ACC SVP of Advocacy Jim Fasules and I had a fascinating meeting with Newt Gingrich last week. I had called him about setting up a time to talk about ACC’s expanding opportunities to use our science-based tools and clinical registries to improve outcomes, quality and system effectiveness.

Our purpose in having this meeting was simply to be on Newt’s radar screen as he meets with so many other constituencies about transformational health care and innovative use of health IT. He needs to appreciate what NCDR, the PINNACLE Registry, and our appropriate use criteria tools are capable of contributing to improving quality and reducing unnecessary spending. I think we succeeded. The last time I talked with him, I was able to scratch the surface of these opportunities but not get into detail, so this was an important follow-up.

We also talked about the Administration’s Medicare cuts to cardiology physician practice viability. In his view they should first stop “paying the crooks” in health care who are costing the system much more than the entire cost of physician services. By crooks, he of course means the insurance companies — just kidding! Poor insurance companies get the brunt of a lot of criticism, and sometimes unfairly.

No, the crooks he refers to are those real criminals who produce the enormous fraud, waste and abuse in the federal health care system. Health care is one-sixth of the nation’s economy (17 percent of the GDP, or $2.4 trillion), and likely to grow to at least $4.3 trillion and 20 percent of the GDP in 2017. It’s estimated that at least 10 percent of what the federal government spends is wasted on overt fraud — I’m talking about mafia-like activities that get away with  billing for services for deceased beneficiaries, billions in procurement payments for services and supplies never issued, and the like. Every administration talks about this reality, and nobody seems to succeed in doing anything about it. It’s easier to cut physicians it appears. Newt thinks that overt fraud reform could save between 10 and 20 percent of the total Medicare and Medicaid budget. Sounds better than the 2010 Medicare Rule to me.

The ACC this morning held a press conference on health care reform as part of the National Coalition on Health Care, of which the ACC and a number of other specialty societies and consumer groups are members. Ralph G. Neas of NCHC, Ron Pollack of Families USA, Mary Andrus of the Consortium for Citizens With Disabilities, Terry Gardiner of the Small Business Majority, Mary Wilson of the League of Women Voters, and Richard Kirsch of Health Care for America Now and I were the featured speakers. From today's Advocate:

The press conference was in keeping with the College's ongoing efforts to work with multiple stakeholders to enact health care reform that protects patient access, addresses tort reform, improves quality/coordination and reduces disparities in care. The ACC had the opportunity to highlight the cardiology community's concerns with the current legislation and urge the elimination of provisions that have reduced public trust and increased partisan rancor.

Even more importantly, it also placed us front and center with key consumer groups who have the ability to help us not only with crucial elements of reform, but with mitigating the impacts of the 2010 Medicare cuts. ACC leadership was also able to individually educate the media in attendance on the impacts of the CMS Medicare cuts on the practice of cardiovascular medicine and patient access to quality care.

Your ACC continues to navigate a critical path through the reform quagmire that truly meets the needs and goals of the cardiology community, while also protecting the patient-physician relationship. Click here to read the ACC's recent letter from ACC President Alfred Bove to House and Senate leaders outlining both the College's areas of support and areas of concern.

In other news, efforts continue to fight the cardiology payment cuts included in the Rule. Please take a few minutes to call or write your representatives and urge them to cosponsor legislation (H.R. 4371) introduced by Rep. Gonzalez (D-TX). We've set a goal of 100 more cosponsors -- contact your member today (so far we're at 77 -- but we'll need a lot more to force some action). To see if your member is already one of the 77 cosponsors and to say thank you, click here. ACC staff is working on generating similar legislation in the Senate. For more on ACC's efforts related to Medicare payment reform, go to http://www.campaignforpatientaccess.org.

We’re about to take another slap if the recent deliberations of MedPAC become real. They’re bound and determined to kill off in-office imaging for all specialties, not just cardiology. To force by public policy all imaging to hospital sites is going to cause quite a problem for patients, both in inconvenience and in increased overall cost. (ACC President Fred Bove has a great President’s Page on the democratization of imaging in the next issue of JACC; watch for it.) Nonetheless, our current version of the IPAB (Independent Payment Advisory Board) is MedPAC, and here’s what they’re doing:

MedPAC staff recently made a presentation to the MedPAC commissioners regarding the “in-office ancillary services” exception (commonly known as the “group practice” exception) to the Stark Law (see the MedPAC slides).  It is this exception that enables private practice cardiologists to provide echocardiography services to their patients.

At the meeting, MedPAC staff suggested that the Commissioners consider three options for addressing the increased utilization that ostensibly results from this exception, especially in the area of clinical lab services, radiation therapy services and diagnostic imaging:

1. Excluding certain services from the group practice exception, such as outpatient therapy and radiation therapy and diagnostic tests that are not usually provided at the time of the office visit.  (According to data presented by MedPAC staff, ultrasound is provided on the same date as the office visit less than 30 percent of the time, so echo likely could not be provided by group practices if this test were adopted.)
   
   
2. Payment tools such as reducing payments for self-referring physicians, packaging services and bundling services.
   
   
3. Establishing a prior authorization program for physicians who self-refer.

In case you’re not watching closely, I need to alert you to the fact that the entire payment system — in both the public and private sector — is in severe disarray. If most doctors are working for hospitals in order to remain viable in the near future, which might be administratively simpler for Medicare and the insurers, the need for payment reform and for physician involvement in it will become even more pressing, because hospital-based costs are going to drive health care costs up. And then, next year, the thrust will be to slash hospital reimbursements. The status quo of the current payment systems, as exemplified by this entry, needs to be changed. Price controls don’t work. When do we wake up here? This is a bad dream.

Nobody seems to know what’s going to happen next or what the actual chances of getting reform legislation passed might be. I don’t know about you, but considering all the pimples, warts and wrinkles in HR 3962 and 3590, there is an impulse to breathe a sigh of relief over the opportunity to push the reset button and get this more effectively. On the other hand, the real potential of a complete derailment is really worrisome.

Here’s the reason to keep the champagne corked about the prospects of a prolonged logjam in getting health reform passed: The access to care problems are growing and cost a lot of money in EMTALA and uncompensated care costs; despite the fact that at its best, U.S. health care is the best, quality is uneven and coordination of care is seriously messed up; and most disturbingly, costs are rising more than twice as fast as GDP and our ability to pay for health care. Allowing the status quo to drift forward will mean draconian measures for rationing and tiering of care for most Americans sometime in the near future; and it will most certainly mean ongoing reductions in physician practice revenues and practice and hospital viability. Medicare is moving rapidly toward overt bankruptcy.

Senate Minority Leader McConnell said the Massachusetts election made clear that the voters didn’t want government taking over health care. Whaaaat? The Massachusetts universal coverage law is in many ways not too different from what the Senate proposes -- and Sen. Scott Brown (D-Mass.) voted for it and doesn’t want it repealed. Maybe the voters were fed up with back room deals like giving unions a free ride exemption from the ‘Cadillac plan’ tax (when they are the only ones with such plans), and with stinky deals like Ben Nelson’s and Chris Dodd’s state bonanzas. Maybe we didn’t need 2000 page bills with so much complexity they created distrust. Whatever, they’re all running around crazily bumping into each other here in the Capitol. It’s absolute chaos. 

Pelosi is right that she has nowhere near the votes in the House to simply pass the Senate bill. That ain’t happening. And using the “reconciliation” process to jam something through with 50 votes to avoid a filibuster is not a likely strategy now, because the public won’t like it. One can only hope that Congress can muster a smidgeon of bipartisanship to create a much simpler solution than what is proposed for reform that addresses the access problem, improves coordination and quality with the participation of the profession, and slows the cost curve toward sustainability. We should all be committed to that as a nonpartisan, necessary thing to protect both the economic and social viability of this country.

So, this is not a time for either chest-pounding or antidepressants. Rather, we have another window of opportunity during this whole congressional season to shame both parties in Congress into acting more responsibly. We can do better than this.

 

The Office of the National Coordinator (ONC) for Health IT, led by Dr. David Blumenthal (our keynote speaker at the ACC.10 Health IT Spotlight Session), released on Dec. 31 his proposed parallel regulatory schemes for implementing “meaningful use,” and for “certification of electronic health records.” In both of these documents (500 pages for meaningful use, and 126 pages for EHR certification) the ONC has articulated the national strategies and policies that the IT industry, the profession, hospitals and health insurers can expect soon. There’s a lot at stake here -- physicians who qualify as meaningful users with however this comes out will be eligible for up to $44,000 of federal support for health IT implementation over 4-5 years. To qualify, one must comply with meaningful use and buy and use an EHR that meets the federal standards.

The ‘meaningful use’ proposal is very heavily slanted toward primary care, and may not support many specialty practices, at least as crafted in draft one. That said, the ACC could very much benefit from these strategies as they evolve if we are nimble in shaping how they turn out, even though the first version of meaningful use is dizzyingly complicated.

There are some pretty radical recommendations in these documents. But maybe we need to blow up some of the status quo thinking on bringing medicine into the e-age. We’re going to put a lot of time and effort at ACC through our Health IT Committee to evaluate this all carefully and try to make both of these proposals better.

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

Notwithstanding Harry Reid’s plethora of public statement snafus, Ben Nelson’s being booed out of a popular restaurant in his hometown on his health reform behaviors, and despite the fact that Republican Scott Brown won the “Kennedy” Senate seat over Democrat Martha Coakley in Massachusetts (wiping out the 60^th Dem vote needed for reform in the Senate), I remain optimistic about health reform.Mr. Reid and Ms. Pelosi seem to have a very shaky but barely sufficient majority of votes needed to move a compromise bill through both houses and on to the President in time for the State of the Union. Who would have thought this to be possible a month ago? Of course, lots of things could derail it, but it seems to be moving forward.

The ACC, along with most of medicine, is extremely concerned about the proposed IPAB (Independent Payment Advisory Board), which is an outgrowth and evolution of the IMAC (Independent Medicare Advisory Commission), itself a version of ‘MedPAC-on- steroids.’ The Senate has of late proposed the IPAB consist of 15 physicians that would oversee (guess what?) physician spending. Hospitals, long-term care and pharmacy costs would seem to be excluded.

What? First we have the SGR as a volume-based expenditure target for doctors only, and now we are going to have a second process to limit physician spending? At the same time, hospitals will continue to have their “market basket” formula, which gives them a tidy 2 to 4 percent increase every year, without expenditure targets. Until we physicians decide to increase our investment in our future (and the future of our patients) by getting more involved in the political action and PAC activities, the hospitals, health plans will continue to have much more leverage than we do.  It looks now like the SGRrrr will get only a short 2-3 year fix in the talks this weekend. No good.

The ACC is also pushing still for tort reform, including certificates of merit, health courts and other provisions that a fairly large number of Democrats will support. Of course, we could get support for tort reform from almost the entire contingent of Republicans in both the House and Senate, except they won’t help now because they don’t want to give the Democrats any credit for something they believe is their domain. Some progress on tort reform looks possible. The ACC signed on to a multi-society letter drafted by the Health Coalition on Liability and Access (HCLA). We are a member. HCLA lobbied for the kind of tort reform language that the ACC has long supported directly with Harry Reid and Nancy Pelosi this week.

Health reform may be imminent. Hold your breath. Whether you want to see this proceed or are adamantly opposed, the nation could be doing something as significant as occurred in 1965 with the establishment of Medicare and Medicaid soon.

Congress and HHS are sure that we’ll just accept whatever cuts they levy on us. We usually do. Congress doesn’t understand that the current Medicare policy is killing private practice of cardiology.

Maybe they’re right -- cardiologists will probably find ways to adjust to this. But the negative effects on patient access and costs will be real.

Would opting out of Medicare be an option? First, for many of our members, Medicare is 60% of the practice -- opting out may be tough. Taking no new Medicare patients is an option. But, at some point cardiology has to stop just accepting what Medicare doles out if we expect change. In Europe and elsewhere doctors and patients have a private practice option to exercise if the national health service entity is unfair. We really do not have that!

Although the legal option was dismissed, there are two important directions that we must pursue until the adverse effects of the Physician Fee Schedule rule can be reversed.

Option One: Legislative
The legislative route is still a viable option. We need to understand that nothing much will happen in this regard until Congress resolves the health system reform issues, one way or another.  However, the Gonzalez bill now has over 70 cosponsors! Note that we probably need 100 more cosponsors before the Speaker and leadership will demand a solution, and find a way to achieve one.

Other constituencies have prevailed in similar uphill battles in Congress to reverse bad Medicare policy with a legislative fix like we have proposed. Rehabilitation services were cut a few years back by 40 percent or more, and most medical professional societies looked the other way or tacitly supported the cuts in order to get more money for an SGR fix. But the rehab doctors and their patients persisted in showing the harm that was occurring with the cuts until they got to a threshold of about 170 members of Congress committed to a solution for them. At that point, Congress reversed most of their cuts in one of those quick, almost invisible stealth actions tied to a fast-moving bill. We need to get a similar thing to happen -- one Congressperson at a time until we exceed the critical mass. WE need to move fast to prevent other specialties from visiting members first to undermine our dilemma.

But here’s what’s really going to be powerfully effective is: directly communicating with the 465 members of the House and Senate (out of 535 total) who haven’t yet signed on to the Gonzalez bill as House members or to propose a bill in the Senate. This is going to be a struggle which will succeed one member of Congress at a time by virtue of their awareness of damages being done to patients and practices in their domain. Sen. Mary Landrieu (D-La.) is on our side — she wrote to Senate Majority Leader Harry Reid eloquently expressing her concerns about the effects of the cuts on cardiology practices. Senator Bill Nelson says he supports us as well. We’re incredibly grateful for the support of members like Sens. Landrieu and Nelson, and more of our lawmakers need to hear the messages she has heard directly from those who have been harmed. There is no other way by which we will more likely succeed in getting the attention we need. 

Option Two: Public Opinion
But there is a second strategy beyond the legislative one, and this is to continue to press in the court of public opinion. This will be most effective locally than it will be in the big national papers. Op-eds, letters to the editor, editorial board meetings and locally produced ads in small town and local newspapers and other media venues will have more direct impact on members of Congress than anything else we do in the PR area. The ACC will still be posting critically timed ads in the news venues that go directly to Congress, but we need to make this a local grassroots media blitz to have the most impact. 

That’s the challenge. The ACC will be ready to help all of you at the local level with talking points, media suggestions and whatever else you need (contact us at advocate@acc.org). Once again, documenting real damages to practices and frustrations for patients is what we need to succeed; but one-on-one messages will make it happen.

As our attorneys, ACC's witnesses, staff, and I were about to board our flights to Florida for the scheduled hearing on our preliminary injunction and expedited discovery motions related to the Medicare 2010 Payment Rule, Judge William Dimitrouleas of the US District Court Southern District of Florida denied our motions. Basically, he refused to hear our case.

We are deeply disappointed in the judge’s decision not to hear our case based on his opinion that the federal courts do not  have jurisdiction to review Medicare physician payment determinations.  Nevertheless, we continue to believe in the well-documented merits of our case.  The ACC will continue advocating for real payment solutions based on quality outcomes and patient care.

What is deeply troubling about today’s ruling is that it sets the precedent that CMS has complete and unchecked control over physician reimbursement for patient care even where its determinations are based on faulty data.  This only begs the question: Who's next?  Today’s ruling should be a warning to all physicians that anyone is susceptible to falling into CMS’s crosshairs unfairly and without recourse.

Ironically, this rule will increase Medicare costs by shifting cardiologists and their patients to more expensive hospital settings. These cuts are a perverse ‘reward’ for the amazing work cardiologists have done over the past decade in reducing heart disease deaths by thirty percent.

Today’s decision is counted as a loss; however, we stand behind our position that the system erred. The practice expense data used to determine this rule was inaccurate and incomplete.  Reliance on this data will negatively impact patients' access to care.

We have introduced legislation and we remain hopeful that Congress will get the message that these cuts represent bad public policy.

Our ongoing campaign for patient access is about making quality cardiovascular care accessible to the millions of Americans who are battling our country’s number one killer, heart disease. We will continue to fight on behalf of our patients to protect their access to quality care. I encourage you to visit CampaignforPatientAccess.org for more.

It’s time for 2010! Let’s turn the corner here, and not look back too long. 2009 started with George Bush as President -- doesn’t that seem a long time back at this point? And, it’s been a slog all the way through the year for the new Administration on many fronts. That said, the stock market has regained much of what was lost last year; and let’s hope the worst of 2009 is behind us. Our resolution for 2010 needs to be to apply all means to turn around this 2010 Payment Rule, and then also to design and implement a new and better payment philosophy and methodology based on improving payment and quality and effectiveness.

Think how well cardiology would do in such a reinvented system if it were real: we’ve helped America experience a 30+% reduction in morbidity and mortality in cardiovascular disease in the past decade. A reformed payment system should provide that level of reward -- the overall savings and ROI societal benefits would dwarf any reward to cardiology for these documented improvements. I know a lot of you are skeptical that something this logical and positive could even be realized; but don’t give up -- there is a lot of creative space in the health system reform arena to maneuver in. That said, instead of diving into that creative space when opportunities present, I have been increasingly concerned that we are getting caught up ourselves in partisan rhetoric that will impede our progress to promote our best future and protect our membership and their patients. (Drucker: “The best way to predict the future is to create it.”).  Let’s leave a lot of the cynicism and understandable frustration we’ve all been sharing in 2009 as part of the certain-to-be-damned legacy of the ugly “aughts,” a decade which started with a raging Wall Street, NASDAQ, and housing market, and with unwarranted optimism. 

On Partisanship
A lot of this recent history gets filtered through partisan perspectives. How partisan is health care; and how partisan is the ACC itself? In the public’s mind doctors are mostly Republicans, but is that so? I personally think we’re divided in a partisan fashion as much as the public is. Of course, I guess I should disclose in fairness to you that I am a registered Democrat, although my mostly liberal wife accuses me of being too often on the right side of the great divide. In truth, I reject both party platforms, and the far left and far right extremes that define them. I consider myself a fiscal conservative, and a social liberal. There are more people out there for me to relate to in these regards with each passing year.  Basically, like most Americans, I consider myself to be mostly in the political ‘common sense’ middle -- and in fact most voters now consider themselves to be ‘independents.’ I think that is a good trend. But we need to take heed of it.

Why? Because health care is largely non-partisan, and ACC needs to focus on the merits of each issue, not on a party platform or deliberated slanted party rhetoric, either left or right. If we can do that, we’ll be staying close to our patients and the public in the mainstream -- where we need to be to survive. From a partisan perspective, health care reform is evil for Republicans and good for Dems -- depending on who is in the majority. When Richard Nixon was the champion of reform (he favored the employer mandate that only Hawaii implemented), reform was then “good” for Republicans and evil for Democrats. Partisan politics is gridlock -- and we don’t do well in that future, colleagues.

The challenge of making positive change requires a more discerning, “bi-partisan” course -- we must exert leadership to influence folks on both sides of the aisle. Congress has forgotten completely how to do that; but we shouldn’t fall into the same trap. The vast majority of Americans are concerned about access, and are terrified about the effects of rising costs on families and business -- people mainly want some prudent reform to protect their ongoing access to good and affordable health care.

People are underwhelmed about health reform right now because the left media suggests the current bills lack a public option or single payer; and the right media suggests that we are moving toward communism and a totalitarian state. The bills may be full of screwy provisions in their 2000 pages, but there are sorely needed provisions in there too.

Staying the Same is Irresponsible
As I’ve said in previous blogs (to the praise of some and the consternation of others), the status quo in health care is unsustainable and a certain fiscal nightmare. Doing nothing is not a responsible course real leaders in health care should recommend. Our last 3 ACC  Presidents Jim Dove, Doug Weaver and now Fred Bove have been bold -- and have tried to find a critical path through the reform quagmire that truly reflects the membership’s goals and desires, along with what will protect the patient-physician relationship.  To just say no; or to take a purely partisan stance is not responsible.

Finding a balance is what we need to do together. 2010 will demand a lot of us in the policy arena, and everybody needs to try to be involved---the best way for most folks to do that will be through your feedback on issues to the BOT via the BOG (the Board of Governors) and our state chapters.

But please don’t get your policy perspective exclusively from the NY Times or the Wall Street Journal, or from MSNBC or Fox News -- your colleagues and your patients will be better sources of what is needed. Some kind of bill is almost certain to be passed. We need to make sure it is less toxic than it might otherwise while we’re simultaneously suing the government on the Rule. But considering the Medicare Payment Rule we have faced for the past 6 months, 2010 has got to be better, doesn’t it? (Or, let’s be sure we make it so anyway?)

I’m an inveterate optimist I must admit; although I am somewhat envious of pessimists -- they they are never disappointed. I admit the year is not starting off swimmingly, but there have to be some blue skies ahead out there…