An article in JAMA earlier this month provides support for the importance of early follow up for patients discharged from the hospital following heart failure. The paper was written by Adrian Hernandez FACC, who chairs our Hospital to Home (H2H) Measurement & Evaluation workgroup, and co-authored by AHA President Clyde Yancy FACC and others. In short, it found that Medicare patients discharged from the hospital with higher rates of follow up, as defined as receiving outpatient evaluation within one week of discharge, had lower readmission rates. Not too shocking, right?

ACC’s Hospital to Home has been touting early follow up as one of its ways of reducing readmissions. The easy first lesson of H2H is the importance of seeing the patient within the outpatient setting within one week of discharge. As this study so nicely points out, this could go a long way in reducing readmission rates (talk about bending the cost curve!).

No, it’s not that Conservative Republican Sen. Bennett got unseated by the Tea Party. Rather, it’s that the White House and Congress got a jolt this week from Utah (published in the Washington Post) about health care costs rising very fast in the nation’s most frugal Medicare spending state other than Hawaii. If there’s any state that is expected to have medical spending under control, it’s Utah. Its many non-smoking and non-drinking family-oriented citizens are considered the healthiest in the nation, and Intermountain Healthcare, often cited by Mr. Obama as an example of efficiency and value, is a trend-setter in restraining costs.

But unfortunately, several Medicare data observers including the D.C.-based Center for Studying Health System Change noted an alarming increase in Medicare costs in Utah this year and in the past several years. In fact, Medicare spending in the Provo region is rising 8.6 percent annually, nearly double the national rate of 4.7 percent, according to the Dartmouth Atlas of Health Care.

Dartmouth and others have noted that other low-cost areas, Oxford, Miss., Wausau, Wis., Durham, N.C., Rochester, Minn. (of the Mayo Clinic), also have had significant upticks in costs as well. This is making everyone nervous here in Washington. The commercial insurers report that the prices in Utah still remain lower than the national average, but the increases are keeping some policy wonks here awake at night.

CareFirst, the big Blue Cross Blue Shield plan here in Washington DC, Maryland, and Virginia reports that they see costs and premiums rising by 100% over the next 5 years here! As a result, CareFirst has developed a scary new cost cutting strategy, proposing to return to using primary care as gatekeepers on specialty services, but paying primary care physicians up to $300,000 if they save money by referring patients to lower cost services. Yikes.

*** Image from Flickr (D Sharon Pruitt). ***

A little-known provision of the health care law (PPACA) purporting to create a “value index” for physicians in Medicare has physician groups concerned. Championed by Maria Cantwell (D-WA), the provision would require the HHS secretary to add a payment modifier to the Physician Fee Schedule based on the “relative quality and cost of care provided by physicians or physician groups.”

Just how will this be determined? According to the provision:

“Quality of care is to be evaluated on a composite of risk-adjusted measures of quality established by the Secretary, such as measures that reflect health outcomes. Costs, defined as expenditures per individual, are to be evaluated based on a composite of appropriate measures of costs established by the Secretary that eliminate the effect of geographic adjustments in payment rates and take into account risk factors ... and other factors determined appropriate by the Secretary.” [emphasis mine]

Once the quality and cost measures are established in 2012, rulemaking would begin in 2013, followed by payment based on the policy in 2014. In 2015, there would be “payment consequences” for physicians, and all physicians would be paid under this formula by 2017. 

Now, we’re all about creating value in the health care system (goodness knows it’s the only thing that will get us out of the current mess we’re in) BUT to say that the HHS secretary can determine at HHS how quality is defined is not going to work. It has to be up to the people providing care and their specialty groups to determine what is “value-based care.”

Not surprisingly, physician groups are worried about what this will mean. The Congressional Budget Office said it will be budget-neutral, but it’s a little unclear how some physicians who do well will get paid more without taking money from physicians who do not do well (again, on measures not created by doctors). Continually taking payment away from providers is not going to increase quality. It’s just going to continue to force providers to integrate their private practice into hospitals, ultimately, driving up the cost of care for the system.

At this point, it’s a little too Ivory Tower to get behind. Judging physicians based on a formula they’ll have no say in creating is not a policy the ACC can support. Consumer groups like AARP and Consumers Union better jump on issues like this with us. If these kinds of matters aren’t handled in partnership with the profession, they will result in disastrous and erroneous outcomes. 

*** Image from morgueFile (jdurham). ***

The 21% cut to physician payment in Medicare looms and will kill access for seniors in Medicare if it proceeds. It’s amazing that Congress has gotten themselves into this dilemma.

Senate Finance Committee Chair Max Baucus (D-MT) and Ways and Means Chair Sander Levin (D-MI) on Thursday released a new combined tax extender and sustainable growth rate (SGRrrr) proposal, due to be voted on this week. It’s part of the American Jobs and Closing Tax Loopholes Act, which is an amendment to the House’s Tax Extenders Act of 2009.

Initially, its vote was thought to happen on Friday, but was then delayed to next week. This delay is a clear signal that leaders did not have enough votes to move the package as it stands now.  Between now and early/mid next week, they may make modifications to the package in an effort to collect votes.  There are no guarantees but if they don’t act soon, the SGR patch will AGAIN expire.

The SGR provision of this bill covers three and a half years, with a 1.3 percent update for the rest of 2010; a 1 percent update in 2011, and "two buckets" for payment in 2012-2013 (GDP plus 1% generally, and GDP plus 2% for primary care) with no negative updates allowed.

The ACC was deeply engaged in the politics around this all week. House and Senate leadership asked for our help to try and get a multiple-year SGR proposal funded and passed, rather than kicking the can down the road on a monthly or yearly basis. The House is fully supportive of going for a minimum of five years, but it’s the Senate that has less interest. There are no Republicans that are supporting us on this issue in the Senate, except possibly Maine’s Sen. Olympia Snowe.  

Part of the political dynamic of concern here was that AMA’s Board got cold feet on supporting less than a 10-year fix because of the threat of attacks on them by a number of states and specialties that simply don’t understand that the money is not there for a ten year solution ($370 billion). Our Advocacy Steering Committee, on the other hand, understands this and supported the multi-year fix, and ACC President Ralph Brindis, MD, MPH, FACC, urged AMA to proceed with a multi-year fix as proposed. Thereafter, the AMA came back around Friday and stated that, with great reluctance, they also support this approach. This is very good. 

This 3 ½ year package apparently costs around $70 billion, although CBO hasn't released its score yet.  The House amendment will need to be merged with a similar Senate amendment into the original act before it can take effect. But Congress DOES realize this is about patients more than it is about doctors. Patients have extreme difficulty now finding a Medicare physician in most areas of the country. The 21 percent cut will cause chaotic access problems.

The million signature campaign in which we are engaged with other societies to urge Congress to fix this problem has so far gotten 80,000 patients and doctors to write their members of Congress demanding an SGR fix, with copies also to Secretary Sebelius and the White House.

The ACC sees the handwriting on the wall, and we’re working on designing payment reform systems that will have a true upside for both doctors and patients in a rapidly changing future. That said, we still need to get the flawed SGR out of the way, and we sure hope a multi-year solution manifests next week.

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

Just as we envisioned, our NCDR^® registries are becoming powerful tools for comparative effectivenessresearch (CER). The TRANSLATE-ACS Study, led by the Duke Clinical Research Institute (DCRI) in collaboration with the ACC, is a longitudinal, observational study ofacute coronary syndrome (ACS) that relies on the CathPCI Registry^® for much of its data collection. The overall goals of TRANSLATE-ACS are to examine in-hospital and longitudinal outcomes of ACS patients managed with percutaneous coronary intervention (PCI), and to assess post-discharge care patterns and treatment adherence.  In particular, the study will look at how physicians are making treatment choices among approved antiplatelet therapies; factors influencing adherence to these medications; and real-world effectiveness, safety and costs in a broad-based patient population.

TRANSLATE-ACS intends to enroll approximately 17,000 STEMI and NSTEMI patients treated with PCI and discharged on an ADP-receptor inhibitor (clopidogrel, prasugrel, ticlopidine).  For sites already participating in CathPCI, many of the data elements collected for TRANSLATE-ACS will be automatically imported from the registry. Patients will be followed centrally via telephone up to 15 months after discharge to assess patterns of treatment and even rates.

This study, headed up by John Messenger, MD, FACC, and Tracy Wang, MD, FACC, and Eric Peterson at Duke, MD, MPH, FACC, complements ongoing ACC efforts to expand the role of registries in CER and conduct CER using a continuum of information from the inpatient to outpatient settings.

Recruitment for TRANSLATE-ACS is underway, so if you are interested in participating or would like to get more information about the study, I encourage you to e-mail DCRI at TRANSLATE-ACS@mc.duke.edu. 

The American Osteopathic Association recently conducted a survey around the impact of Medicare reimbursement cuts on physicians. Some of the most telling findings:

• 24 percent said they probably would not or definitely would not continue to see current Medicare patients. 
• 33 percent were undecided as to whether or not they would continue to see their current Medicare patients. 
• Only 42 percent said they would definitely or probably continue seeing their current Medicare patients if the cut were to occur. 

The numbers are not a surprise. Hello. We’ve been saying all along that some physicians simply won’t be able to continue to see Medicare patients due to the draconian payment cuts. Just yesterday the AP/Houston Chronicle came out with a piece saying that more than 300 doctors have dropped from the Medicare program over the last two years. Again, not surprised.

But some docs are concerned that we may not have the right to decide whether or not to see Medicare patients under the PPACA. The American Medical Association’s (AMA) Virginia Delegation has submitted a resolution with several other states as cosponsors to address what it perceives as a threat under the PPACA to medical licensure. Proponents of the resolution believe that insurance mandates in the health reform law will result in political pressure to require docs to participate in all health insurance programs — including Medicaid — as a linkage to their licensure. The resolution asks the AMA to advocate against this requirement with the end goal of federal legislation.

Let's take an informal poll here:

Shift happens. That’s what a lot of worried hospitals, physicians, insurers (and probably patients) are thinking as they contemplate the uncertainties of health care reform. It’s like we’re all going to reform school together. Recently I pointed out that clinging to the status quo was going to take the nation down a black hole of rising national debt, unaffordable premiums for individuals and small businesses, and an unsustainable world of hurt.

As physicians, we’re already feeling that in all the price controls being slapped on the practice of medicine by all public and private payers happened before reform passed. The SGRrrr debate about whether or not to cut physicians another 21 percent in Medicare is a poignant and decade-long example of that.

With its warts and all, the PPACA (Patient Protection and Affordable Care Act) forces us into an environment of forced change. I hear a lot of grousing about it, but it’s here and it’s not going away. There are quite a few things we don’t like in the bill; and quite a few needed elements not included, but things have to change to expand access, to increase overall quality, and to align increasing costs to more closely track GDP.

Even if we don’t yet know precisely how that needed change should manifest to best accomplish those things, we still need to get at it. Importantly, as reform progresses we also need to make sure that we protect health research, science and innovation, which are significant contributors to the health of the American economy we can’t afford to undermine.

It’s all very tricky, and as I've stated before, there will be winners and losers. My question to each of you is: Do you know which you want to be? (Duh)

Hospitals are scrambling faster than doctors at present to build networks and prepare for integration. Not suffering apparently from ‘mural dyslexia,’ hospitals see the ‘handwriting on the wall’ as a need to change their game to prevent their bottom line from being slashed. PricewaterhouseCoopers broadly advised hospitals this week to prepare to promote continuous quality improvement strategies or risk severe upcoming penalties. PWC said appropriate hospital admissions, hospital-acquired conditions and payments tied to value-based care will be three key areas of focus on to remain profitable for both public and private care. 

Our own ACC cardiologist colleagues are already engrossed in a migration to hospital employment or contractual integration. Cardiologists are smart folks, and I do not see this as a migration of lemmings. But it may be an intermediary step leading toward different future structures. In California, for example, big news last week was that more than 20 major hospitals of Southern California have formed a foundation (with physician officers on the board) to bypass California’s “Corporate Bar on the Practice of Medicine” in order to create the equivalent of employed doctor networks. The Corporate Bar in California prevents hospitals from hiring doctors directly, so the new foundation model will hire doctors who will then exclusively contract with the organizing hospitals to provide care across the Los Angeles and Orange County region.

Wall Street investors believe that some of these changes were bound to occur with or without the PPACA and health reform. Medical students are not graduating aspiring to enter private practices, and would clearly prefer to be employed in groups or networks that minimize on-call, handle the administrative hassles, produce the flow of patients they will treat, and offer more control of their lifestyles. Meanwhile, hospitals and insurance companies, according to Wall Street, need to consolidate to reduce administrative costs and improve efficiencies. Thus, physicians will also need to consolidate or network to effectively negotiate with consolidated hospitals and payers. Health reform is just going to speed these processes up. A lot of these kinds of changes already have occurred in other industries. All of us recognize that such dynamic changes always produce winners and losers. 

Believe me, I recognize how difficult all this is to swallow for people out there who are taking care of patients, participating in reducing morbidity and mortality by 30 percent over the last decade, and working very, very hard to produce high-quality care now. You have to be asking, why do we have to endure this crazy process of massive change at the same time? There’s no easy answer. Change is tough, and unfortunately health care in this country, to be sustainable, has to change.

Hopefully we can make the changes necessary to ferret out the waste and ineffective aspects of the system and still produce the desired ongoing progress in science, quality, patient-centered clinical improvement and practice vitality. The risks really are enormous. The College has to be there as a partner with all of you as we go through these significant times of transition. But the opportunities are enormous as well.

*** Image from Flickr (worldsislandinfo.com). ***

A few realities are becoming apparent to everyone in health care as the health reform law (PPACA) processes -- and implications of future changes -- start to become palpable. There are probably 10 different policy wonk meetings going on every day here in Washington interpreting what health care reform means for you and me. I’ve had probably 100 discussions about reform this week with people in many affected constituencies, and what follows are some of the more common reflections I encounter.

Insurance Rate Regulation
If Congress pursues insurance rate regulation as an additional means of reining in flagrant premium increases, is this a good thing for you and me? Duh, no. If the insurance companies have less money to spend, guess who they will cut first? We should take the position if such legislation develops that it is poor timing given all the other insurance regulatory changes in process. And, we need to correctly argue that the nation needs a different strategy from price fixing and rate regulation. It doesn’t work. It has unintended consequences (think the Medicare Rule).

We need to develop a system that competes on a level playing field to improve quality and outcomes that aligns the incentives of insurance companies, hospitals and doctors. Since Wellpoint decided to withdraw its request for a 39 percent increase in California premiums (that sure was a dumb move), maybe the heat will be off for a while. But as you may have seen, the California insurance regulator says Wellpoint used faulty data to inflate and exaggerate health care cost increases. In fact, Secretary Sebelius sent out an urgent message to all governors and state insurance commissioners to examine premium increases and rate review authorities. I’m actually feeling a little bit sorry for the insurance companies — they’re being treated almost as badly as doctors.

Physician Hospital Employment
Are hospitals buying up doctors’ practices to position themselves for success in an era of accountable care organizations (ACOs), bundled payments and cost scrutiny? Duh, yes.

Most of the pundits here in Washington think the mega-trend of hospital employment of cardiologists will turn out to be a good thing for society and health care. That may be true for some members, but it will vary from circumstance to circumstance. But if docs are employed, do we work harder? And, would hospitals be better off contracting with doctors rather than employing them? Again, circumstances will vary. 

One thing for sure: Hospitals don’t have enough capital to buy up all the physician practices they want. That’s why there’s an opportunity to work with them to create registry-linked community networks that will allow them to achieve the “clinical integration” exemptions from antitrust laws to negotiate insurance rates across a community. This opportunity could be worth millions for hospitals.

Medicaid Expansion
The Medicaid expansion has some mega-problems associated with it. Fifteen million or more uninsured adults are slated to be newly covered through Medicaid, but the Medicaid physician panels are woefully small. Who will take care of these patients? True, internists, family doctors and pediatricians will become eligible in 2014 for two years to be paid at Medicare rates (a good thing). But after that, the funding isn’t guaranteed. And, specialists are to be paid at the current Medicaid rates — which are like paying with dirt. That looks kind of ugly.

One important thing to note, however: We have learned that if cardiologists register with the state Medicaid program first as internists or pediatricians and then as cardiologists as a second specialty, they will be eligible for the increases. Primary care gets a 10 percent payment boost in Medicare, as well, and it appears that cardiologists can also avail themselves of this opportunity if they register first as internists (or pediatricians) and as cardiologists as a second specialty. In Medicare, however, one must be able to prove that 60 percent of care-giving is in office visits to qualify, which will not work for many procedural cardiologists. 

Patient-Centered Medical Home
The patient-centered medical home (PCMH) was the topic of two big meetings in D.C. in the past couple of weeks. I attended one sponsored by Health Affairs, and one of the attendees came up and said, “Jack, what’s a specialty guy doing here?” That should give you an indication of one of the controversies: namely, what if a specialist should actually provide the medical home service for a kid with serious congenital heart disease or a patient with very difficult-to-manage heart failure? Can we?

Technically speaking, the answer is any physician or group of physicians can register to get the extra capitated compensation that will flow to medical homes for managing and coordinating care, IF they meet the required provisions. But there are a lot of hoops to jump through, and the feeling is that very few specialists will want to do so. The ACC disagrees. A very large number of cardiologists in the later parts of their careers actually take care of patients both as a cardiologist and as an internist. Gerontological and pediatric cardiologists already have developed medical homes for elderly patients and congenital heart disease (CHD) kids and adults. We need to educate our members about how to apply for these additional PCMH payments if they choose to participate.

For more on how the PPACA will affect cardiovascular practice and patients, view ACC’s overview of the PPACA legislation (.doc) and its impacts.

*** Image from Flickr (Benimoto). ***

Something positive actually happened at the Department of Health and Human Services for cardiologists on Friday!

The Centers for Medicare and Medicaid Services (CMS) on Friday released a technical correction to the 2010 Medicare Physician Fee Schedule, which results in significant payment increases for myocardial perfusion imaging (MPI) codes, cardiac CT codes, and cardiac catheterization codes, retroactive to Jan. 1, 2010. The correction notice also includes a minor increase in the Medicare conversion factor (from 36.066 to 36.0791) effective June through December 2010. Our colleagues at ASNC deserve major credit here for their technical work, persistence, and serving as the lead agency in pressuring CMS to correct their RUC-related errors on the nuclear codes. 

However, this is not the BIG FIX needed to protect private practice, but it is a positive step for sure. The danger here is we don’t want Congress to think this will fix the problem. This will NOT stabilize private practice, and does nothing at all for ECHO, consults, or most practice expense cuts. Half of cardiology private practices have already sold their practices to employment and are now employees -- this positive step in the right direction is too late for them. But those still considering selling their practices to survive may see this partial step as a good sign. All in all, this definitely helps.

The corrections the Secretary approved to MPI and CT codes address errors made in incorporating RUC recommendations on direct practice expenses (e.g., medical supplies, equipment time) for these services. The errors included incorrect practice expense values for CPT codes 75571-75574 and 78451-78454. For example, the corrected national average payment for 78452 (SPECT MPI, multiple) is $439, compared to the $379 published in the November Final Rule.

The correction notice also includes changes to malpractice RVUs for cardiac catheterization services. CMS agreed with ACC, SCAI, and the AMA that cardiac cath services should be assigned malpractice RVUs based on the higher surgical risk factor. However, the published RVUs and payment rates did not correctly reflect that policy change. With this notice, CMS has corrected its error. The payment changes -- for example, an increase from $235 to $253 for 93510-26 (Left heart catheterization, professional component) -- reflect the higher risk associated with invasive procedures.

The ACC has prepared a chart outlining the specific corrections (.xls). 

The ACC continues to apply pressure to CMS to address the other imaging cuts included in the 2010 Medicare rule. Most importantly, we continue to press for a phase-in of the bundled nuclear codes and an approach to restoring echo and other services through adherence to appropriate use criteria -- we are working closely in repeated visits with members of Congress and CMS to help them understand the extent of the cuts, their impacts on practices and the need for a formal policy that phases in cuts of a certain magnitude over time. In the meantime, stay tuned for more information as it relates to notifying private insurance companies of these new corrections, since they typically track Medicare payments.

The painful effects of the Medicare 2010 Payment Rule are killing private practices as you know. But as more members of Congress realize that, more are listening to us. The ACC had some very positive meetings on the Hill in the last week. We are now up to 120 co-sponsors for our Gonzalez legislation. Let me repeat that: 120 co-sponsors!  Congress is beginning to realize they have to do something. But their question is ‘what?’

There is still an interest in phasing in the nuclear codes because of the consistency issue. There is also an interest in studying the impact on Part B costs by shifting cardiology practices to hospital employment as a way to convince the Congressional Budget Office to support a solution that protects private practice of cardiology.

Voluntary AUC Compliance
The dilemma is how to propose a longer-term solution that Congress will buy into. All the staff leaders and their members with whom we have met get very excited by the idea of rewarding voluntary compliance with appropriate use criteria (AUC) for imaging with significant payment increases, and perhaps as we have suggested, by applying the HOPPS (hospital) payment schedule or a high percentage thereof to those who participate. This could work!

I believe there really is a way to make this idea (since it would be voluntary) a win-win for Congress and cardiology. We would probably have to extend the voluntary participation in AUC program beyond cardiology to any physicians (internal medicine and family practice) who would use it for imaging purposes, but in reality only cardiology would be ready to widely implement this kind of a pilot (2011) and then full implementation (2012 and thereafter). This could very well be our pathway toward private practice viability -- but we need something short term from Gonzalez to stop the bleeding while this kind of AUC program is ramping up.

We are making the point emphatically, however, that Congress needs to give private practices that are currently negotiating or eyeing moving to hospital employment a positive indication -- a sign -- that they can still be viable in future years. Something needs to happen this year that sends this message, even if the financial rewards don’t begin until 2011. Regarding Gonzalez, we still need more cosponsors and to keep the pressure on. Now is not the time to become dejected and give up. We must keep the pressure on.