Managing a physician practice, hospital, academic institution, health insurance company, or any other health sector business is going to be tougher in some ways than perhaps ever in history over the next decade. Why? Because health care of necessity will undergo unprecedented change, and much of how it will shake out is uncertain. The ongoing explosive increase in knowledge and science is itself a blessing and unprecedented challenge. But it’s the economics and financing of health care that generates the most uncertainty in terms of how to position for success and excellence.

Who can guess what the Supreme Court will do when they (most certainly) review the constitutionality of the Affordable Care Act? It is uncertain. How will the solution to the debt ceiling affect health care funding? It is uncertain. But, because the “bullish forces” which underlie health care reform -- pressures to reduce costs; improve consistency of quality; move away from volume-based fee-for-service reimbursement; focus on population-based health improvement; greatly promote integration/mergers of physicians, hospitals and insurers; and get more uninsured people into coverage -- are unrelenting, major shifts in financing, payment systems and delivery models are inevitable. To what extent will changes manifest, how fast, and in what directions? Who knows? There is a lot of uncertainty!

For example:

• Shifts in amount and type of reimbursement: What will happen with reimbursement and payment reform? How much average funding will be available per person? McKinsey & Company believe millions more people will be covered with more overall dollars added to the system in five years, but that the per capita funding -- across public and private payers -- will drop, regardless of the ACA.  How does that affect practice? It ain’t positive, gang. New forms of reimbursement are already developing -- to what extent will these developments plus regulatory change affect the viability of private practices?
  
  
• Changes to Medicare (and Medicaid): Federal budget pressures could produce unexpected crises in funding. The debt ceiling discussions could create some really big nightmares if drastic cuts are enacted or created through poor public policy. How do we plan for the future -- will private practice survive if massive cuts occur? Can payment reforms head off draconian changes that may be imminent?
  
  
• The future of integration: Will accountable care organizations work and become a common phenomenon? Will hospitals or physicians or insurers dominate them?
  
  
• The future of CV technology and imaging and innovation: CV technology and imaging has been under financial assault for a decade as its use and contribution of costs has increased dramatically -- largely due to new diagnostic and therapeutic benefits conferred. But will these economic assaults continue, or will new scientific evidence actually promote increased investment in and appropriate use of imaging and new technology? Will these technologies now spread hugely across the developing world, versus primary prevention -- or will both things occur?

Managing in uncertainty will require that we depart from traditional strategic planning to instead develop an array of scenarios of possible developments and have action plans to apply to the various scenarios that we could face. That’s not how most of us are approaching the uncertainties of the next 5-10 years. There will be spectacular winners and big losers in this era. But, we cannot approach this future with a status quo, ‘business as usual’ philosophy, folks.

I was fortunate to get some consultant folks to visit Heart House from McKinsey this week to talk with ACC senior staff about the importance of starting to model scenarios around the many uncertain variables we face in cardiology and CV care -- to be ready for likely discontinuities and/or crises -- and to take advantage of possible opportunities for members and the patients they care for.  It was fascinating. It made me aware of how important it is to get this kind of management and leadership education to our board and other physician leaders as well. In fact, all of medicine needs to begin to think about how to prepare to be nimbly able to respond to the irony of certain change in the face of uncertainty.

Former ACC President Ralph Brindis, MD, MACC, during his presidency frequently discussed the portrayal of physicians as knights, knaves and pawns, following the publication of a piece in JAMA on the topic. In their commentary, Sachin Jain, MD, MBA, and Christine K. Cassel, MD, argue that physicians are portrayed as being “motivated by virtue (knights) or rigid self-interest (knaves) or … [as] passive victims of their circumstances (pawns).” This is important because a “society's view of human motivation influences whether it builds public policies that are permissive, punitive or prescriptive.”

This discussion theme continues on the KevinMD blog, where Kevin Pho, MD, discusses the “underlying tension between physicians and health policy experts.” He writes: “Health policy experts take subtle jibes against physicians in their analysis,” effectively treating physicians as the “knaves” mentioned by Jain & Cassel, and thus recommending policies that are punitive. However, Pho notes that physicians are hardly innocent in this debate, as “doctors generally discount [health policy experts’] opinions because they haven’t gone through the rigors of physician training.” 

Pho goes on to say that doctors need to be involved because they have the trust of patients, as shown by a 2009 Gallup poll that found physicians have the highest level of public trust on health care reform. The ACC conducted a public survey in 2008 and found similar results. Because of this, Pho writes, “it baffles me when policy experts don’t give doctors many olive branches when making their health reform arguments.”

I agree. Efforts to make changes to the health system would go along a lot smoother if health policy “experts” attempted to obtain the support of physicians. It’s short-sighted to address the health insurance system, which arguably was the hardest hit by the Affordable Care Act, without addressing the physician payment system. There’s so much that needs improvement in our current health care system, and physicians have first-hand experience with much of it. Health policy experts might be better able to craft solutions if they stopped viewing physicians as “knaves” and started seeking our support. Together, we can improve the health care system in a way that both reduces costs and improves patient care.

As part of ACC’s ongoing series on e-prescribing, ACC staff interviewed South Denver Cardiology CEO Brenda Lambert, RN, AACC, and Amy Hurley, RN, Director of Clinical Services at South Denver, about their experiences with e-prescribing and how it has affected their practice. The deadline to demonstrate successful e-prescribing under the Medicare E-Prescribing Incentive Program is June 30, 2011. Health care providers who cannot demonstrate successful e-prescribing by June 30 will have their 2012 Medicare payments penalized by 1 percent.

1.      What does e-prescribing mean to you? What are some of the benefits you’ve seen?

Lambert: We embraced e-prescribing as soon as we could with our electronic medical record (EMR) system. It’s been up for a year and was quite easy to do. So for us it was an easy implementation.

Some important things it’s meant to us: We always had a difficult time when patient called in for a prescription to make sure they had been seen in our office in the past year. We now know when their last visit was and if we can go ahead and e-prescribe or need to have them make an appointment.  If a patient or pharmacy contacts us we know if they’ve been seen all in the matter of less than a minute. We’ve increased efficiency and maximized patient care.

It has also help with legibility – I’ve personally experienced poor signatures or poor writing and the pharmacy would have to call back and double check what the prescription says. With e-prescribing it does improve patient safety as well.

We’d like to see a bidirectional piece added where we can see if the patient hasn’t picked up the prescription yet so we can do some follow-up, but that’s not in place at this time.

Hurley: It is also very convenient for the patient; if they’re in the office their prescriptions are ready for them at the pharmacy by the time they get there. Also, there’s a large database in our e-prescribing system that allows us to have access to all of the pharmacies in our area, so if the patient doesn’t know the information, we have it.

2.      Are there any downsides? What challenges have you had to overcome to implement e-prescribing?

Lambert:  More on our EMR side, there are times when meds aren’t used as much as others and you have to tweak dosages but it’s just a matter of identifying that and having it changed. Just like any system there are things that have to be improved.

We have had some problems for in-person pharmacy pick-up in terms of liability for payment. For example, if we e-prescribe to Walgreens and the patient decides between here and there they don’t want the medication, then that’s the end of it – they haven’t paid anything.

With mail in, once we click that button, the patient is liable for paying for the meds and can’t return it. Because of e-prescribing we’ve had multiple problems with patients saying they don’t want to take the medication anymore and wondering who will pay for what was delivered. We tell them they do.

3.      Are there any stories or reasons why e-prescribing has worked for you and your practice?

Lambert: There are many comments from patients saying how nice it is that they don’t have to wait at the pharmacy when they get there: once they arrive, the prescription is there and it’s correct. It’s been a huge patient-pleaser. It’s funny how you get used to it – I went to the doctor and he didn’t e-prescribe and I was surprised. I thought our physicians would resist, but it went as smooth as silk. Our physicians took to it immediately.  

Hurley: It’s a lot more efficient and more organized and cuts down on paper. We all know patients who lose a piece of paper no matter what it is – this is a slick, efficient way of doing things.

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Resources are available at cardiosource.org/HealthIT to help ACC members learn more about e-prescribing.  

Past ACC President Ralph Brindis, MACC, et al., was published in BMJ recently on the need for international collaboration in device clinical standards. Brindis and the other authors discuss differences in the stringency of the approval process between Europe and other parts of the world and stress that patients around the world should be protected by similar requirements for device safety. The authors discuss the recommendations of the Global Harmonization Task Force, which includes representatives of regulatory agencies in Europe, North American, Japan and Australia, to promote common principles for evaluating devices. The authors write:

"…it would be inappropriate for higher levels of evidence to be required in Europe and North American than in parts of Africa and Asia. There should be no ‘region of least resistance’ where devices could be approved more rapidly and on the basis of less evidence. Rather, efforts should be concentrated on developing a global approach. For each type of high risk device, this should include a specific determination of how safe is ‘safe enough’ relative to its therapeutic benefit."

Their recommendations make sense, although I think it might be difficult to implement in reality. Additionally, I would argue that the U.S. process is too burdensome, and we could stand to learn something from Europe. However, any loosening in pre-market requirements must be made up by post-market surveillance, which we do poorly now. We can use the ACC’s NCDR and other registries to uplevel post-market surveillance, accelerate speed of products to market, and improve the safety profile of such products. This is promoting innovation -- it’s heading offshore unless we get more proactive here.

A JAMA article using NCDR data came out this week that looked at whether the findings of the COURAGE trial are being implemented clinically. As you recall, COURAGE suggested that providing optimal medical therapy (OMT) to all patients should be attempted before performing PCI (angioplasty and stents) for patients with stable coronary artery disease (CAD), and that many recipients of angioplasty and stents would have benefitted just as well on OMT alone, and without the PCI procedures (of course, that also implies the patients are actually taking their meds, and we know 50% of the time, even when appropriately prescribed, they are NOT).

The study cohort was comprised of 467,211 patients, of whom 37.1% underwent PCI before and 293,795 (62.9%) underwent PCI after publication of the COURAGE trial. Before COURAGE, OMT was used in 44% of patients before PCI, and 65% of patients received it at discharge. There was only a slight change in use of OMT prior to PCI after the COURAGE trial (43.5% prior to COURAGE and 44.7% after COURAGE). The use of OMT after PCI increased from 63.5% to 66% in the time period following publication of the COURAGE trial. 

The authors concluded that OMT is markedly underutilized in patients with stable CAD. The findings show there is a need to improve how the results of comparative effectiveness research are distributed and become features of care, and how research is translated into practice. 

Thirty-four percent of all office-based prescribers were using e-prescribing by the end of 2010. Cardiologists had the highest adoption rates (49%) followed by family physicians (47%). Providers created 326 million e-prescriptions in 2010, up from 190 million in 2009. Wow!

If 49% of cardiologists ARE e-prescribing, that means that 51% still AREN’T e-prescribing. Since we’re just a month and a half away from providers being penalized for not e-prescribing, this is not good. If you aren’t e-prescribing by June 30, your Medicare professional fee reimbursements will be cut by 1% in 2012. This requirement applies to ALL health providers participating in Medicare who are eligible for billing numbers: physicians, nurse practitioners, physician assistants, etc.

There’s still time to get an e-prescribing system set up and complete the requisite number of e-prescriptions before the deadline. Check out http://www.cardiosource.org/healthIT for more resources on how to get started. Also, check out the other posts on this blog about e-prescribing. This deadline is real and quickly approaching. If you don’t want to take the 1% cut in pay, you’ll need to get started now.

The House Energy and Commerce Committee approved comprehensive medical liability reform legislation, the HEALTH Act (H.R. 5), on May 11 after a day-long markup during which the committee considered more than a dozen amendments. The vote was mainly along party lines with a few exceptions. Republicans Lee Terry (R-NE) and Morgan Griffith (R-VA) voted against the bill and Democrat Rep. Matheson (D-UT) voted for it. (Thanks Rep. Matheson!)

The ACC supports the HEALTH Act, which was introduced by Rep. Phil Gingrey (R-GA). One amendment was withdrawn, one was approved and the remainder defeated. The successful amendment, offered by Rep. John Dingell (D-MI), would make drugs and devices subject to punitive damages if they are misbranded or adulterated and it is the cause of the plaintiff's harm. The issue of states’ rights and potential preemption of state law was brought up repeatedly during the markup. In addition, many Democrats on the committee, including Reps. Eliot Engel (D-NY), Anthony Weiner (D-NY), Jay Inslee (D-WA), and Jan Schakowsky (D-IL), stated that physicians’ premiums are too high and something needs to be done, but they do not support caps as an answer; rather, reforms that address the insurance companies are a better solution. Inslee also suggested that evidence-based standards of care should provide protection to physicians.

The legislation, which was approved by the House Judiciary Committee earlier this year, will now go to the House floor for a vote.  It should pass, but is unlikely to go anywhere in the Senate, unfortunately. It’s still important to push for caps on non-economic damages anyway. The educational value may pay off later on.

Last week the House Energy and Commerce Committee had a landmark hearing to ostensibly evaluate alternatives to the Medicare SGR physician payment formula (or the SGRrrr expressed as a growl) in a hearing titled: “The Need to Move Beyond the SGR.”  The idea is to eradicate the SGRrrr.  Hello. It’s getting to be about time, now that the formula has accumulated over $300 billion in national debt, due to its flawed design by Congress and their inability to face the bad advice they got to stop the nonsense and dump it. This hearing is a follow up to the Committee’s March 28 letter to 51 medical organizations requesting feedback on long-term physician payment solutions. The half-dozen panelists’ suggestions for an SGR replacement varied slightly; however, all agreed that a full repeal and replacement with a new payment model is necessary for sustainability within health delivery. 

Despite some differences around the edges, the proposals from the AMA, the American Academy of Family Physicians (AAFP), the American College of Surgeons (ACS), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) lay out remarkably similar paths toward eliminating fee-for-service (FFS) reimbursement or drastically reducing its role. Don’t you think this is remarkable?

The AMA and other physician reps advocated for a 5-year period of stable payments while new payment models focusing on quality and efficiency are tested and evaluated. This makes sense. AAFP suggested an increased focus on patient-centered homes, as well as an increase in the primary care incentive payment included in the Affordable Care Act (ACA) to 20 percent.  The AMA is getting aggressive about payment reform, in part as a means to once again push Congress to fix the SGRrrr mess.  Costs are going through the roof for insurance and Medicaid and everything else.  Except -- believe it or not -- for Medicare -- which for the first time in many years is projected to inflate at ONLY 3-4% over the coming decade.  But, of course, by 2020, with the Boomers in full force in consuming Medicare costs, the Medicare costs are going to explode. 

The SGRrrr will cut payments to doctors in 2012 by 30%, effectively killing Medicare access for many patients. Of course, if the SGRrrr were to be eliminated at full cost, that would add $300 billion in Medicare costs to the debt dilemma.  I don’t think they have the guts to do it, but we should work at making it happen.

Congress can and will hold payments to doctors flat in fee-for-service Medicare until some kind of payment reform is implemented that changes the cost curve, which is one reason that Medicare costs are lower than previously. But none of this is sustainable.  Most doctors will just throw in the towel. Even AMA, despite pressure to protect the status quo, is realizing that new payment models are needed, and fortunately they are working with us and others to figure out how to get out of the mess we’re in.

By David May, MD, PhD, FACC, senior physician and founder of Cardiovascular Specialists, PA, in Coppell, Texas, president of the Texas Chapter of the ACC and a member of the Board of Governors’ Steering Committee.

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Like a Sergio Leone western, e-prescribing (e-Rx) has been viewed by many as a dark and foreboding landscape in which physicians must have a broad, sweeping view of the electronic health care vista alternating with intimate, close-up reflections on each patient encounter. In reality, e-Rx accomplishes neither of these things perfectly. It is, however, here to stay.

The concept of e-Rx is quite simple.  The ability to submit an accurate, understandable, legible prescription without typographical mistakes from the point of care to the pharmacy is a vitally important part of any safe health care system.  Because of how important it is, the development and facilitation of the e-Rx process is one of the key elements in the overall plan for the further advancement of the electronic health infrastructure for the U.S.

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 provides the guidelines for the incentive program we now define as the e-Prescribing Incentive Program. It was implemented in 2009 as a stand-alone program in addition to the Physician Quality Reporting System (PQRS). Providers who wished to participate in the e-Rx program could but did not have to participate in the PQRS incentive program.

Two years post-implementation, where does the program stand? Let’s review the good, the bad and the ugly.

The Good
The electronic submission of a prescription from the point of care to the pharmacy reduces errors by providing accurate, dose-correct prescriptions without illegible handwriting in a timely fashion. It benefits providers and pharmacies by allowing 24-hour submission and its asynchronous communication eliminates the “phone tag” delay associated with telephone submission and the twisted, often illegible faxed-in prescription. For patients, medicines are available in a timely and expeditious fashion with accurate tracking available. In my private practice, we’ve seen fewer mistakes in prescriptions, faster turnaround time in the pharmacy, and incentive payments in 2009 and 2010 of 2% of our Medicare Part B professional reimbursement through the e-Prescribing Program.

The Bad
The implementation of e-Rx submission requires providers to alter their normal work flow and develop additional skills. In addition, the enhancing and maintaining staff training is mandatory. For example, in my practice, the nurses are responsible for making sure the prescriptions make it to the right pharmacy for the patient. We had to devote a lot of resources to training to make sure this happens for every prescription. With a little creativity though, we were able to make this a more enjoyable experience by implementing the training as a game.

In addition, e-Rx requires great attention to detail, in that if your Internet access is not reliable, electronic submission can be problematic. Due diligence is necessary to be certain that submission has “gone through” successfully, and this is a departure from handing a patient a prescription and being done with it.

The Ugly
Like the PQRS incentive program, e-Rx incentive “carrot” is rapidly changing to an incentive “stick.” The 2012 payment adjustment reporting period is Jan. 1 to June 30, 2011. Practices that have not submitted 10 e-Rx submissions per provider by June 30, 2011, will be penalized 1% of their Medicare professional fee reimbursement for 2012. In addition, registry submission of the e-Rx information is not allowed for this time frame. The e-Rx information must be submitted by claim with the appropriate G code and evaluation and management code.

The E-Prescribing Program may not be perfect, but unlike a Sergio Leone western, it’s a reality. In order to avoid a one percent (1%) decrease in the covered professional Medicare reimbursement for 2012, you must be e-prescribing before June 30 of this year. See www.cardiosource.org/HealthIT for more resources to get started.

EP blogger John Mandrola, MD, FACC, (aka Dr. John M) wrote recently about a study looking at outcomes for atrial fibrillation patients who received the majority of care from a nurse rather than a cardiologist. The study looked at whether patients who were counseled by a nurse on their first visit, and nurse and a cardiologist on their second visit, and all remaining visits by the nurse have different outcomes than those who receive usual care. The nurses put together treatment plans guided by software programs intended to increase adherence to practice guidelines. The hypothesis of the study was that the larger amount of patient education done by the nurses would improve outcomes.

This is exactly what the researchers found. Of the 712 patients participating in the study, the abstract of which was presented at ACC.11, significantly fewer patients in the nurse-counseling group experienced heart-related deaths (1.1% vs. 3.9%) and there were fewer heart-related hospitalizations (13.5% vs. 19.1%) for those patients.

Mandrola says the study “offers an optimistic view of health care delivery reform” and I couldn’t agree more. Patient education is a huge component of successful care for cardiovascular patients, and it is very difficult to adequately complete in the short time that you have during an office visit. (As Mandrola notes: “…thoroughly explaining AF takes nearly the same time it takes me to isolate the pulmonary veins – a lot longer than the 10 minutes allotted for a typical office visit.”)

Innovative care models are necessary to improve the quality of care we offer patients. Since we’re unlikely to get more time for an office visit anytime soon, this means exploring how we can effectively provide care through other members of the cardiovascular team or by using educational software that is customizable for each patient’s unique health situation. Additionally, the impending cardiology workforce shortage will place additional demands on a workforce already stretched thin, and we’ll need to rely on other health care providers to fill the gap.

What do you think of this study? Do you think increased counseling by cardiovascular care associates can help improve care?