
• Bill sponsors were not likely to maintain the $230+ billion investment in Medicare physician spending if the AMA did not register support for the bill (hospitals, the home health sector, Medicare Advantage plans and pharmaceutical companies are all facing cuts in the tens and hundreds of billions of dollars); and
• As an early supporter, the AMA is well positioned to help shape revisions to this bill, as well as the final legislation that will ultimately be presented to the President.

The AMA message also points out that the organization is continuing to share its concerns with the White House and legislators about reform legislation and the pundits’ assertions that doctors are anything less than committed to doing what’s right for their patients. I think we can all get behind that message. AMA is getting beat up over it’s support of H.R. 3200. We didn’t take a full support position; but their push to get the SGR fix will be a big help to all docs if it succeeds.

The two economist titans, Uwe Reinhardt and Paul Ginsberg had an interesting point-and-counterpoint on payment reform last month that was published on the Health Affairs blog.  Reinhardt suggests shifting away from the present, price-discriminatory system of semi-arbitrary private sector pricing toward an all-payer system. He sees this as a transition to a future system based on bundled payments per episode of illness for acute care, and a new and better version of capitation for chronic care and prevention.

Ginsburg suggests that an all payer system might put pressure on doctors to contain costs in a "far less radical" manner than the public option proposed by many advocates of health reform. Ginsgurg praises the "success" of Maryland’s all-payer system. (Health Affairs will cover Maryland’s in detail in their Sept. 9 issue).

I am fond of both of these exceedingly thoughtful and smart gentlemen. But, I think both suggested methods could be scary for doctors and patients without a phase in or glidepath from where we are to any new model. As they sparred in a friendly fashion, I was reminded metaphorically of the old Godzilla and Mothra movies, where the altercations resulted in no damage to the fighters, but instead destruction of the infrastructure all around (and I supposed we would be the people running down the street screaming).

Uwe's proposal would be far simpler than competition around the present 20,000 or so itemized charges or list prices each hospital uses, or the more than 9000 list prices for doctors in the physician fee schedule. He also suggest associations (like ACC) might negotiate with insurers in a region (a state?) as is done in Germany, and make the results binding for both doctors and insurers. Doctors would then charge all insurers or patients the same price for identical procedures.  Medicare and Medicaid could be part of the arrangement he thinks. Pretty radical. Some major anti-trust relief would be needed, and there are clearly risks associated. But, hmmmm.

I asked this question back in March during ACC.09, and the winner was payment reform, closely followed by malpractice and access issues. Given everything going on now, let's see how it changes.