The ACC partnered with hospitals (AHA), insurers (AHIP), AARP, AMA and others on a study on the impacts of the various proposals out there to cap Medicare premiums and/or propose across-the-board Medicare and Medicaid spending cuts. These proposals do not fairly estimate the downstream impacts that will occur to everyday citizens and to health care. We selected the Lewin Group (I can obviously get a family discount there). The study was released to members of Congress and the public. It’s a necessary part of this necessary discussion on how to reduce the national deficit. But let’s do it with eyes wide open and with an objective understanding of the impacts of various proposals -- and new ones pop up every day.

A call for across-the-board spending cuts is imminent. We asked the The Lewin Group to specifically examine the Commitment to American Prosperity (CAP) Act -- since it passed the House -- even though we recognize that deficit reduction is a process, and that the CAP Act is unlikely to be the final piece of legislation brought to a vote. We think similar consequences would result from any across-the-board measure that limits spending. Recognizing and supporting the need for deficit reduction for the nation’s well being, the report calls for payment reform and other approaches. We think this is the right approach.

President Obama and VP Joe Biden and Senate Minority Leader Mitch McConnell (R-Ky.) are now trying to wrestle out a plan before the debt ceiling default hits in another month. If there are no additional revenues proposed, the Lewin Group projected that the CAP act or similar across the board cuts would produce:

• Cuts by nearly 20 percent over ten years to Social Security benefits;
• Cuts to Social Security and other income support programs that would force 3.8 million people into poverty -- 2.1 million of them seniors, a 45% increase;
• Lost health insurance for 5.1 million individuals;
• Cuts to hospitals that could force most to operate in the red, jeopardizing access to care;
• Dramatic reductions in fees for physicians that would lead to fewer physicians participating in Medicare;
• Lost jobs for up to 1.3 million health care workers; and
• A nearly 5% increase in health insurance premiums due to cost-shifting of federal payment shortfalls to private employers.

The message to Congress should not be to avoid making cuts to balance the budget and eliminate the deficit over the next decade or so. That needs to happen. But, without additional revenues, the consequences to medicine, patients, and health care will much more grim than anyone’s talking about.

More coverage: "Doc Groups Get Figures on Feds' Spending Cut Plans," MedPage Today

The ACC and the Society of Thoracic Surgeons (STS) earlier today released a societal overview of transcatheter valve therapy (TVT). The overview highlights the issues that will be faced as cardiology and surgical societies try to guide the process of rational dispersion of this very new and important technology. Transcatheter aortic valve replacement (TAVR), one form of TVT, has been documented by the PARTNER trial to improve outcomes in patients with severe aortic stenosis who are inoperable. It has been found to significantly reduce mortality and composite endpoints at one year compared to medical therapy for specific patient populations, including balloon aortic valvuloplasty.

The overview makes several key points:

1. Use of team-based care will be critical to TVT success. The therapy cannot revolve around just surgery and cardiology, but must involve interventionalists, echocardiographers, hospitalists and others who deal with structural heart disease and heart failure.
2. Providers performing TVT must be very skilled and well-educated in the field. The devices can substantially improve outcomes, but there are potential side effects that may be very significant and clinically important.
3. Randomized trials have included only patients with severe aortic stenosis who are at very high risk for conventional aortic valve replacement, or patients who are not surgical candidates because of a variety of comorbidities.  Accordingly, we do not have randomized trials on other patient groups. For this reason, patient selection is critically important.
4. Efforts need to be focused on evaluation of data on the outcomes of patients both in the hospital and for longer-term follow up. Understanding outcomes will be important in identifying areas that need to be modified or improved. The use of registries will be exceedingly important to complete this task.

The document provides a 20,000-foot view of TVT, and is the first of a series of documents that will address the topic in a more detailed fashion. More specific documents on pre- and post-procedural issues and training and credentialing will be developed jointly by the ACCF, cardiovascular specialty societies, and thoracic surgery societies and released in the future. It’s also important to note that many key milestones for the technology must be met – including FDA approval. TAVR is scheduled to be considered by an FDA panel on July 20, with the agency to make a decision following the results of that hearing.

TVT technology has the potential to be transformational for the field of cardiology and thoracic surgery. However, this transformation will not happen overnight. It’s going to be a long road with many hurdles.

Additional Resources:

• 10 Points to Remember on the ACC, STS Position Statement on TVT
  
• PARTNER Cohort A: TAVI vs. Surgical AVR
• PARTNER Cohort B: Transfemoral TAVI vs. Medical Management

UPDATED: 6/28/11

Last week, the Medicare Payment Advisory Commission (MedPAC) released its June report. Not good, folks.

The report includes four recommendations related to the provision of imaging services in Medicare.  Most troubling is the last recommendation, which encourages the creation of a prior authorization program for practitioners who order substantially more advanced diagnostic imaging services than their peers. The ACC strongly opposes prior authorization because requiring prior authorization would increase the administrative burden on Medicare, increase physician practice costs and could interfere with the physician-patient relationship, potentially delaying timely access to life-saving procedures. The ACC continues to believe that the adoption of decision-support tools based on appropriate use criteria is a better option than prior authorization.

 

MedPAC recommendations are non-binding but, in a Congress that is very concerned with spending cuts, these recommendations could easily be picked up for potential enactment.  In addition, these recommendations could also be picked up by CMS without further Congressional action. CardioSource has more  on the report’s other recommendations.

I was privileged to participate in and represent the ACC at the UN Summit on Non-Communicable Diseases last Thursday at their headquarters in New York City. The UN and the WHO have understandably focused most of their substantial global health efforts, along with the large private philanthropies, on communicable diseases -- mainly on HIV, tuberculosis, malaria, and nutritional deficiencies and disease related to abject poverty and hunger.

These causes are still important. But, we are really just learning how many people globally with communicable diseases also suffer from preventable and treatable non-communicable diseases -- cardiovascular disease, cancer and other chronic diseases. The summit brought some disturbing facts to life: 

• The world for the 1st time has more overweight than underweight people, and more deaths of adults annually than of children.
  
  
• There are now more urban than rural people in the world -- and this contributes to changes in diet, exercise, and lifestyle that have caused non-communicable diseases to increase alarmingly.
  
  
• There are 36 million preventable non-communicable disease deaths globally, with the biggest rise in Africa -- non-communicable disease mortality has become far more common than communicable disease, with rapid growth rates. Tobacco use causes 1/3 of all global cancer.
  
  
• Although oncology, neurology, pulmonary and endocrinology are all important globally, cardiovascular disease is the biggest threat -- tobacco, diet, increased diabetes all contribute. CV disease kills more people globally than any other cause.

Speakers at the event pointed out that there are lessons to be applied from global efforts to eradicate communicable diseases to how to similarly impact non-communicable diseases. After the summit, I met with World Heart Federation CEO Johanna Ralston and many other international leaders to discuss how we can leverage ACC’s expertise and the 5,000 international FACCs around the world -- who represent the most prominent cardiologists in more than 100 countries -- to be able to collaborate globally on reducing mortality related to non-communicable diseases, including how we measure progress and ROI on future investments. The main UN session on this topic will occur in New York in September. The ACC will be there in force. The world needs far more resources to address this growing crisis.

Another cardiologist, this time in Tennessee, is being accused of unnecessary stenting, theheart.org reported last week. The Department of Justice is investigating accusations brought by a Jackson, Tennessee cardiologist against another Jackson cardiologist, Jackson-Madison County General Hospital, Regional Hospital of Jackson and a Jackson radiologist. The allegations state that the cardiologist overused cardiac services, including cardiac sonography, scintigraphic stress imaging, angiography, angioplasty and stenting, to defraud Medicare. The two hospitals and the radiologist condoned or assisted the cardiologist’s inappropriate use, according to the allegations.

This is one of a series of reports about abuse of cardiac services across the country. Hospitals and physicians in both Maryland and Pennsylvania have come under fire under similar claims. The abuse of services brings a bad name upon cardiology, sullying the reputation of the whole profession.

We need to prevent these abuses from happening. One way in which the ACC is doing so is by supporting the Society for Angiography and Interventions’ (SCAI) Accreditation for Cardiovascular Excellence (ACE). ACE offers formal, objective, and independent evaluation and monitoring of cardiac and endovascular interventional facilities to ensure that they meet the highest possible standards for patient care and safety. The purpose of this program is to ensure the removal of any perceived or real conflicts of interest in oversight of hospital and physician quality performance. ACE accreditation criteria also calls for use of registries like the National Cardiovascular Data Registry (NCDR) and adherence to appropriate use criteria (AUC) -- both of which are already widely accepted and respected by professional and regulatory communities nationwide. Last month, ACE accredited its first hospital – Bon Secours St. Francis Health System in South Carolina – for cardiac catheterization and angioplasty/stenting. Review of other hospitals’ lab programs is underway.

However, ACE alone would not have prevented the abuses alleged in Tennessee. Additional quality tools – such as appropriate use criteria, practice guidelines and other clinical documents – are needed. These quality tools can provide states, payers and purchasers of care with critical, transparent metrics with which to evaluate quality of care, especially necessary as the health care community shifts from a fee-for-service reimbursement model to one more focused on outcomes-based care and commensurate reimbursement.

The ACC has the knowledge base and expertise as a cardiovascular leader to advise and implement quality programs and tools, and has many underway. Addressing service overuse proactively will allow the field of cardiology to remain ahead of the curve and avoid future allegations. Working together we can ensure our patients receive high quality and effective cardiovascular care delivery driven by physician oversight and leadership.

The New York Times on Sunday featured a piece on “judge-directed negotiation” as a possible solution to current medical liability problems. The approach involves assigning a judge with medical knowledge to hold a settlement conference early in the lawsuit process to more actively push for settlements. A nurse with legal training assists the judge in the settlement conference. The approach has been used in the Bronx, and thanks to a $3 million federal grant, will be replicated to Brooklyn and Manhattan, and eventually Buffalo. As I’ve written previously, the Affordable Care Act (ACA) offers funding for pilot programs to test ways of reforming the medical malpractice system.

Judge-directed negotiation works because it “bypasses years of court battles, limiting legal costs while providing injured patients with compensation that is likely to be less than a jury would award but can be paid out years earlier, without lengthy appeals,” according to the Times. New York City public hospitals report that the switch to judge-directed negotiation, along with some other changes, has saved $66 million in malpractice costs per year. AHRQ estimates that implementing the system nationally could save more than $1 billion annually.

In Mississippi where I practice, we implemented tort reform in 2004, to which Governor Haley Barbour (R) attributes much of the economic development we’ve seen over the last seven years. Some of the reforms included:

• Changing rules of venue to prevent abusive court-shopping
• Removing "joint and several liability" rules
• Protecting sellers of products as long as they believe the product is being used as approved
• Putting caps on punitive damages
• Putting caps on non-economic damages
• Requiring the plaintiff's attorney to show that one qualified expert finds a reasonable basis for the case, or has attempted to contact three experts for a consultation (whether or not they agree to do the consult)

Agree with Barbour’s positive economic assessment or not, the laws have created definite “wins” for our state’s physicians and health care system. The number of malpractice claims dropped 91 percent between 2004 and 2009, while the largest liability insurer dropped its premiums 42 percent between those years. We need to see those kinds of results nationwide.

However, passing reforms like the ones in Mississippi would be challenging, if not impossible, in a lot of other states. Although it’s unclear if judge-directed negotiation can have quite the same results as the reforms in Mississippi, it may be easier to implement nationwide and, thus, be able to provide more relief. We’ll have to see how the scale-up of the program goes.

It’s truly schizophrenia in Washington these days when it comes to health reform -- the best way to describe how we as a nation are reacting to the Affordable Care Act (ACA) is insanity.  Half the nation is diligently preparing to implement the imperfect law -- which has a lot of necessary elements of what the nation needs to reset the health care button. But the other half is politically opposed, and hopes it just goes away or gets legally squelched by the Supreme Court.

The ACA’s considerable strengths are its needed insurance reforms; its expanded promise of access for 35 million Americans (if Medicaid reimbursement is fixed); its expansion of prevention services without cost barriers; its more logical financing of the stunning costs of very high-risk persons; its closing of the seniors’ pharmaceutical coverage ‘donut hole;’ its promotion of comparative effectiveness research and primary care and workforce research; and its aspirations to improve quality and lower overall costs. These are big and needed improvements to the status quo. And if the Congressional Budget Office is right, the law if implemented will now save as much as $500 billion over ten years, because the costs per beneficiary have increased only 4% this year, and are expected to stay at that rate for 10 years.

But, the law’s weaknesses are numerous too: it evidences mainly aspirational thinking about how to improve quality and lower costs. For example, ACOs are worthy ideas to experiment with, but will they work? They are hugely untested. This week alone both Mayo and Geisinger announced they will not seek to become ACOs as the regulations are currently drafted. And the ACA’s wish to control costs with the Independent Payment Advisory Board (IPAB) as currently designed is not likely to do much -- price controls have never worked in health care. And ACA's noble goal to increase the attractiveness of primary care is great -- but accomplishing that is a major challenge.

All of these and other noble goals are “wishes,” not implementable achievements. We do have to do all of these things. It is still to be determined how we will do these things -- which is why ACC’s role in reform is so important. I believe amending our way through the law’s flaws make the more sense than repeal -- and I think many Republicans privately agree, although Washington rancor prevents us from moving toward consensus on anything -- or in being honest about our views.

In what might be the mother of the dozens of challenges to the ACA, representing two dozen states, a panel of appellate judges this week held a hearing on the alleged central issue here: can the federal government require Americans to buy medical insurance? The individual insurance mandate in the ACA is the key issue being attacked. The three judges (selected at random from among 10 members of the United States Court of Appeals for the 11th Circuit) had radically different opinions about it. At the end of their hearing, Chief Judge Joel Dubina termed the litigation "a very difficult case," offering few clues as to how the court might rule. In the past two months similar hearings in appellate courts in Cincinnati, Richmond, VA., and now Atlanta have evidenced widely disparate views. It’s schizophrenia, and along judicial partisan lines it appears -- which is where ultimately the Supreme Court is likely to come down.

At issue this week was the decision of Judge Vinson of Florida Federal District Court, who as you recall invalidated the “individual mandate” insurance requirement, and then ruled that the mandate was so central to the law’s functioning that the whole law needed to be invalidated. Vinson’s argument was that the Commerce Clause of the Constitution gave the government broad authority to regulate interstate commerce, but not so broad as to penalize people for the "inactivity" -- that is, for declining to buy a commercial product (ACA doesn’t force you buy insurance, but taxes you if you don’t).  The ACA supporting lawyers say all Americans are of necessity in the health care market -- everyone needs healthcare, and urged the judges to see the law not as a mandate to buy an insurance policy, but as a requirement to pay their fair share of payment for care that individuals would inevitably require -- in other words it is like regulating whether people are paying cash or credit. So, who can guess what will happen to this when it gets to the Supreme Court next year?

Talk about managing through uncertainty!

This post is written by Denise Milestone, RN, of Parkview Health in Fort Wayne, Ind.

*****

In the last two years that e-prescribing has been used in my health system, Parkview Health in Fort Wayne, Ind., we’ve seen some major benefits, as well as overcome some challenges. The implementation process at Parkview was fairly straightforward. We started with a small group of physicians and nurses who were required to e-prescribe, and then we slowly added more practitioners to this group. We put out statistics on who was e-prescribing and how much and shared that with staff, so that physicians and nurses could see how they were doing compared to their peers. This did a lot to encourage adoption. Our staff seemed to pick it up most easily if they were younger and more computer savvy, but it was pretty simple for everyone to adopt. I would say it took about a month or two for everyone to get the hang of it.

I see the top three benefits of e-prescribing at Parkview as the following:

#3: E-prescribing cuts down on Parkview’s faxes and phone calls, both for the original prescription and for e-refills. We save on a lot of paper.

#2: Younger patients love it. It’s very convenient for them and they like not having to keep track of the prescription paper. But, it does seem like older patients miss having paper prescriptions and aren’t as comfortable with the idea of e-prescribing. We really have to educate not only the physicians and Parkview staff, but also the patients on the benefits of e-prescribing.

#1: Patient safety has improved. Not only is legibility addressed, but pharmacies are able to see in the system what drugs a patient is being prescribed and can make sure there aren’t any adverse events.

This is not to say e-prescribing is without challenges. In particular, we’ve had trouble adjusting prescriptions that start at one dose (like prescribing a patient a 20mg tablet twice/day) but then after a set period of time increase (like to a 40mg tablet once/day). Previously we have noted this clearly in the prescription area. Now, we have to add a comment in the notes section with instructions for the pharmacist, which occasionally causes confusion.

Also, because not all pharmacies are able to accept e-prescribing, there still some manual work that has to happen. Fortunately, our e-prescribing system knows which pharmacies cannot accept e-prescribing and will then revert to the old-fashioned way of faxing the prescription. This has definitely improved over the two years we’ve been e-prescribing -- more pharmacies than ever accept e-prescribing -- but there are still some that do not. It gets easier each year to e-prescribe.

Overall, the e-prescribing process was very easy to implement and its benefits have outweighed the minimal downsides we’ve experienced. We’re extremely happy e-prescribing, and so are our patients.

Has anyone else experienced the challenge with noting the dosages? How have you addressed?

The term “social media” has attracted considerable interest.  Opinions about the concept vary widely, a result of many factors including a) the purpose by which it is aimed, b) the age, background, and audience of the person either sending or receiving the information contained, and c) the specific format being used.

Social media has great potential in the medical profession as a means to enhance collaboration between physicians and enhance communication between health care providers and patients.  However, there is also a potential downside: specifically, the consequences relating to unprofessional behavior.

Examples of unprofessional behavior were identified in a survey of physicians’ of Twitter (JAMA). This study found that while only 3% of tweets were unprofessional, they could have important consequences because they could potentially violate patient privacy, be sexually explicit or discriminatory, or contain objectionable profanity or possible conflicts of interest.  Well-documented, albeit very isolated, examples of physicians and other health care providers losing their hospital privileges after posting patient-specific data on Facebook also highlight potential consequences of misuse of social media.

The events prompted the American Medical Association (AMA) to publish a policy this year on “Professionalism in the Use of Social Media,” which outlines how physicians can engage in social media in a way that supports “personal expression, … foster[s] collegiality and camaraderie within the profession,” and “provide[s] opportunity to widely disseminate public health messages and other communication.” The policy offers the following six tips:

• Never post identifiable patient information online.
• Set high privacy settings for your social media profiles.  It’s important to routinely monitor your online presence, including “Google-ing” yourself, and viewing your Facebook profile from the view of someone who is a friend and someone who is not. Do not tweet anything you’re not comfortable with the whole world seeing, even if your account is private.
• Maintain appropriate professional boundaries with patients answering specific questions but avoiding extraneous exchanges of information. 
• Separate personal and professional content online.
• Let someone know if you feel one of their postings on a social media site is unprofessional for a health care professional.
• Recognize that what you post online can affect not only your reputation, but the reputation of your institution and the medical profession.  This is particularly the case if you identify yourself as a physician or medical professional on a social media site.

The bottom line is this: physicians have a plethora of special concerns that they need to take into consideration in exploring the use of social media.  But, with a little bit of caution and a lot of common sense, social media is a worthwhile endeavor. As I wrote in my last JACC President’s Page: social media and the Internet “will offer unparalleled opportunities to reach the global world of cardiovascular specialists, patients, and society as a whole. It will provide opportunities for people to define and optimize their own individual approaches to learning, their own learning portfolios—the definition of personalized learning.”  It will offer patients access to information relevant to their own personal needs.

By picking and choosing how you engage and who you engage with, social media can do whatever you want it to. For example, if you want to use it to learn more about a topic, you can use Twitter to follow others who tweet on the topic, basically using Twitter as a news aggregator. If you want another way to educate your patients on cardiovascular issues, you can start a blog that discusses topics that came up during your work week (without discussing patient specifics, of course). Or, if you’re interested in networking with other health care professionals online, you could join the ACC LinkedIn group or Facebook fan page -- or any other cardiovascular-focused group, of which there are many -- to do so. Social media truly is a source of endless possibilities. You are limited only by your creativity and time.  There’s a great report from Ellerin Health Media (.pdf) that shows examples of approaches that physicians have taken on social media structure to optimize its value. 

Here are some useful links if you’re interested in learning more:

• "Professionalism in the Use of Social Media" (AMA Policy)
• "For doctors, social media a tricky case" (Boston Globe)
• "Professionalism in the digital age" (Annals of Internal Medicine)
• "Online Posting of Unprofessional Content by Medical Students" (JAMA)
• "When Facebook goes to the hospital, patients may suffer" (LA Times)
• "Nurses Fired Over Cell Phone Photos Of Patient" (WISN-TV)
• "Physicians on Twitter" (JAMA)
• "The Social Physician" (.pdf) (Report by Ellerin Health Media)
• "President's Page: Clouds, Science, and Education" (JACC)

Do you use social media? What sites are you on and how are they useful to you?

 

The New York Times last week featured commentary by senior CMS advisor Peter Bach, MD, and former special assistant to President Obama on health care and economic policy Bob Kocher, MD, on why medical education should be free. Bach and Kocher argue that argue that by making medical school free, medical students will be more likely to go into primary care (I’m not so sure about that, gents). This is important because “fixing our health care system will be impossible without a larger pool of competent primary care doctors who can make sure specialists work together in the treatment of their patients … and keep track of patients as they move among settings like private residences, hospitals and nursing homes.”

Bach and Kocher propose making medical school tuition free, continuing stipends during primary care training, but eliminating specialty training stipends to cover the tuition costs (so, specialty training would actually have a tuition attached to it -- and could be quite expensive). They write: “Because there are nearly as many doctors enrolled in specialty training in the United States (about 66,000) as there are students in United States medical schools (about 67,000), the forgone stipends would cover all the tuition costs.” This works, they write, because specialists go on to “highly lucrative” careers following the training.

The idea is worth exploring -- but, it might be just as effective to offer multi-year loan forgiveness for those who actually go into primary care practice, along with higher primary care payment. It would be cheaper and just as effective. The other issue is working to make primary care more exciting again. That said, free medical education is fairly common in other industrialized countries, and these countries are not generally experiencing the same dearth in PCPs as the U.S.

What do you think of Bach and Kocher's idea?