I had a follow-up discussion this week with David Blumenthal, M.D., President Obama’s national coordinator for health IT. It was smart to have Blumenthal at the Atlanta ACC.10 meeting because he learned a lot more about NCDR, our appropriate use criteria projects and the commitment to quality of care. Given that the three basic overarching principles for “meaningful use” are e-quality improvement, e-prescribing and the ability to exchange data between various provider levels (hospitals, pharmacies, other doctors, etc.), Blumenthal is very excited about advanced quality of care projects using NCDR and PINNACLE.

He is not certain how many doctors will avail themselves of the stimulus money for health IT implementation beginning in 2011, although, like me, he hopes it will be universally applied for. As you recall, Medicare participants will be eligible for up to $44,000 over five years for health IT if they qualify for meaningful use, the requirements of which will be phased in. Medicaid participants will be eligible for $63,000 and those who participate in both programs will be eligible for $63,000. We need to get back to Blumenthal about ways to participate together as soon as the meaningful use process has turned into an official set of regulations.

Colleagues---- The administration finally announced, as we had long expected, that Don Berwick, MD, will become the new Administrator of CMS (Medicare and Medicaid), subject to Senate confirmation. Berwick, a pediatrician by training, is a good friend of the ACC. I have known him for decades, interacting on many projects. This year, ACC and Berwick’s Institute for Health Improvement are partnering on the H2H, or Hospital to Home, a national project designed to systematically reduce heart failure readmissions to hospitals. This is a positive announcement for us and for Medicare and Medicaid at a critical time.

Unless you were in a cave, you saw that the reform process has had numerous bumps in the road, and I suspect there will be lots of glitches and challenges for the next three years until it is fully implemented. The Republicans could succeed in repealing it, which is their declared No. 1 interest, but the odds are against it. And the Democrats still want to amend elements of the bill they couldn’t fix in the last week’s shenanigans.

Most of the pundits in Washington think that Mr. Obama’s commitment to be very persuasive in educating the public about things in the bill he thinks the public will like (but as yet do not understand) will have a positive effect over time. Let’s face it; most Americans know only the sound bytes about the reform bill that have emanated from both the Democratic or Republican leadership.

Senate Republicans found a few glitches in the House version of the “reconciliation” bill (that amends the original Senate bill), and sent it back to the House Tuesday to amend and re-ratify. The House fixed the issues quickly, and the reconciliation bill passed just two days after the Senate bill. The process is done from the Democrats’ point of view. 

From the ACC point of view, given that we did not blanket-endorse nor overtly oppose either bill, we are free and able to start working on amendments we’d like to see change. We will wait for sponsors for such amendments to emerge in the Congress. We believe there will be an opportunity to significantly modify the Independent Payment Advisory Board (IPAB) piece to fairly include other constituencies (besides just doctors) for cost control measures; and we believe a growing constituency to promote more significant tort reform than is contained in the legislation is going to manifest. The bill will be implemented sequentially. 

Chronology of the Health Reform & Reconciliation Bill

Immediately

• Health insurance reform implementation fund of $1 billion is available in HHS for moving forward with insurance reform regulations
• Preservation of the right to maintain existing coverage is protected
• National efforts to combat health care fraud (not focused on physicians) will be funded and launched

Retroactive to Jan. 1 

• Small business tax credit for covered employees becomes available (this will be popular)

June 2010

• High-risk pools for individuals with pre-existing conditions will be formed
• A re-insurance program to cover early retirees is created

July 2010 

• Immediate information will be available to consumers from HHS to identify most affordable coverage within a geography

More...

The New York Times today had an article on the transition of more and more physicians and medical students away from private practice to larger health systems. From the article:

... An increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries at hospitals and health systems. And a growing number of older doctors — facing rising costs and fearing they will not be able to recruit junior partners — are selling their practices and moving into salaried jobs, too. 

Read the full article, and then I want to hear what you think. Is this a good thing? What have been your experiences with private practices vs. a larger health system or hospital?

The ACC was lucky enough to have two members, Westby Fisher, MD, and Sarah Clarke, MD, attend ACC.10 & i2 Summit and blog about their experiences. As their final post, they each addressed two patient scenarios all too common in the U.S. health system: one patient with good health insurance and one patient without (in the U.K., this translates into one patient with private health insurance and one with coverage from NHS). 

From the U.S. perspective, Dr. Fisher outlines the expected costs that Fictitious Patient #1 will incur. Thurgood Powell has a $5,000 annual deductible, which significantly defrays that $440,000 worth of medical care he receives after receiving a drug-eluding stent, elective bypass surgery, and finally ICD implantation and home monitoring.

Fictitious Patient #2 (humorously named Mortimer T. Schnerd) is not so lucky. Why? Because he’s uninsured. Without insurance to pay for his expensive bills, Schnerd receives his care at the public clinic with some coverage by Medicaid. If he’s “lucky” and it is determined that Schnerd is disabled enough by the heart condition, he could eventually qualified for Medicare, which would make it a lot easier (although by no means easy) to find a health care provider to provide follow up care. Because let’s face it, with the rate that Medicaid reimburses physicians, it’s like finding a pot of gold at the end of a rainbow to find a provider who will take a new Medicaid patient.

Meanwhile, over in Britain, things are a little bit different. Dr. Clarke writes about how during emergency situations (like, say, a heart attack) even with private insurance, patients are treated through NHS. The only difference in Powell and Schnerd’s care if that Powell “can choose his physician, ... will receive treatment more quickly and at a convenient date compared to the NHS” and “has a more comfortable stay in a private en-suite room in the private wing of the hospital.”

Thoughts
Drs. Fisher and Clarke’s analysis bring up some interesting points, given the historic health care reform bill that was just signed. To begin, Schnerd’s going to have more options for insurance from now on. Beginning in 2014, he’ll receive tax credits to help him purchase health insurance from an exchange, as well as help with his deductibles and copays. He won’t be expected to spend more than $695 to $1,096.20 on premiums, with maximum out-of-pocket costs for deductibles and copays capped at 15 percent of the total costs. If he doesn’t get any insurance though, he’ll be stuck paying a fine of about $695 per year. (See how the health insurance law will affect you with the Washington Post’s calculator).

Powell on the other hand, won’t see any changes under the bill. Based on this scenario, that seems to work out well for him. 

At least in the NHS system, as Dr. Clarke points out, no one has to pay to receive the treatment they need. They just need to have money if they want the treatment when they want it (as opposed to when the system wants to provide it) and for any luxuries. This delay can certainly lead to problems... problems getting timely access to care (which in CV care can mean the difference between life and death) and problems getting care at a time that works for your schedule. It’s a classic battle between cost and timely access. We’ve heard it over and over again during the health care debate.

Dr. Fisher is careful to avoid any discussions beyond the facts, but I think it’s important to note one other thing about Schnerd’s care: You can be sure that if Schnerd was an actual person without health insurance and he received $440,000+ worth of medical treatment, he went through A LOT of emotional distress thinking about how to pay for it. In this case, yes, he ultimately had his bills covered. For a lot of uninsured people though, this is not the case. They become saddled with thousands, if not tens of thousands, dollars worth of medical debt. That’s not a health care system, that’s a health care disaster.

Which is why the health reform bill passed. It’s far from perfect – and there are many provisions the ACC simply cannot support – but it’s a recognition that the system is flawed and needs reform. Rest assured, the ACC will be working with Congress, the President and Secretary Sebelius to seek amendments and push to add tort reform.

A Big Thank You
Finally, I want to close with a big “thank you” to Drs. Clarke and Fisher. Each did a spectacular job covering the science at ACC.10 & i2 Summit, providing a unique experience for readers. Covering three days of breaking trials and the latest science certainly isn’t an easy task, and after a long day of sessions, they both still managed to squeeze out several very thoughtful blog posts a day. All I can say is WOW. And of course, in my typical style -- THX!

Regardless of how we individually see the vote by Congress yesterday to approve HR 3590, it was truly a major punctuation point in US history. I mean, WOW.

President Brindis put out his first ACC Advocate statement about it earlier today, which I've included in this post. It is a very sweeping piece of legislation for sure. But is it the ‘done-deal’ and ‘now we’re done’ moment? No way. There will be (I prophecy) hundreds of ‘amendment’ bills proposed by R’s and Dems over the next 2 years, and the ACC will (I promise) be engaged in a large number of them. For those of you who are angry or alarmed about this evening’s historic event, there will be many avenues through which to vent your frustration. This is not over.

Here's the text of Ralph's Advocate:

March 22, 2010

Health reform bill passes. That's the headline in newspapers across the country today. Congress last night narrowly passed monumental legislation that sets the nation on a new health care course and extends true health care access for more of our patients. Your ACC over the last several years has been actively advocating for Congress to fix the current health care system to focus on quality and improve access to care. The bill passed yesterday makes significant headway in making coverage more affordable for the millions of uninsured Americans -- including those with heart disease. It extends Medicaid qualifications, increases the age limit for young adults on family plans and eliminates pre-existing condition exclusions for health insurance. The legislation also addresses congenital heart disease, chronic disease management, prevention and wellness and includes funding for innovative Medicare and Medicaid pilot programs that could improve care coordination across sources and sites.

While the bill is a start, it includes several onerous initiatives, including the creation of an "independent payment advisory board" and prohibitions on physician-owned hospitals. It also fails to address several of the principles that your ACC has deemed essential for real reform. It does not include delivery and payment system reforms that provide incentives for improvement of quality and outcomes, nor does it repeal the flawed sustainable growth rate (SGR) formula used to calculate Medicare physician payment. It also fails to implement medical liability reforms that reduce legal and defensive medicine costs.

Now the real work begins. The Senate this week is expected to vote on a separate package of amendments that was also passed by the House yesterday that could alter portions of the health care reform bill. Your ACC is now poised to lobby for changes and lead the process of implementation. In fact, we are already working across multiple areas to ensure appropriate use of diagnostic equipment; promote adherence to clinical guidelines and appropriate use criteria; improve care coordination through the use of clinical registries; and reduce hospital readmissions and racial and geographic disparities in care. The ACC firmly believes that carefully crafted partnerships are critical to enacting real reforms and expediting the progress needed. The College looks forward to working with you, Congress and other key stakeholders to develop a health care system that puts patients first and rewards -- not penalizes -- physicians and other medical professionals for their commitment to quality and evidence-based care.

Bottom line: I predict that yesterday’s historic accomplishment for the Dems will prove to be an overall positive for all Americans, because it provides the nation with a needed sense of direction. The status quo is the worst option before us. Change is needed. We now have three years to get tort reforms, better solutions to cost containment, real improvement in quality, and a means to protect the profession of medicine built into the ultimate reform scenario.

From ACC’s point of view, we have to stay focused on making sure that we ARE going to get all Americans covered; we ARE committed to fix the unsustainable inflation in health care costs without stifling innovation or the practice of medicine; and we ARE going to need to work over the next the three years to fix the stupid stuff in the 3000 pages to make these needed changes happen in a smart fashion.

History is messy. Yesterday only underscores that. But now we know we are moving toward needed change, not stuck in some very real muck.

Don’t forget to submit your photos of the meeting here for your chance to win an Amazon Kindle loaded with a year’s subscription to JACC. We’ve gotten some great submissions so far, but I know we can get some others before the contest closes March 26.

Well, folks, another great annual meeting has concluded. I think it’s safe to say we’ve covered all the major CV issues during these three crazy days, along with many not-so-major issues. I personally have enjoyed all the talk of health care reform (if it should ever happen) and of quality of care issues.  I’ve had the opportunity to meet with some true visionaries: U.S. CTO Aneesh Chopra, M.P.P., Anthony Atala, M.D., Richard Satava, M.D., to name a few, plus the many leaders of the international cardiovascular societies who travel great lengths to attend the meeting. I hope you’ve found the meeting to be enjoyable and have some clinical insights you’ll take back to your everyday practice. Make sure to mark your calendars now for ACC.10 and i2 Summit: April 3-5 in New Orleans.

I want to hear from you: What’s been your favorite part of the meeting? Answer the poll below and leave a more detailed response in the comment section below the poll.

There have been a lot of great LBCTs at ACC.10/i2 Summit. Which do you think was the best?

Some post-ACC.10 blog coverage to look forward to: Our ACC member bloggers will be giving their take on the differences in the US & UK health system in the form of two hypothetical CV patients, Thurgood Powell and Mortimer Schnerd. From Dr. Fisher:

We thought it would be interesting to compare and contrast two heart patients - one with insurance and one without insurance - from our two health care systems, to illustrate how these patients obtain health coverage, might be managed, and how things look from the patient's perspective.

...

For the purposes of the exercise, we'll take two patients, Mr. Thurgood Powell, a highly successful 57 year-old businessman making $250,000 (£166,128) per year with his company PoshPosh Entertainment, and Mortimer T. Schnerd, a pleasant 43 year old man who is unemployed but working part-time in the local K-mart, earning $17,400 (£11,562) per year. Both men will experience heart attacks, both men will present to Emergency Rooms in both countries, and both men with require 4-day ICD stays and require the implantation of an automatic defibrillator and follow-up for the first year after the heart attack. Beyond that, heck, who knows. But that will at least give us a starting point to discuss the good, the bad, and the ugly of both health care systems and to compare and contrast the two systems. We will purposely refrain from political commentary in our posts (that's for you to do in the comments section!). We only ask that the commentary discussion be respectful and civil. I would be thrilled to hear what the British think of their health care system/costs/etc. over on Sarah's blog and the U.S. perspectives on this blog.

So there you have it. Look to their blogs (Dr. Clarke and Dr. Fisher) for the full discussion, and I'll be posting my response here as well. 

Other posts from Dr. Clarke today:

• Want to know more about AF??!! See this new website and other trial results from the ACC!: The ACC and Heart Rhythm Society have launched a new website just for AF !!! Take a look!
  
  
• DAT post DES…how long??: The aged debate goes on! How long should we be giving dual anti-platelet therapy (DAT) after DES? Current guidelines suggest 12 months….
  
  
• Cryoablation for PAF: STOP-AF: Whilst anti-arrythmic drugs (AAD) are not without morbidity or mortality, and radiofrequency ablation requires mutliple lesions and can be associated with complications, cryoablation offers PVI with a single continuous cryolesion. But what are the complications?