The ACO concept -- while arguably still pretty foggy -- is certainly attracting a lot of attention in the health sector.  But, are ACOs going to eat up the non-integrated private sector?  Certainly not imminently.  But the ACO concept is worth some serious consideration by the profession. The ACC is certainly going to explore how the concept might be beneficial to some members and patient populations. There is potential here -- maybe.

Assuming the Affordable Care Act prevails in its legal challenges (and if it somehow does not, something similar to it needs to be created post haste to deal with the rising numbers of uninsured persons and costs of US health care), ACOs represent are a major element of the law, and the Secretary of Health and Human Services will have broad authority to provide financial incentives for them. Money is promised to flow here.

In fact, ACOs have become central to current thinking about how American health care might find ways to bend the cost curve and better organize health care. Huge conferences occur every week in DC it seems on what ACOs might be and how to build one. The idea is to bring doctors, hospitals, and health plans and Medicare (and Medicaid) together in ways that would hopefully streamline health care, improve patient health status and outcomes, reduce variation in care, and lower costs. Sounds like a fairy tale, doesn’t it? But, hospitals are wildly buying up physician practices to be ready to create ACOs. Health plans, particularly United and CIGNA, have already started buying up medical groups to build ACO networks and pilots -- health plans do NOT want to see hospitals predominate in this proposed transition of the delivery system. Even many physician IPAs and medical groups in California, Colorado, and elsewhere are similarly gearing up. All are hoping to land CMS “innovation center” grants.  ACO policy wonks and consultants are multiplying and are in evidence everywhere one looks.

This frenetic activity is all certain to keep churning along, driven by market forces, even if the ACA controversy drags on through next year. However, the ACA directs the Secretary of HHS and CMS to publish regulations on how ACOs will be structured and financed. The big question is -- where are the proposed regulations from CMS?  The ACO regulations were promised in January, then February, and now it’s mid-March. Whassup? 

Rumors are that the regs have gotten hung up over anti-trust concerns with DOJ and the FTC (Federal Trade Commission). Since ACOs will likely only be effective if they can bring physicians, hospitals, and health plans together to cover a large population and geography, issues around market dominance and anti-trust develop.  One of the ridiculous aspects of current US anti-trust policy that health plans are exempted from most market domination provisions. Hospitals and doctors are not. The Secretary supposedly has authority in the Affordable Care Act (ACA) to waive some anti-trust concerns for ACOs, and this is likely to be challenged by the FTC and the current Congress. So, the regs are in limbo. But that’s not stopping the action sans ‘regs.

Modern Health Care this week carried a story on an anti-trust debacle developing in Nevada as an ACO there tries to take shape. The Nevada attorney general's office and the FTC have launched an inquiry into a patient-care collaboration between Reno-based Renown Health and a local cardiology practice, Sierra Nevada Cardiology Associates. The alliance was the first step in forming an accountable care organization for the two organizations. 

"Their interest is not unexpected given the size of the transaction, and we've met and are cooperating and providing requested information," said Terri Hendry, Renown's spokeswoman, said in the article. "We are confident that this change is in the best interest of consumers and will result in improved coordination of heart services in the region." The ACC is monitoring this process and the entire process of the amazingly rapid changes occurring in the US health care delivery system around integration, physician employment, population based health systems, and payment reforms. Whew. A lot is happening, folks, despite what Congress thinks they can control.

Authors David A. Alter, Therese Stukel, et. al. demonstrated in Health Affairs this month that lower socioeconomic status in Canada is related to lower health status, even with good access to health care services. If poor access to health care were the main cause of lower health status, then universal access should eliminate a lot of the problem. The authors studied 14,800 patients with generally unlimited access to primary and specialty care across Canada's universal health care system. The cohort of patients studied was initially free of heart disease, but after tracking them for more than ten years, these patients had comparably higher rates of CV morbidity and mortality. They found that low income patients used more health care services than their counterparts with higher incomes and education. But disturbingly, they basically found that despite increased use of health care services, patients with lower incomes and education levels had still had poorer health outcomes and higher mortality.

The take home lesson for us in the U.S. appears to be that we should not presume that expanded access to care will of itself eliminate historical disparities among at-risk groups. The authors felt that universal access does reduce some disparities. They are, however, suggesting that major national lifestyle and behavioral prevention programs will be necessary to actually improve health status in these populations. One other point, they were not using registries to give the doctors of these patients continuous feedback as the ACC is suggesting in U.S. health reform as a powerful way to systematically reduce disparities.

It’s hard to believe that in roughly three weeks we will be in New Orleans for ACC.11 and i2 Summit. I hope everyone is as excited as I am for a great ACC.11 meeting. Be sure to join us for the Showcase Session on Sunday and then on Monday night at Convocation, where we welcome the first ever group of AACCs (cardiac care associate ACC member). If you arrive early, don’t miss the CardioSmart Health Fair being co-sponsored by the Louisiana and Mississippi Chapters. There’s also the All-Chapter Reception on Sunday night, which is always a great venue to come together and network with our colleagues from across the U.S. and now around the world.

The March/April issue of Cardiology should be arriving in mailboxes in the next couple weeks and provides a great preview of the many activities for the entire cardiovascular team, including FITs, CCAs. There’s also a section on BOG/Chapter activities, Advocacy and Practice Management-related sessions, and the Late-Breaking Clinical Trial schedule. Also, the ACC for the first time ever has launched an online community for attendees and others interested in the meeting to network and get access to exclusive content. 

See you in New Orleans!

The Medicare physician payment un-Sustainable Growth Rate formula (SGR, or SGRrrr expressed as a growl) is once again heading for a train wreck of 29.5% Medicare cuts for all physicians on Jan. 1, 2012, unless Congress once again acts in their budget discussions to postpone the next chapter of this seemingly endless doomsday timetable. To his credit, President Obama requested in his budget an additional two-year moratorium on SGR cuts to extend through January of 2014, but the cut-crazy Congress isn’t crazy about the $55 billion price tag for this SGR-cut extension it seems.

BTW, imagine if leaders of Congress were even more progressive in their thinking and were willing to fund less than 1% of that cost -- only around $500 million (budget dust) -- which could create an interoperable NCDR-like registry system across all specialties to systematically reduce costs by improving quality of care. Ironically, at last week’s meeting in DC of the Physicians Consortium for Performance Improvement (PCPI), the quality measure and QI consortium convened by the AMA, ACC attendees participated in a discussion with many other specialties in which we suggested just that. We did so after seeing a terrific presentation underscoring the advantages of such a system that is up and running and funded by the government in Sweden. It’s fantastic. 

But I digress. Back to the SGRrrr.  The Trustees of the American Medical Association and other medical societies have warned that such a huge pay cut would force physicians to turn away not only seniors but also military families whose TRICARE coverage is based on Medicare rates.

We all signed an AMA-created letter to House and Senate leaders last week outlining the problems mounting as the SGR threat looms once again. The letter asks Congress to replace the SGR formula.  Of course that would cost about $380 billion, so I’m not holding my breath on that one, welcome as it would be. After all, Congress has been postponing SGR-required cuts every year since 2003, causing them to balloon in size in successive years. It’s a national tradition now.

Last December, the previous (lame duck) Congress spared doctors a 25% cut which would have hit January 1, 2011, by postponing it for 1 year. This Congress seems kinda frozen at the moment, on this and all issues.

This post comes to us from Mike Mirro, M.D., F.A.C.C., and James Tcheng, M.D., F.A.C.C., ACC's Health IT Committee co-chairs. Mirro practices at Fort Wayne Cardiology in Fort Wayne, Indiana. Tcheng is a professor of medicine at Duke University School of Medicine and director of the Biomedical Informatics Core at the Duke Translation Medicine Institute.

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The ACC recently submitted comments on proposed draft recommendations for Stage 2 of the Electronic Health Record (EHR) Incentive Program. The EHR Incentive Program, created under the American Recovery and Reinvestment Act of 2009, has $17.2 billion to give to Medicare and Medicaid providers who can demonstrate “meaningful use” of EHRs between 2011 and 2015. The program has three stages, the first of which started at the beginning of this year. Stages 2 & 3 are intended to become progressively more challenging. Our comments addressed the proposed requirements for participation in Stage 2.

The ACC has always been highly supportive of encouraging the use of health information technology (IT) by members, as we believe it can improve quality of patient care, improved practice workflows and increased efficiencies. That said, we have serious concerns about the speed at which the Department of Health and Human Services (HHS) is pursuing Stage 2 of Meaningful Use, without allowing for adjustments from Stage 1. The reality is that most new programs encounter difficulties and challenges in the beginning and adjustments will need to be made. Here are some of the problems ACC sees with the EHR Incentive Program so far:

• Physician practices have experienced difficulties finding an affordable competent lab solution that both meets certification requirements and communicates with the base EHR modules.
• Use of the ICD-9-CM to define problems rather than use of clinical datasets creates difficulties and added expenses for practices, who usually have to pay to update CPT codes in their systems
• There are different measures for the e-Prescribing and the EHR Incentive Programs, meaning a physician can successfully e-prescribe in the EHR Incentive Program, but then get dinged by negative updates in the e-Prescribing Program.
• The meaningful use criteria focus entirely on technical and functional health IT and ignore product usability. The future certification program should focus on clinical product usability.

HHS should be taking this time to make adjustments to the program rather than pushing forward aggressively with Stage 2. The government’s desire for implementation must not get ahead of the technology, the ability of vendors to develop cost-effective solutions, and the ability of physicians to purchase and implement the new solutions while maintaining high-quality patient care. The potential downsides of this excessive speed to patient care cannot be ignored (mainly, access and safety). However, just to be clear, despite the flaws mentioned above, we still feels that it is in ACC members’ best interest to participate in the early stages of this program to maximize the amount of incentive payments they can receive. You can read ACC’s full comments on CardioSource, as well as learn about how you can participate in the program.

Don’t miss an ACC Webinar on March 15 that will discuss this program -- along with the e-Prescribing and Physician Quality Reporting System -- in greater detail. Register now. Also, don't miss these ACC.11 & i2 Summit 2011 sessions for more on Health IT on April 3rd:

Session 1: Lessons from the Trenches -- 8-9:30 a.m
Session 2: EHR Meaningful Use -- 2-3:30 p.m. 

Plus:

• EHR Vendor Rounds in the ACC Expo's EHR Pavilion
  April 3 and 4, 9:30 a.m. (Meet at coffee station near EHR Pavilion)
  
• Health IT Gadgets & Gizmos "Show & Tell"
  April 4, 11:15 a.m. (ACC Central Theater)

President Obama made a strong push for support of the Affordable Care Act (ACA) at the National Governors’ Association (NGA) conference in Washington last week. I was on a call with some other health care leaders arranged by the White House before Obama visited the NGA to test out the recommendations he planned to make there. Obama had decided to suggest that the 50 states consider applying for HHS-certified state “waivers” from the ACA, as the law is currently to be implemented nationally. This is kind of a radical change in the administration’s position.

Most states are moving ahead with ACA implementation as provided in the Act. But the President’s unexpected push at NGA for “state model ACA waivers,” in accordance with the Wyden-Brown “Empowering States to Innovate Act,” might make some Republican critics a little more hopeful about the ACA; while annoying the left-leaning Democrats. The President's push for the waivers is another sign that he is moving toward the political middle, where most Americans are more comfortable (me included).

In addition, Obama is recommending that the Wyden-Brown act be amended to be effective in 2014, instead of the current version, effective in 2017. This will make Wyden and Brown ecstatic; and may swing some Republican-leaning states to get more involved. Some left-leaning states as well it seems.

Any state model must meet the basic standards of the ACA—meet the access and affordability standards without adding to the national deficit. A proposed set of regulations on how states can comply will be issued in the next few months.

Meanwhile, Florida Judge Vinson, who found the ACA unconstitutional, was pressed by Obama to interpret his decision -- did he want an injunction to halt implementation or not? He surprisingly said the act could be implemented until the appeal of his decision is completed. Some media sources hailed that as a huge victory for the Administration……. It wasn’t. Vinson expects the appeal process to be expedited at the next level (Federal Circuit Court of Appeals) in as short a time as a week. He still wants the law stopped (of course, the appeal may not happen that fast, and it will likely go to the Supreme Court no matter what).

Of course, the Republicans in Congress also hope to use the budget impasses to prevent the ACA from incrementally going forward by de-funding HHS. But most states are still moving ahead anyway, assuming the law will eventually prevail.

Inappropriate stent use made the news again last week, after a Pennsylvania hospital announced it plans to review two cardiologists accused of implanting 141 stents inappropriately. The article came out just two days after the Maryland State House held hearings on new legislation that underscores the need for accreditation & certification of catheterization labs. The bill, the Maryland Cardiovascular Patient Safety Act, was drafted by the ACC, the Maryland Chapter of the ACC and SCAI following meetings with state policymakers. We have been working to get this bill introduced.

Maryland has been at the forefront of the stenting controversy. Larry Dean, M.D., F.A.C.C., SCAI president, Sam Golderg, M.D., F.A.C.C, Maryland Chapter governor, and Mark Turco, M.D., F.A.C.C., Maryland Chapter governor-elect, and I wrote a President’s Page for the Feb. 17 issue of JACC that addressed how we see the situation of procedure overuse, which is neither confined to the state of Maryland or the field of interventional medicine. To be perfectly clear, the ACC does not condone inappropriate use of coronary stenting, overuse or misuse of any cardiovascular technology or therapy.

That said, what’s happening in Maryland is a prime example of how a negative situation can be turned into a positive opportunity to improve quality and appropriateness of care. Working with Maryland lawmakers, we were able come up with a solution that allowed state officials to feel that quality in cardiovascular care will being ensured, while allowing physicians to determine the specific manner in which that can best be achieved.

“We are all in the same boat in a stormy sea, and we owe each other a terrible loyalty,” wrote English author G.K. Chesterton. How we react to this overutilization storm will determine our future. We must take stewardship for the health care system into our own hands, so that society will view us as true professionals who can be trusted to practice appropriate use of resources because we are basing our treatments on the latest and best scientific evidence.

You can read more about what the ACC, ACC Maryland Chapter and SCAI have been working on in Maryland in this previous blog post; in particular, the comments section offers great insight into the views of ACC members.

The ACC Political Action Committee board met this past weekend in San Diego to plan our strategy over 2011 and beyond. President Ralph Brindis, Past President Fred Bove, and I joined ACC SVP of Advocacy Jim Fasules and his team and the PAC board in the discussions. Chair Bo Walpole noted that the PAC finally reached the $1 million level this year, putting us in the top ten of the professional PACs, which is good given that the PAC is only been around since 2002. That said, we bet correctly on 83% of the political races we invested in.

ACC’s PAC is somewhat unique in focusing very much on ways to improve cardiovascular quality of care. The board is very clear that whatever we endorse or invest in must meet the standard that it is in the best interest of patients, science, and improved patient care, whether that be Republican, Democrat, Independent, whatever. We focus our efforts on lawmakers and candidates who are in a position to impact our members and the care they provide. We used our influence to encourage Democratic leadership in the last 2 years to create health legislation that met these goals. We are now going to focus on the new Republican House leadership on developing ideas about what they want to propose to solve our nation’s health problems, rather than just opposing what’s on the table. We have solutions in hand in terms of reducing unnecessary spending and improving quality of care at the same time.

The ACC has been educating members over the last year about the upcoming switch in the coding classification system for diseases from ICD-9 to ICD-10. This switch, which takes effect Oct. 1, 2013, is huge. The health care system will go from using 17,000 diagnosis and procedure codes to using over 155,000. The Health Business Blog recently featured a podcast interview between David Williams, who writes the blog and is co-founder of MedPharma Partners LLC, and Ray Desrochers, HealthEdge COO, on the upcoming switch to ICD-10 and why it’s such a big deal. Desrochers makes a good analogy of the switch to ICD-10 as the modern health care version of Y2K:

"ICD-10 has been called the Y2K of health care.  ICD-10 ... introduces a whole different level of complexity that most of the organizations out there today are not ready to deal with.  Remember that many of the technology platforms that are running today’s payer organizations are 20, 25, even 30 years old. When you start to talk about change, particularly significant change like this, they’re not able to easily accommodate that.

Also, similar to Y2K, you’re not only talking about a larger number of codes, you’re also, at the same time, about codes that are much longer than their ICD9 counterparts.  So you start to think about this and you go through all of the same experiences that existed in Y2K in terms of needing to analyze the databases, needing to expand fields, needing to migrate and convert data, etc. So that’s what organizations across the country are looking for as they head towards the 2013 ICD-10 standard." [The full interview transcript is available on the Health Business Blog.]

Because of the longer codes, the transaction standards used for electronic health care claims, Version 4010/4010A, must be upgraded to Version 5010 by Jan. 1, 2012. ICD-10 codes must be used for all health care services provided and hospital inpatient procedures performed in the U.S. on or after Oct. 1, 2013. After that, claims can’t be paid.

The ACC has resources available on our website to help members get ready for the transition, which you need to start now. Check out: What You Need to Know about ICD-10 and especially the ICD-10 Checklist.

Increasingly, insurance companies are selling health policies that are pure vaporware in terms of their claims of “out of network” coverage, when preferred or needed by beneficiaries. So, when patients choose an out-of network doctor or hospital, the actual coverage is paid at a small fraction of the actual cost. Patients are stuck with the difference, and physicians are often stuck with non-payment. The reality is that these policies are misrepresentations of actual coverage, and recently physician and patient advocates in New York (and other states) and the AMA have successfully filed suit against blatant abuses. Catherine Hanson, JD, a fantastic AMA health attorney, has been all over these issues on behalf of doctors and patients.

FairHealth is a two-year old organization formed out of a settlement in New York that AMA and MSSNY (Medical Society of the State of New York) and others against these kinds of abuses. Former ASMA President Nancy Nielson, MD, former Aetna CEO Jack Rowe, MD, consumer advocate attorney Sarah Rosenbaum and others are working to educate the public and patients about these problems, and try to encourage fair practices by the industry. AMA is also proposing a “truth in benefits” act in Congress to remedy these injustices and rip offs.

Has your practice seen non-payment as a result of scan insurance coverage?