Last week brought more meetings with Congressional leadership about the Medicare Rule nightmares. The recent Cardiology Advocacy Alliance (CAA) visits were helpful. We met with the Grassley’s staff this week (Senate Finance minority), and they were somewhat receptive to indexing cardiology payment for echo, stress testing, SPECT, etc., to the hospital (HOPPS) schedules, IF appropriate use criteria use and transparency were included. Appropriate use criteria could get us out of this hole, folks -- AND, the ACC is getting ready to be able to launch point-of-care AUC systems that could make this idea real!

This is where we need to go! Meanwhile, the sign-ups to the Gonzalez bill, which would mitigate some of the effects of the physician fee schedule, keep growing. Congressman Dingell (D-MI) -- a truly powerful influencer of Dem leadership -- agreed to sign up last week. This is big news.

As you know, the ACC has partnered with the Texas Medical Association (TMA) on a petition drive to fight the flawed SGRrrr and preserve patient access. The idea is to obtain one million patient signatures to petitions to Congress to get the SGRrrr fixed. The specific task is to get these materials available in every doctor’s office for patients to see, read and voluntarily pursue. So far, nearly 60,000 signatures have been obtained through the campaign.

We were the first specialty society to partner with the TMA on this campaign, and we continue to work toward the goal of gathering one million signatures from health care providers and their patients to share with Congress and the president. I encourage you to sign the online petition today if you haven’t done it yet! Hopefully all ACC Chapters will engage in the effort -- Colorado is already going big time. 

Congress’ leaders (Reid and Pelosi) have stated they want to get a long term SGR fix negotiated before the Memorial Day recess at the end of May. That is only 6 weeks away.  I know the fatigue level is high, but we need to stay with it so we can get this mess behind us. Join in the million person signature campaign please.

*** Image from Flickr (Johan Jonsson). *** 

It was clear from the intense and engaging conversation of the combined specialty and large state society staffs assembled Friday at Heart House that there are various policy opportunities that need to be pursued by the profession. These are the issues that every society felt were compelling and worthy of joint policy consideration before the onslaught of amendment bills and regulations hits us:

• Payment reform: We all believe we should be collaborating on how this occurs, and in the kinds of pilots proposed. We suggest a multi-society workgroup on payment reform, ACOs (accountable care organizations), data standards and quality improvement be formed later this spring.
  
  
• Tort Reform: The ACC shared our ideas and our evolving coalition to secure tort relief for practices and hospitals that achieve “meaningful use” of health IT. There was great enthusiasm for this idea.
  
  
• Registry and Data Collaboration: All societies present felt that we need to stand together on being the purveyors of clinical data and quality and outcomes data. I see a lot of potential additional society collaborations on registries that are possible.
  
  
• Regulatory Collaboration: The health care reform law (PPACA) will create a nightmare of new regulatory challenges -- it already is. We should probably stay out of the proposal to go further in regulating rate increases for insurers. But that is coming. Everybody at this meeting wants to join with the ACC in advocating that CMS should itself develop the newly required alternative sites of care for patients of doctors with in-office imaging. It’s absurd to think that practices could organize prices charged and locations of alternative sites! If they want this to happen (not a bad idea), they should do it!

HHS and the Office of the National Coordinator for Health IT (David Blumenthal and his team) reported last week that in the latest year they could measure accurately -- 2007 -- 34.8% of private practices had an EHR. That’s a 91% increase in use since 2001. However, only 3.8% of practices had “fully functional” interoperable, clinical decision support capable, e-Rx capacities. But, they surveyed the practices then that said they were definitely going to move ahead and install an EHR. If most actually did, ONC estimates that over 50% of practices will have an EHR (not fully functional) this year. We’re getting there.

The ACC was lucky enough to have health IT experts speak at our Health IT Spotlight Session at ACC.10, including Blumenthal, US CTO Aneesh Chopra and Marc Overhage of the Indiana Health Exchange. Check out the two video below for interesting interviews on the future of health IT with Chopra and Overhage.

We had several meetings this week to keep the idea of a tort reform bill alive as an addendum to health care reform. The problem is that Democrats have been beholden to the trial bar in these regards (and Republicans have also taken quite a bit of money from lawyers!). Republicans have the additional problem of not wanting to see the Democrats succeed in any area, and therefore don’t want to support tort reform with the President signing any bill that might come forth.

We have to overcome all of this. What surely isn’t possible politically (unfortunately) is to promote the best solution—namely, instituting caps on noneconomic damages, as has been so successfully achieved in California, Texas and a few other states. And, as you know, state legislatures and state courts have been attacking and reversing some of those laws which instituted noneconomic damage caps recently, under the direction of the trial bar. 

The ACC is working on bringing together representatives of industry, insurance, hospitals and hopefully other professional societies to suggest that major protections for medical malpractice assaults should be instituted as part of an incentive-based approach to implementing “meaningful use” in the future. After all, if physicians adopt a vision of meaningful use, which includes electronic health records, clinical decision support systems, use of registries, e-prescribing and other significant and costly innovations, there need to be incentives and a reward process. One of the best rewards might be to offer protections in Medicare and Medicaid from malpractice assault for those who adopt these kinds of innovations!

We are continuing to explore and promote this kind of important step, which could be linked to other innovations such as health courts and certificates of merit. Any such set of innovations would lead to a reduced number of patient safety incidents and reduced relative risk. This ought to cause a significant reduction in premiums in addition to any specific legislative protections we might develop. Stay tuned.

*** Image from Flickr (walknboston). ***  

Congress last week stumbled around on the SGR issue back and forth between the Senate and the House, playing Russian roulette again with the 21 percent cuts physicians face. In fact, they went over their own deadline, meaning the cuts technically already occurred for claims filed after April 15. But, they finally ‘saved’ us again for a few days.

Congress created a two-month fix (really only a month and a half since April is half over) at the end of the week. This gives them until June 1 to seek a longer-term solution.

High ranking House members this week told me they believe Congress will somehow find its way to a 10-year solution before the end of this year. The President and the White House are aligned toward this goal, and the House has already agreed to support such a solution. The Senate still is problematic, and Republicans have not agreed to sign on to writing off the debt. There is absolutely no way Congress is going to come up with a $300 billion-plus additional spending arrangement for the 10-year fix. We are still working with all 50 states and about 15 specialties on the Million Signature Campaign to keep the pressure on. Thanks for your help.

***Image from John Wardell.***

Update on the SGR from today's Advocate:

April 16, 2010

Another reprieve ... President Obama last night signed H.R. 4851, the Continuing Extension Act of 2010, into law, following on the heels of votes in both the House and Senate. The law reinstates Medicare physician payments to where they were on March 31 and again postpones the 21.3 percent Medicare Physician Payment cuts related to the flawed sustainable growth rate (SGR) formula until the end of May.

What does this mean for April Medicare claims? The Centers for Medicare and Medicaid Services' (CMS) temporary hold on the processing of physician claims filed as of April 1 officially expired yesterday. However, with Congressional action so imminent, it is unlikely many claims were actually processed at the lower payment rates. However, CMS has said that any claims paid that reflected the 21.3 percent cut will be reprocessed automatically without any action required from physicians.

Contact Congress NOW! The continuous Band-Aid approach to the SGR is clearly not working. Your ACC is urging all members to contact their members of Congress and urge them to find a permanent solution to the SGR using the toll-free grassroots hotline (800-210-7193) or via email (click here for the House and click here for the Senate). In addition, ACC members are encouraged to sign on to a petition to Congress, urging them to stop the SGR cuts. You can sign your name by clicking here.

Read the full Advocate below.

ACC Advocate 4.16.10.html (4.94 kb)

Earlier this week a study came out that examined what influences care decisions by cardiologists. It found that nearly 25 percent said that malpractice concerns play a role (in the hypothetical situations asked about). According to a MedPage Today article on the study:

About 17% of respondents said patient expectations frequently or sometimes affected the decision to order a test, increasing to 29% for expectations of referring physicians. ... About 27% of respondents said they would order a cardiac catheterization if they knew a colleague would order the test in the same situation, and almost 24% said they would order cardiac catheterization solely because of malpractice concerns.

Let's ask our readers... how often do malpractice concerns influence your care decisions? Frequently? Never? Or somewhere in between? Leave more in the comments section by clicking on the "comments" button in the bottom right of this post.

With yesterday the last day on the CMS hold on processing payments, Congress needs to act on the SGR today to stop a 21.3 percent reduction in physician payment.  The ACC has partnered with the Texas Medical Association (TMA) on a petition drive to fight the flawed SGRrrr and preserve patient access. We are the first specialty society to partner with the TMA on this critical campaign. During one of the seven rallies held last week across Texas to launch the campaign, TMA President William H. Fleming III, M.D., said: "We need more than Band-Aids. We need more than sutures. We need a complete transplant. This is all about Medicare patients' access to physicians' care. Congress created this problem, and only Congress can fix it." The goal of the campaign is to gather one million signatures from health care providers and their patients and share them with Congress and the president. To sign the online petition, go to: Me and My Doctor.

Let's hope we hear some good news later today. Either way, the ACC isn't going to stop fighting until we get a payment system that places an increased focus on evidence-based medicine and quality of care improvements.

UPDATE (11:12 am): The Senate has passed a two-month patch to give them more time to discuss a long-term fix. The House still must pass the same bill later today.

UPDATE (10 am 4/16): The House voted last night to approve the measure, which would postpone the cut from taking effect until June 1.

This post is brought to Lewin Report readers from Dr. Ralph Brindis, ACC's current president. Dr. Brindis is the Senior Advisor for Cardiovascular Disease for Northern California Kaiser and a Clinical Professor of Medicine at the University of California-San Francisco. Dr. Brindis has previously posted on this blog about NCDR and coverage with evidence development.

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Un- or under-insured patients are more likely to delay seeking emergency care for an AMI (or heart attack, for our non-cardiovascular professional readers), according to a study that came out yesterday afternoon in JAMA.

Using data from 3,721 AMI patients accessing care between April 2005 and December 2008 at 24 hospitals, researchers determined that 44.6 percent of patients with financial concerns and 48.6 percent of uninsured patients, compared to 39.3 of insured patients without financial concerns, waited MORE THAN 6 HOURS from the onset of their symptoms to seek medical care. 

In heart attack treatment, time between symptom onset and treatment is a matter of life or death. The authors recognize this in their paper:

“Because prehospital delays are associated with higher AMI morbidity and mortality, demonstrating that patients’ [insurance status can put them] at higher risk for prehospital delays is important because it would suggest that reducing financial barriers to care ... could reduce delays and improve outcomes.”

Health Care Reform Potential
As the D2B Alliance has shown us, optimal AMI care involves receiving treatment within the first 90 minutes of arriving at the hospital. But the improved outcomes this speedy treatment can provide are limited if the patient waits more than six hours to come in for treatment.

The recently passed health care reform law could help out in this regard. Through its insurance reforms, it is predicted that millions will gain access to health insurance. However, as this study indicates, it’s not enough to have health insurance; patients also must have health insurance without financial concerns. With the expanded access to insurance, this study indicates that we potentially have a unique opportunity to help improve outcomes for patients with emergency conditions by reducing delays in treatment, and reducing the stress that comes with having to choose between seeking treatment and maintaining financial stability. 

Other Causes of Delays
Some patients are leery about calling 9-1-1 and emergency ambulance services not just due to inappropriate concern about potential ambulance costs to themselves and their families but also lack of heart attack symptom awareness. Terrific systems of care now already in place to offer timely heart attack care need to find ways of being fully effective for all our patients. This requires improved patient education and awareness about heart attack symptoms (which can be assisted through ACC’s patient education portal, CardioSmart); improved access to care in general; and, importantly, societal programs to improve socioeconomic status.

This important study describing disparities in care related to socioeconomic status provides health care providers extra motivation to improve care for the disadvantaged. 

Study Implications
Finally, the authors note that although the findings of the study only directly address AMI care, they may speak to other medical conditions. It’s quite possible that patients also may delay treatment for other medical conditions requiring speedy treatment because of financial concerns, such as stroke, pneumonia and appendicitis. They write, “As a result interventions that broaden and ensure the affordability of health insurance coverage in the United States may reduce times to presentation for all emergent medical conditions.” We’ll find out over the next couple of years if the insurance reform in the new health care law will help reduce these times and therefore improve outcomes.

-- Ralph Brindis, M.D., F.A.C.C.