Health and Human Services Secretary Kathleen Sebelius chatted recently with MedPage Today about President Obama’s proposed 2012 budget and the provisions of interest to physicians. As Jack wrote last week, the proposed budget contains enough funding to freeze physician payment under the sustainable growth rate at current 2011 levels for two years. While this certainly is an improvement over having to fight off the massive draconian cuts that the SGR full enactment would entail every year (or every few months, as has happened the last couple of times), this is hardly the permanent fix that the ACC has been pushing for. Sec. Sebelius explains what she feels is the rationale for this limited freeze: pass the 2-year freeze to “start a conversation with Congress,” and then immediately work on a permanent solution. Sebelius notes that there is nothing more important than having doctors in Medicare, and acknowledges that physicians are getting weary of going year-to-year having their pay jeopardized.

She’s right there. There have been several reports in the media of physicians dropping out of Medicare as a result of cuts present in the Physician Fee Schedule and the constant uncertainty of the SGR. However, it’s a little unclear if passing a two-year fix will actually give Congress two years to work on an innovative payment system that rewards high-quality care (what the ACC and other medical societies would like) ... or two years to avoid dealing with the massive cost this type of effort would likely require. I hope that Congress steps up to the plate to truly solve the SGR dilemma for us physicians over the next two years.

Check out the video on the KevinMD blog for Sec. Sebelius’ take on other health care issues, including health IT, the Affordable Care Act, fraud and abuse and the medical loss ratio.

Last week was a two-ring circus over budget issues. First, the 2011 budget for government for THIS year is not approved, and the entire federal government will be devoid of funding March 1 if they don’t get that done. Then, they are also of necessity now reviewing the 2012 budget, which was released last week. For 2012, the newly elected members of Congress obviously plan to make HUGE cuts in federal programs. 

Here are some of the highlights (or should I say ‘lowlights?) of the proposed 2012 budget:

• Medicare and Medicaid: Proposes $62 billion in savings over 10 years to Medicare and Medicaid, while Medicare costs increase by an estimated $54 billion. This will be done by saving in Quality Improvement Organizations and dedicating penalties for failing to enact electronic health records into the Medicare trust fund. This all seems kinda nebulous to me.
  
  
• SGR: The 2012 Budget provides $54 billion to temporarily freeze physician payments at current levels for 2 years. This 2-year fix is paid for by squeezing payments to hospitals and physicians (kind of ironic?) as well as increased usage of generic drugs. The specific offsets include:
  • Reducing the Medicaid provider tax threshold starting in 2015
  • Strengthening Medicaid third-party liability 
  • Tracking high prescribers and high prescription drug users in the Medicaid program to reduce waste, fraud, and abuse
  • Recovery of inappropriate payments to Medicare Advantage plans
  • Creating a system to validate high-risk services ordered by physicians and practitioners

• Tort Reform: The ACA included grants to states for implementing medical malpractice reform initiatives beginning in FY 2011, although Congress has yet to allocate funding for the full year.  The President’s budget proposes $100 million for these grants in FY 2012, followed by $50 million each year through FY 2015.  
  
  
• Medical Research and Public Health: Increasing NIH funding by $1 billion (from $30.8 billion to $31.8 billion); cutting CDC funding by 9% (from $6.5 billion to $5.9 billion); cutting AHRQ by 8% (from $397 million to $366 million), but transferring $24 million from Patient-Centered Outcomes Research Institute to bring AHRQ to $390.4 million.

HHS Secretary Kathleen Sebelius has been busy testifying to the various committees about the proposed budget. Last Tuesday, she testified before the Senate Finance Committee and on Wednesday before the House Ways and Means Committee. At both committee hearings, the SGR came up multiple times. Chair Max Baucus (D-MT) opened the Senate Finance Committee hearing by emphasizing the importance of enacting permanent repeal of the SGR and noted the negative effects uncertainty in physician payment has on physician practices and Medicare beneficiaries’ access to quality health care. Senator Orrin Hatch (R-UT) echoed the Chairman’s remarks, clarifying the need to find responsible ways to pay for a permanent solution.

Medical liability reform was also a heavily discussed topic at both hearings. Senator Tom Carper (D-DE) discussed during the Senate Finance Committee hearing the importance of reducing instances of defensive medicine and the impact medical liability reform can have on reducing overall health care costs. Sec. Sebelius referred to the provision in the budget that would establish cost saving measures within medical liability programs. When asked her position on medical liability reform in the Ways and Means hearing, the Secretary said she does not support caps but supports the President’s goal of exploring other reforms.

Sec. Sebelius at the Ways and Means hearing said the budget reflects the point that you “cannot build prosperity on a mountain of debt.” Duh.  

Page one from the State Advocacy Workgroup's playbook says that if you "work with state medical societies and physician specialty groups, ... state officials will listen." Recently, joint advocacy efforts by the ACC’s Colorado Chapter and other physician groups saw just that result. The Colorado Supreme Court has been working to streamline the judicial process to ensure trials don't drag on indefinitely. While physicians have long pressed for governmental efficiency, especially in courts, the proposal was fraught with problems. It set pre-trial rules and deadlines for discovery and expert testimony, preventing physicians from responding to new arguments and evidence during trials.

One medical group raised its concerns to the state Supreme Court, and they received a form letter expressing thanks for raising the issue and a promise to consider their concerns. When the issues were raised not by one group, but by 24 physician groups, the Colorado Chapter of the ACC and the Colorado Medical Society, the results were much different. As a result of the collaboration, the CO Supreme Court panel set up a series of workgroup meetings to allow physicians to express their concerns and help re-write the policy. And because defense lawyers expressed similar concerns, the Chapter is hopeful that sensible rules of procedure will result.

This is a great example of how locking arms with friends across the House of Medicine, chapters can set the stage to protect physicians on dangerous ground either in the court room or state capitols. CO Chapter executive Lianna Collinge, former ACC CO Governor Eugene Sherman, M.D., F.A.C.C.,  and current ACC CO Governor Thomas Haffey, M.D., F.A.C.C., set a fine example for all Chapters.  

Speaking of medical liability reform, Rep. Phil Gingrey, M.D., an OB-GYN from Georgia, has introduced the “Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act” (H.R. 5). The ACC is supporting this legislation, which would increase patient safety; ensure that injured patients are compensated quickly and fairly; improve provider-patient communications; and foster an environment for affordable and accessible medical liability insurance. The House Judiciary Committee approved the bill yesterday. The committee rejected all amendments, except one, on party line votes. The committee accepted an amendment by Cong. Scott (D-VA) removing collateral source rule reform from the legislation.  More details are available on the committee’s website. Stay tuned to “The Advocate” for updates and next steps. This issue is an ACC Advocacy priority! Read the ACC letter on the bill.   

A study in JACC yesterday looked at the inclusion of three new attributes to predict in-hospital mortality following PCI that has implications for public reporting of hospital performance. In Massachusetts, where the study was conducted, reporting of in-hospital PCI mortality rates has been required since 2003 through the NCDR CathPCI Registry. However, since the CathPCI Registry was not built for public reporting and not intended to identify high-risk clinical scenarios, physicians in 2006 recommended inclusion of three additional attributes, which they deemed “compassionate use” (CU) measures. These measures are: coma on presentation, active hemodynamic support during PCI and cardiopulmonary resuscitation at PCI initiation. The purpose of the study was to see if including these measures was feasible and would improve the prediction model for in-hospital PCI mortality.

Researchers divided patients into two categories: those presenting with STEMI or cardiogenic shock (which they called the SOS group), and all others (the non-SOS group). The findings were definitive:

• The unadjusted in-hospital mortality rate was 15.6 times higher for CU patients vs. non-CU patients in the SOS group;
• CU patients only represented 1.6% of all SOS patients, but represented 21% of the overall mortality after PCI for the SOS group; and
• Being designated CU was associated with an odds ratio for in-hospital death of 27.3 relative to the non-CU SOS patients, after adjusting for other known predictors of in-hospital mortality.

The authors conclude:

“The Massachusetts experience demonstrates that a small proportion of patients at extremely high risk of in-hospital mortality can be identified using objective, pre-procedure clinical factors that had not been previously collected as part of traditional quality monitoring efforts. Incorporation of these CU covariates in risk-adjustment models led to significant improvements in model performance as well as reclassification of predicted risk in a substantial proportion of cases.”

Editorial
Eric Peterson, MD, MPH, writes the editorial that accompanies the article. He’s right on in his comments. With patients and the government increasingly demanding transparency in health care outcomes, there is a true risk of unintended consequences if we do not do due diligence in taking into account as many predictors of adverse outcomes as necessary. There are plenty of anecdotes of physicians refusing to perform CABG or PCI because they simply don’t want to have a death on their outcomes report by caring for patients whose clinical status is so extreme that their chance of surviving the hospitalization after the emergent CABG or PCI might be less than 30%.

Although the NCDR has a robust risk adjustment model to “level the playing field” to take account of these very ill patients, Resnic, et al., offer CU risk adjustment measures that appear to be an improvement in accurately risk-adjusting the severity of illness for these infrequent but critically ill patients. The use of the CU measures might hope to mitigate against the negative unintended consequences of public reporting – that is to say, physicians would be more willing to take these ill patients to the cath lab for emergent PCI rather than refusing to do so.

The challenge of the CU risk-adjusted measures is for its accurate “coding” by the data analysts when submitting their registry reports. A robust auditing system of all patients deemed to meet CU criteria is necessary to assure accuracy in the coding of these patients.

What do you think of the study findings? Should (and if so, how) CU criteria be incorporated into public reporting efforts?

CMS Administrator Donald Berwick, MD, and CMS Chief Actuary Richard Foster testified before the House Ways and Means Committee last week at a hearing titled, “The Impact of the Affordable Care Act on the Medicare Program and Medicare Beneficiaries.” We were there.

In the fall, Dr. Berwick testified before the Senate Finance Committee but this was his first time in front of a House committee. After discussing his background in medicine and what he views to be the many the benefits of the Affordable Care Act (ACA), Dr. Berwick held his own during tough questioning. This was also a ‘sniff him over’ process, given he has been promoted for confirmation again.

In his opening statement, Chairman Dave Camp (R-MI) noted the contrast between Dr. Berwick’s optimism on the ACA and Mr. Foster’s bleak outlook for Medicare due to the ACA. Foster has disagreed with others and the Congressional Budget Office on ACA savings, which Foster thinks are unlikely to be achieved. Democrats used the hearing to try to “shatter the myths about reform,” as stated by Ranking Member Sander Levin (D-MI) during his opening statement. Democrats repeatedly pointed to what they view as the most popular provisions of the law and what would happen if the law was repealed. In other words, this was a genuine partisan circus event.

There were plenty of controversial questions and answers. On tort reform, Dr. Berwick said he supports “exploring a national solution” on medical liability but would not comment on non-economic caps. Rep. Vern Buchanan (R-FL) told Dr. Berwick about a letter he wrote to CMS regarding concerns of Florida cardiologists with Medicare payment cuts for cardiology services (this "2010 Rule" issue preceded Berwick’s coming to CMS, but he’s sure hearing about it). When  Rep. Sam Johnson (R-TX) described physicians no longer participating in Medicare and having to reduce staff, benefits and charity care, Dr. Berwick stated that enrollment in Medicare is the highest ever for physicians. Poor Dr. Berwick -- he wants to talk about improving quality and patient safety and lowering costs in those ways, but there was no chance of that. Too bad he couldn’t just speak his mind, though. He had a lot of constructive non-partisan things he could have shared there, but that wasn’t what this hearing was about.

What did we and the nation learn from this hearing that we don’t already know? Nothing.

Quality of life and length of life are heavily dependent on health care (as well as on genetics and economics). As health care is gradually extended to the poor of the world, and particularly in Asia, they are discovering ways to provide modern care at very low costs, and not just because wages and salaries are less.  Actually in the US, we should recognize that rising employer and family health care premiums are depressing wages and/or disposable income here! In fact, in 2016 the percent of household income spend on health care -- on average across all American families -- will be 45%!

So, anyway, Asian medical innovation will be affecting your practice and/or your doctor sooner than you realize. China and India are revealing how medical costs can be slashed in the US and EU. How? In various ways, including call centers, remote imaging interpretation and medical tourism. Foreign training of medical professionals willing to immigrate here and work for lower salaries (for a while anyway) is also a factor. But, frugal innovators in India and China are also making cheaper medical devices that work effectively. Companies like China’s Mindray and India’s TRS stripped down imaging scanners that cost one-tenth of similar equipment here. ECG machines in Asia cost $500 or less, instead of $5000, for example. A night in a US hospital room costs 25 times as much as a similarly equipped modern hospital room in India or China. GE, Phillips, Medtronic, and other US companies are investing heavily in these countries, and positioning to participate in these markets effectively, and manufacturing cheaper products. Could this reflect Toyota/Honda versus GM and Ford comparisons in the US during the 1980s?

The Economist says two factors keep good but cheaper devices and infrastructures out of the US. First is that we as patients here don’t care about costs much when employers or government is paying the bill -- patients have to contribute out of pocket more for their care in Asia (so will we soon). Second, they say the FDA’s propensity to be risk averse currently prevents introduction of such products, which can’t afford to go through their expensive and lengthy processes.

Today’s post comes to us from Mark Kremers, MD, FHRS, FACC, a practicing EP and former president of Mid Carolina Cardiology in Charlotte, N.C. Dr. Kremers is presently the chair of the NCDR ICD Registry Steering Committee.

*****

In the Feb. 1 issue of JACC, Van Rees, et al., report on a retrospective single-center analysis of inappropriate ICD shocks in large population of primary and secondary prevention patients implanted from 1996 to 2006 in Leiden, Netherlands. Inappropriate shocks, an undesirable consequence of ICD therapy, can occur for multiple reasons and negatively impact patient’s psychological and physical well-being.  This paper extends previous data from the Sudden Cardiac Death-Heart Failure Trial (SCD-HeFT) and the MADIT II study by looking at patients outside of a clinical trial and including secondary prevention patients.   Initial ICD programming was standardized with a detection of 188 bpm treated with ATP x2 and then shocks, and a second zone at 210 bpm treated with shocks only.  Stability, sudden onset, and others discriminators as available in dual chamber and CRT devices were also activated but the number of intervals to meet detection was not specified. 

After 41+/- 18 months, 13% of patients experienced at least one inappropriate shock episode and the cumulative incidence increased to 18% at five years.  Inappropriate shocks were associated with age < 70 and a history of atrial fibrillation and were most frequently in response to supraventricular arrhythmias.  ICD type did not impact frequency but there was a trend to more inappropriate shocks in a group implanted since 2004. This may relate to a change in device indication over time with inclusion of more primary prevention patients. While the SCD-HeFT and MADIT II studies differ in time frame, device programming, and patient populations, all demonstrate a similar incidence of inappropriate shocks and a disturbing trend of increased mortality associated with these shocks.

In the Van Rees paper, inappropriate shocks were associated with a 60% increased mortality risk, which, however, is lower than the previous studies and may relate to the different populations studied.  The authors speculate that the shocks are directly causative of the increased mortality due to the myocardial trauma that high voltage shocks induce.  A cumulative mortality risk of shocks as described in this paper, and CHF as the leading cause of death in shock recipients described in SCD-HeFT, support this theory.  Alternatively, the finding in all studies of an association of inappropriate shocks with both a history of AF, and with appropriate shocks raises the possibility of shocks as a marker, but not the cause, of the increased mortality risk.  It may well be that there is a contribution of both.  The Longitudinal ICD Study, conducted by the Cardiovascular Research Network (CVRN) and supported by the NHLBI, AHRQ, and ACCF, is following 2,600 patients and will track the occurrence of ICD therapy to hopefully shed additional insight on this issue.  

We are left with a conundrum. In selected populations, ICDs improve survival.  Individuals however do not always reap this benefit and the use of ICDs, like many therapies, is associated with morbidity and even mortality in some recipients.  The potential for benefit is a poor consolation for experiencing real injury, and, thus, patient selection is essential in limiting the potential harm of ICDs.  This is particularly relevant as a recent study based on ICD Registry data raises concerns about appropriate ICD utilization. Additionally, since a significant portion of appropriately implanted ICD patients never receive therapy, further investigations to improve patient selection would be valuable.  Programming to increase rates, and the number of intervals to detect, use of antitachycardia pacing and other enhancements may reduce inappropriate shocks, and underscore the importance of individualizing ICD programming.  Lastly, further improvements in detection specificity without compromising sensitivity (e.g. pressure sensing and other unique detection enhancements) remains an important goal.  Incorporating these concepts will allow ICD implanters to meet a basic tenet of our profession, “primum non nocere” (First do no harm).

Does this study detailing inappropriate shocks with mortality influence your decision making regarding ICD utilization?

The US Senate conducted their expected vote to repeal the ACA (Affordable Care Act), as demanded by Minority Leader Mitch McConnell (R-KY). Dems lined up in unity to protect ACA, and the effort was defeated as expected, and along purely partisan lines 51-to-47. This effectively kills the House bill to repeal the ACA. So, in this regard, the ACA’s prospects of proceeding toward full implementation (in 2014 and thereafter) was enhanced by this outcome.  

Nonetheless, and at the same time, you all saw the parallel potentially calamitous legal ruling from Florida US District Court judge (a Republican appointee) Roger Vinson. This judge opined that the ACA violates the Constitution and therefore cannot proceed in the 26 states (25 of which are R states) that have filed suits against on common grounds. These filings all claim that the law is over-reaching and violates the controversial “Commerce Clause” of the Constitution. Unlike two other court decisions opining against the law’s ‘individual insurance mandate,’ Vinson’s ruling would void the entire law. He opines that the individual mandate provision is such a central and interwoven provision of the ACA that halting implementation of the act is necessary, and thus requiring that the whole law be voided. However, he didn’t issue an injunction to actually halt its implementation, believing the federal government is obligated by tradition to honor his decision, unless or until his order were to be successfully appealed.

Regardless, the federal government says it will NOT halt implementation, which already has proceeded to issue rebate checks to millions of seniors to cover their ‘donut hole’ prescription costs; establish high risk pools for those unable to get insurance; and implement various insurance reforms including allowing children up to age 26 to piggyback on their parents’ coverage. Federal attorneys cite in their defense that two similar courts have opined that the law can stand as is. But this new decision complicates things.  Proponents of the ACA are a bit scared. As we have noted before, the controversy must and will go to the Supreme Court before it is resolved, and most likely first through the federal appellate courts, meaning this controversy will drag on for a year longer. 

State and other ACA opponents will ask that implementation be halted following this decision; while the Administration and supporters will ask for a stay of this ruling until they appeal it. People who already have received new benefits, including voting seniors, won’t like having to pay back their benefits if the law is voided!  So this will be interesting to watch.

The Republican governors in the states of Wisconsin and Florida have already stated they will halt all activity around health reform and the ACA. I suspect Arizona will follow. But, most states are going to proceed, if cautiously, noting they will otherwise get too far behind to catch back up, and hoping they can contain or slow health care cost increases through such efforts.

Most DC constitutional legal experts still seem convinced the law will sustain legal challenges at the Supreme Court, based on historic decisions and precedent around the Commerce Clause. And Congress hasn’t stopped its own pro- and con- actions around the ACA.

I think that’s important to consider for us as doctors and health care professionals and patients. We are politically spread over the spectrum like the general public. But health care is not a mainly partisan issue. Do people have the freedom to avoid health coverage, and then allow EMTALA to require us physicians and hospitals to provide the care, and/or include the costs of uncompensated coverage for all other American at an average of $1000 per year? I think fixing the ACA is smarter than repealing it (this also seems consistent with ACC reform principles). But I also agree with most Republican opponents of the ACA that the deficit must be seriously addressed, something liberal Dems don’t want to take very seriously.  

I think individual liberty requires taking responsibility for yourself. As physicians, we get stiffed if people want to opt out of health coverage (or refuse to chip in for their fair share of health care costs). So does every insured person currently have to pay for those who don’t chip in for their own health care needs -- and we all end up needing health care. But this is the discussion we need to have as a nation.

I still suspect the law will stand, and get amended significantly to fix its glitches and gaps. No guarantees though. And all said, it’s important to remember that with or without the ACA, folks, we’re heading  up a metaphoric creek without a paddle if we irresponsibly drift along with the status quo any further. Health reform is essential to remedy the economic nightmares created by the incessant and future projected cost increases of US health care, public and private; and the fact that the average family is now spending more than a third, and will be spending in less than 5 years nearly half, of their income (45%) on health costs is unsustainable for business, families, or government! Hello. We live in a time with amazing health care options and services. But we have to figure out how to pay for them, and how much to pay for as a society. Doing nothing in the current circumstance is NOT an option.

Last weekend, nearly 150 new ACC leaders took part in the College’s annual Leadership Forum in Washington, D.C. Each year the ACC welcomes a new group of leaders, and the Leadership forum is their opportunity to learn more about their roles and responsibilities, the ACC, its policies and available resources.

Given the rapid and massive changes to the health care landscape over the last several years, the ACC has been working to transition the Leadership Forum into what essentially serves as the equivalent of pre-season training for a sports team. This year’s Leadership Forum focused on providing participants with the tools to successfully lead a team.

Some of the event’s highlights:

• ACC President Ralph Brindis, M.D., Ph.D., F.A.C.C. and CEO Jack Lewin, M.D., outlined the challenges facing the CV community and highlighted the need for leadership in changing times.
• Joseph Grenny, author of Crucial Conversations, provided a lunchtime address that focused on ways leaders/influencers “have the power to change anything.”
• Dan Reeves, former pro football player for the Cowboys and coach, talked about how his leadership experience as a winning football coach and player coupled with his ability to achieve team camaraderie has enabled him to achieve success.
• ACC Chapters were also recognized for their outstanding accomplishments in the areas of Quality, Advocacy, Education, and Membership and Community.

As chair of the BOG, I’ve seen the challenges facing cardiovascular professionals in academia, private practice, hospitals and integrated systems across the country. Incoming leaders need to know how to adeptly manage these changes, while at the same time continuing to ensure quality, appropriate cardiovascular care. The need for strong and effective leaders at all levels of the College, as well as within the CV profession in general, has never been greater. This year’s Leadership Forum is testament to the fact that there are great leaders, who are in a position to help lead the new cardiovascular team into the future.

Take a look at the January/February issue of Cardiology magazine, which is all about leadership, and leave your thoughts in the Cardiology Discussions forum.

Here are some pictures from the event, taken by Thomas Haffey, D.O., F.A.C.C., governor of Colorado Chapter of the ACC:

	BOG Steering Committee member Margo Minissian, ACNP-BC, MSN, CNS, and ACC President Ralph Brindis, M.D., F.A.C.C.
	Brindis and former NFL Player and coach Dan Reeves
	Brindis, Dan Reeves’ cardiologist Charlie Brown, M.D., F.A.C.C., Reeves, Robert Vincent, M.D., F.A.C.C., Gov. of GA, Board of Trustees member C. Michael Valentine, M.D., F.A.C.C.

What challenges will cardiology face in this politically tumultuous year? Read on. Last week the Coalition of Cardiovascular Organizations (CCO) met at Heart House to forecast, discuss, and seek consensus on what is on the horizon in 2011 on the congressional and state advocacy agenda. President Ralph Brindis, MD, FACC, President David Holmes, MD, FACC, and President-Elect Bill Zoghbi, MD, FACC, with ACC SVP of Advocacy Jim Fasules, MD, FACC, and I represented the ACC, along with the officers and staff leaders of Heart Rhythm Society, Society of CV Angiography and Interventions, American Society of Echocardiography, American Society of Nuclear Cardiology, Society of CV Computed Tomography, Society of CV Magnetic Resonance, Heart Failure Society of America, Society for Thoracic Surgery, the Association of Black Cardiologists, and Society of Atherosclerosis Imaging and Prevention. The Society for Vascular Surgery couldn’t attend.

It was a great exchange! Here’s my view of what we came up with as consensus priorities:

• Payment reform issues, including the getting rid of the SGR, are critically important to all. There was a general sense that we have to look beyond fee for service, and explore other bundling, episodes of care, and global budget opportunities, where an upside is conceivably possible, but certainly not easy to achieve. Some members will want to stay with fee for service, and we need to protect them as well. But re-aligning incentives and going where opportunities are is a big challenge for all of us. Business as usual is not going to work.
  
  
• Championing quality improvement is a major part of how we take on the above issues. We need our registries and accelerated abilities to continue to translate science into better clinical guidelines, performance measures, appropriate use criteria, and other tools to do that. This is how we will lead in cost containment and improving value.
  
  
• Addressing and monitoring workforce issues, including what the heck is really going to happen to primary care? What will the future role of specialists be?
  
  
• We need tort reform -- we have ideas here.
  
  
• Accountable care organizations and pressure for integration -- needs to be implemented such that physicians are not at a disadvantage to hospitals or insurers in the design and governance of such structures if they proceed. In some form, I believe, they will.
  
  
• Myriad specific issues: The RUC and CMS assaults on cardiology; precertification issues with insurers; RBMs; meaningful use, PQRS (formerly PQRI), fair e-Rx incentives and requirements; protecting private practice viability; adding value to hospitals where members are employed, consulting cuts, etc. We need to develop leadership skills too!

Doing all of this is tough in a zero-sum Medicare game; with ongoing disparities in evidence; with no respect for long-term value (VADs, transplants, TAVI); and docs not paddling together.