This just in ... A new ACC member survey provides insight into just what the impacts of the cuts on practices will be. The practices surveyed said staff layoffs (42%), elimination of service lines (33%), limiting office hours (14%) or not accepting Medicare (13%) were options they were considering as a result of the cuts. Only one-quarter reported no action and those which will not change practice patterns tended to be in academia or work in hospitals. That being said, even academic institutions and hospitals are not untouched by the rule.

Patients seeing solo practitioners (100 patients seen on a weekly basis) will be hit the hardest with anticipated cuts across the board in staff, service lines, Medicare payment and office hours. Medicare patients will also be extremely inconvenienced as 13% of practices (17% of private practices) anticipate a need to reduce the number of Medicare patients or stop accepting Medicare payment. Cardiovascular practices report that about 50-60% of their patient volume is Medicare patients. Taking that into account, calculations reveal that at least 14% of the Medicare population receiving cardiovascular care (or 7% of all cardiovascular patients) would be directly impacted by the anticipated cuts.

The survey also shows a clear trend toward hospital migration. Almost one-in-five (18%) of active, practicing cardiologists in the U.S. have already migrated to another practice or hospital and 28% say that a practice merge is on the horizon. When you look at practice type, private practices which expect to be hit the hardest by the recent ruling are more likely to consider integration into a hospital system (39%).

I’m back in D.C. today after a whirlwind couple of days at AHA. It was an exciting trip, reminding me how much I look forward to ACC’s own scientific session in March (not to be missed!).

That said, there’s still one major item left to discuss from AHA’s meeting: the release of ACC Foundation/AHA/Society for Cardiovascular Angiography and Interventions focused updates on the management of patients with ST-elevation myocardial infarction (STEMI) and the management of patients undergoing percutaneous coronary intervention (PCI). It’s only fitting that the document was released during AHA – the update takes into account many of the major trials conducted recently for cardiology and released at AHA and ACC’s meetings. The update makes new recommendations to ensure patients reach lifesaving therapy for STEMI as quickly as possible. 

The update recommends that each community develop a STEMI system for triage and transfer of patients that complies with the standards set forth by Mission Lifeline. The system should include destination protocols to STEMI Receiving Centers and transfer protocols for patients who arrive at STEMI Referral Centers and are primary PCI candidates and/or are fibrinolytic ineligible and/or in cardiogenic shock.

Another significant change recommended in the update is greater acceptance of PCI of the left main coronary artery. The update suggests it may be considered based on favorable anatomic condition and an increased risk of adverse surgical outcomes.

UPDATED: 11/19 with CVN video, as promised.

On Monday I attended a plenary about managing patient expectations in the face of the current cost-savings-focused environment. As doctors, we sometimes find that patients want the most expensive care or the most tests as part of their treatment because they view it as the “best” care they can receive. However, this usually isn’t true. The best care is the care that’s been validated by science – and high quality science at that. This can be difficult to come by, even in the field of cardiology, which compared to other specialties, has some of the best research available.

Why does cardiology have some of the best, most comprehensive research? Because cardiology has registries, and we use them to collect data in real-life, which we then turn into the research that informs the clinical documents that guide everyday practice. The ACC has a suite of six registries (NCDR) that together pull research from nearly 2,000 hospitals and 180 practices (yes, one of those registries is an ambulatory registry – the PINNACLE Registry -- formerly called the IC3 Program).

At AHA, research from the NCDR is making quite an appearance. There’s a total of 14 abstracts from the NCDR out at AHA, which hopefully you had the opportunity to check out: five abstracts from the CathPCI Registry; four from the ICD Registry, one from the CARE Registry, two from ACTION®-GWTG™ and two from the IC³ Program (now the PINNACLE Registry).

Of particular excitement are the two abstracts from ACC’s IC³ Program/PINNACLE Registry. The first is an oral presentation by Paul S. Chan, M.D., M.P.H., on “A Report of the First 10,000+ Patients.” The study found nearly three in five enrolled patients had coronary artery disease (CAD) and all the outpatient performance measures (PMs) could reliably be assessed. Adherence to the CAD PMs was often suboptimal, suggesting substantial opportunity for improving the quality of outpatient care.

The second (a poster presentation by ACC staff members Kristi Mitchell, M.P.H., and Sunil Gupte, Ph.D.) is “Electronic Medical Record Adoption in Cardiology Practices: A 2009 Snapshot.” This study found EMR adoption within PINNACLE Registry (then the IC³ Program) is slightly greater than that reported in the literature and may be due to the greater number of large practices enrolled. The PINNACLE Registry provides a foundation to analyze EMR adoption and implementation rates in U.S. cardiology practices and to observe trends associated with reducing some of the financial barriers due to the recent provision of federal funding. As such, the PINNACLE Registry will be positioned to determine the impact of EMR usage on clinical quality and patient outcomes.

The large number of abstracts presented at the meeting is a testament to the rich evidence coming from these groundbreaking registries. We need to keep moving forward with our efforts so that ALL clinical decisions can be made on the basis of the strongest level of evidence.

UPDATED: 11/19 with video.

I stopped by the Expo floor and couldn’t help but notice the decline in the number of industry exhibitors. We had similar declines in our exhibitors last year, which causes me to think this is representative of the new nature of our relationships with industry. Our relationships with industry are becoming increasingly sparse, which some would argue is how it should be. Or they would argue that the relationships shouldn’t exist at all.

That’s not the College’s view, though. We believe that although there must be firewall for relationships with industry, done correctly, they can be positive and constructive relationships. These relationships shouldn’t be seen as inherently bad, they just must be effectively and ethically managed, and breaches in ethics should NOT be tolerated.

The ACC handles our relationships by creating a firewall between the funding and the program it supports. The funding is solicited for specific new or ongoing programs/initiatives. The money is dedicated exclusively to an objective – but the industry supporter has no say in how the funds are used for the program/initiative. By using this process, the ACC can still get the valuable financial support it needs to continue to make available quality programming and education.

The College has taken a leadership role in this debate, building consensus on the issue among medical professional societies. (For more on ACC’s stance on relationships with industry, see a post from ACC.09.) We must continue to move toward responsible, transparent relationships that will allow us to maintain quality education and research in cardiovascular medicine.

What do you think?

Some good trials came out yesterday at AHA. Here's the wrap up.

One of today's posts comes to us from Jim Fasules, M.D., F.A.C.C., ACC's Senior Vice President of Advocacy. Prior to stepping up to the plate to lead the College's advocacy efforts during this tough practice environment, Jim was a pediatric interventional cardiologist at Arkansas Children's Hospital in Little Rock.

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At annual meetings like ACC.10 and AHA, cardiovascular professionals keep up with the newest and best science to make sure we’re providing patients with the right care. However, between the dwindling financial support from industry for these events and the even more dwindling reimbursement for CV services, maintaining this commitment to being knowledgeable about the most recent advances is becoming increasingly challenging.

The worst example of this is, of course, the Centers for Medicare and Medicaid Services’ final 2010 Physician Fee Schedule. Although many of the cuts included in the rule are phased in over a four year period (giving us time to fight their implementation), major cuts for 2010 include: 

• SPECT Myocardial Perfusion Imaging (78452): 36 percent cut
• Transthoracic echo with spectral and color flow Doppler (93306): 11 percent cut
• Coronary Stent (92980): 4 percent cut
• EKG (93000): 5 percent cut

ACC.org has a more detailed summary, but even this very brief overview highlights the grave situation cardiology is in right now. These cuts are deep enough over four years to threaten the survival of private practice cardiology. Indeed, many practices have already or are strongly considering selling their practice to hospitals. We are concerned this could have a major effect on access of rural and disadvantaged patients to timely cardiac care.

Our fight against these cuts has just begun. The ACC is working closely with cardiology practices through the Cardiology Advocacy Alliance (CAA) and with the cardiovascular subspecialty societies to mitigate the impact of the cuts. Though we obtained a four-year phase in, it is not enough. We’re continuing to fight on several fronts – regulatory, legislative and legal – to limit the effects of these cuts on you and your practice.

The road is steep though, and we’ll need your involvement more than ever. Visit www.acc.org/CAN to take action and to access the ACC resources available to help you survive these times. More tools will be coming in the next few months -- your feedback on the tools and resources you’d like to see is appreciated. Please email advocate@acc.org with your thoughts.

We’re doing all we can to help you and your practice get through these challenging times for cardiology, while we find a real solution to payment reform. We need to find a solution that reduces the cuts so we can focus on what we do best – providing high-quality cardiovascular care to patients.

-- Jim Fasules, M.D., F.A.C.C.

* Dr. Fasules' 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 (Suviko). *** 

Here is Sunday's daily wrap up from CVN of LBCTs at AHA.

AHA kicked off its meeting with an opening session featuring AHA President and ACC member Clyde Yancy. Yancy helps lead the Coalition to Reduce Racial & Ethnic Disparities in CV Outcomes (CREDO), a joint society effort that stresses research (how accurately can we describe the present disparities?) and action (once identified, how can we target the areas to improve care?). Learn more about it from an interview I conducted with Clyde back in July.

Also speaking during the opening session was Thomas Frieden, M.D., M.P.H., director of the CDC. Dr. Frieden has been a friend to cardiology over the years through his efforts as commissioner of the New York City Health Department, where under his watch, the city cut smoking rates in teens and adults, eliminated trans-fats from restaurants, rigorously monitored the diabetes epidemic, and required certain restaurants to post calorie information prominently.

Another interesting bit on Frieden’s resume: As NYC commissioner, his department ran the largest community EHR project in the country, following a request from Mayor Bloomberg (another friend to cardiology). The project focused on getting EHRs into community health clinics to improve quality and now includes more than half of the doctors caring for patients in Harlem, the South Bronx and Bedford-Stuyvesant – low-income areas that would typically be the last to have access to such technology.

Dr. Frieden’s is an interesting approach – providing low-cost EHR and implementation support – to making sure that practice are able to implement technology. Outside of this program, you find that many offices, particularly those in small practices of one to three practitioners, face significant barriers to adopting technology. Even though the federal government is offering significant funds to help urge adoption, practices face high upfront implementation costs for health IT (we’re talking $124,000 over five years, with only $44,000 in incentives to offset the costs). That’s daunting – and many may not be enticed by the incentives knowing the cost of implementation.

However, our challenge is in reaching out to these docs to communicate the bigger picture: reduced costs and gained efficiencies—not to mention higher quality care for our patients. Getting engaged in health IT will provide the best chance of keeping smaller practices viable in the coming era of payment reform. (If you’re interested in health IT, you should come to ACC.10, where we’ll have a day-long spotlight session on the topic.) The ACC also has great resources online at www.acc.org/healthit.

***Image from Flickr (Prasan Naik)***

Today I’m traveling back again to Orlando (feels like ACC.09 was just yesterday!) for the American Heart Association’s Scientific Sessions2009. The event promises to be exciting ... more than 30 late-breaking clinicaltrials will be released and more than 4,000 presentations made. You’ve got tolove the suspense of wondering which LBCT is going to be the hot one of theconference. I have a jam-packed schedule while I’m here – I’ll be attendingseveral of the plenary and special sessions, and meeting with 10+cardiovascular societies.

Thesebig CV meetings are my opportunity to connect with the other societies andexplore ways we can work together. Given the drastic Medicare payments cuts facingcardiology over the next four years and the rapid pace of health care reform,working together is going to be key to our success.

Just like the European Society of Cardiology’s meeting in August, the ACC has heavy presence at AHA’s meeting. We have a booth down inthe exhibit hall (booth #2023) to give ACC members at the meeting the opportunityto mix and mingle with ACC colleagues and ACC staff (or become an ACC member ifyou’re not already). If you’ve got questions about what the ACC is up to thesedays, you can come down to the booth to find the answers directly from staff.We’ll also have our products available for purchase, along with registrationfor other cutting-edge CV educational programs.

If you’re looking for more coverage of the meeting, visit http://cardiosource.com or follow @Cardiosource on Twitter for up-to-the-minute summaries,presentation slides and videos from the meeting’s LBCTs. 

I'm heading down tomorrow to Orlando for AHA's 2009 Scientific Sessions. Are you joining?