By Thom Rooke, MD, FACC, Krehbiel Professor of Vascular Medicine at the Mayo Clinic and Alan T. Hirsch, MD, FACC, Professor of Medicine, Epidemiology and Community Health, at the University of Minnesota Medical School. Rooke is the chair of the PAD Guidelines Writing Committee. Hirsch is its vice chair.

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The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) today released updated guidelines for the diagnosis and management of peripheral artery disease (PAD), as part of PAD Awareness Month. The updated document provides agreed-upon approaches and treatments for PAD that clinicians can apply to help improve patient care.

PAD is a major American health problem. It affects one out of every 20 Americans over the age of 50, making it one of the most common cardiovascular diseases. In addition, its effects can be devastating: heart attack, stroke, leg amputations and death all can result from PAD. Despite this, scientific advances have made it possible to inexpensively and accurately diagnosis the disease, as well as effectively treat it.

However, reducing its prevalence will require more active detection. The focused update details the specific population who would benefit from an active approach to PAD diagnosis through ankle-brachial index (ABI) diagnostic testing. Specifically, the document recommends that ABI diagnostic testing is performed beginning at age 65, rather than age 70. This decision was based on mounting evidence demonstrating that people 65 and older have a one in five chance of having either symptomatic or asymptomatic PAD. 

Other recommendations set forth in the guidelines include:

• Strengthening efforts to help individuals with PAD quit smoking and, in turn, lower rates of heart attack, stroke and lower limb amputations. This includes consistently asking current and former smokers about tobacco use at each visit, as well as proactively offering support through counseling, pharmacologic therapies and/or formal smoking cessation programs
• Considering leg artery angioplasty as a first line treatment for certain individuals with severe PAD who may face amputation. Because angioplasty does not provide an ideal treatment for all patients with PAD, in particular for those in whom a lifespan greater than two years is anticipated, traditional vascular surgery may be more durable and most effective
• Understanding new data showing that aortic aneurysms can be safely treated by both traditional open surgical and less invasive endovascular treatments with nearly equal efficacy and safety

The guidelines provide a road map to greater prevention opportunities, which will be necessary if we are to reduce the number of people needlessly affected by PAD. Full text of the new guidelines -- which update the original 2005 recommendations and are collaboration with representatives from the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine and Society for Vascular Surgery -- are online, as is a summary on CardioSource.

KevinMD had a great guest post recently by Mary Pat Whaley on the time associated with a patient visit. I think the title sums up the blog well: “Your 10-Minute Office Visit Needs 8 People and 45 Minutes of Work.”

As Whaley notes, even the shortest of office visits have a lot of work behind-the-scenes that needs to be done; seeing the patient is just a small part of the overall visit.  And, I would submit that far more than 8 people and much more than 45 minutes is required.   Health care is a regulation- and administration-heavy field, and this requires time to make sure the regulatory and administrative rules are followed. For example, HIPAA requires privacy forms to be filled out prior to the patient being seen. Verifying someone’s insurance information is time-intensive. Not to mention ensuring that we charge the patient the right co-pay based on their insurer and insurance plan. On top of that, pay-for-performance programs require time- and technology-intensive data collection during and after the visit. All of this, and more, makes up one “10-minute office visit.”

Whaley concludes: “The practice, the patients and the overseers of health care want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.”

I have to agree with her. The complexity of the American health care system is incredible. And, the layers of complexity account for much of the cost. Our system has been built by accretion.  We “reform” the system by adding on layers of regulation, of bureaucracy, of administration.  As you look behind the eight people figured in this visit, the cost if not the time includes coders, compliance workers, claims specialists, re-claim specialists, computer network and now electronic health record experts,  lawyers, front office personnel, and even standard maintenance personnel for the  building.

As the regulation and administrative burdens add on, the cost of practicing gets greater and it is harder to cover these expenses with income.  Add to that more and more cuts to cardiology, and it’s no wonder that a large number of private cardiology practices are integrating with hospitals. Last year, the ACC reported the results of a survey of ACC members that found nearly 40 percent of private group practices were currently integrating with hospitals or merging with other practices. An additional 13 percent of all cardiovascular practices were considering hospital integration or a merger in the next three years to help stem the financial burden.

These are uncertain times for cardiology and for the House of Medicine in general.  To be clear, the ACC supports the triple aim of better health, better health care, and at less cost. But to get there, we will have to deal with the repercussions of massive changes, and may I say probably the accretion of more layers, to our health care system. In my opinion, “dealing” with the repercussions will not be enough – we need to shape the discussions if we want to be pleased with the health care system structure of the future.  And, maybe we can even help peal away some of the layers.

This post is written by President-Elect William Zoghbi, MD, FACC.   

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Yesterday and today, I am in New York City representing the ACC at the landmark United Nations (UN) Summit on Non-Communicable Diseases (NCDs).  ACC CEO Jack Lewin, MD, is accompanying me in advocating for the inclusion of cardiovascular disease (CVD) in the UN’s eight Millennium Development Goals, an imperative step to combating NCDs in the developing world. Driving leaders around the world to address this issue are the astonishing statistics surrounding NCDs: 82% of the 17.1 million deaths caused by CVD occur in the world’s poorest countries -- that’s 14 million deaths per year. Despite this, only 3 percent of global funding is allocated towards NCDs.  

The General Assembly kicked off the meeting by unanimously approving without a vote a political declaration that creates a plan of action for combatting NCDs. Although the declaration does not contain specific targets for reductions in morbidity and mortality, it does contain an agreement to develop a comprehensive global monitoring framework for NCDs in 2012, as well as a set of voluntary global targets and indicators. Other commitments included in the declaration are to:

• Accelerate the implementation of the Framework Convention on Tobacco Control
• Eliminate industrially-produced trans-fats in foods, and implement interventions to reduce consumption of salt, sugars and saturated fats
• Curb harmful use of alcohol
• Restrict the marketing to children of foods high in fats, sugar and salt.

The Declaration calls for increased resources for NCDs through domestic, bilateral and multilateral channels and it recognizes that resources devoted to dealing with NCDs are not commensurate with the magnitude of the problem. However, it falls short of any concrete commitment.

While imperfect, the declaration has galvanized the focus on this pandemic and is critical a first step to improving the health conditions of people worldwide.

Preventing Risk Factors Globally

Released simultaneously with the UN Summit, a Lancet paper, co-authored by ACC President, David Holmes, MD, FACC, focuses on key preventable risk factors for fighting NCDs in developing nations. Specifically, the article stresses the importance of investing in the following, calling them “best buys:”

• Tobacco control/elimination
• Sodium reduction
• Promoting healthy diet and exercise (low fat, sugar and alcohol intake, increased physical activity)
• Generic multidrug treatment for patients with high risk of NCDs

While significant attention has been paid to the above areas in developed nations, little education exists on these issues in the developing world. Worldwide, over 1.3 billion people smoke, 600 million have hypertension, and 220 million battle diabetes. These risk factors contribute to the estimated $500 billion per year NCDs cost in low-income and middle-income countries. Community programs -- such as Let’s Move, which was mentioned by U.S. Surgeon General Regina Benjamin, MD, during a lunch session as a program that could enable people to adopt healthier lifestyles -- are reported to have a 5-year return on investment of $5.60 for every dollar spent.

The Holmes, et al., paper is very clear on the need for worldwide unity and collaboration among leaders from the UN, World Health Organization (WHO), global and local governments, foundations, non-government organizations, and pharmaceutical companies, among others.

As a member of the Partner’s Group of the NCD Alliance, the ACC is epitomizing this collaboration by working with organizations such as the World Heart Federation and the Global Health Council to maximize international efforts to reduce the impact of NCDs. Given the success of NCDR in the U.S., Middle East and Asia, there is potential for developing nations to engage these tools to track their progress on CV care, ultimately improving their patients' outcomes.

Stay tuned for developments in the coming days as we continue to participate in the UN NCD Summit. Follow @ACCinTouch on Twitter for live updates and visit the American College of Cardiology Facebook page for photos and conversation revolving around the Summit. 

The Department of Health and Human Services (HHS) yesterday launched the exciting new Million Hearts initiative aimed at preventing 1 million heart attacks and strokes over the next five years.

The public/private program, which will build on work already underway as a result of the Affordable Care Act, is focused on empowering Americans to make healthy choices such as preventing tobacco use and reducing sodium and trans fat consumption, as well as improving care for people who do need treatment by encouraging a targeted focus on aspirin, blood pressure control, cholesterol management and smoking cessation. It will be led by Thomas Frieden, MD, director of the Centers for Disease Control and Prevention, and Donald Berwick, MD, administrator for the Centers for Medicare and Medicaid Services, along with ACC’s Janet Wright, MD, FACC, who is leaving her post as ACC's SVP for Science and Quality to serve as director of the program.

“Heart disease causes one of every three American deaths and constitutes 17 percent of overall national health spending,” said HHS Secretary Kathleen Sebelius. “By enlisting partners from across the health sector, Million Hearts will create a national focus on combating heart disease.”

I, along with President-Elect William Zoghbi, MD, FACC, Vice President John Gordon Harold, MD, MACC, and Board of Trustees member William Oetgen, MD, FACC, attended the announcement to underscore our long-time commitment to the very issues being addressed by this program. The College is excited about the opportunity to support this effort through our CardioSmart national care initiative, as well as through our continued efforts to encourage the adoption and use of point-of-care tools and data registries. These tools and resources will be critical to helping providers not only provide the most appropriate care, but track patient outcomes.

ACC’s 2011 Legislative Conference had some great afternoon speakers on Monday, including health economist Len Nichols, PhD, and Nancy Nielson, MD, senior advisor to the Centers for Medicare and Medicaid Innovation (CMMI). Both Nichols and Nielson spoke about the need for cardiovascular professionals to get involved in payment innovation. We have the knowledge on how to make it work, they said. If we don’t get involved, someone else less knowledgeable will do it for us.

Nichols talked about the winding road that is payment reform, noting that the current unaccountable fee-for-service and third-party payment system has brought us to a place where the value of care per dollar is less than it could be, prices are above minimal costs and quality is not optimal for every patient. Failure to address these issues in a way that works for patients and providers will very likely result in across-the-board cost controls and/or utilization reviews or benefit cuts, he said.

According to Nichols, new payment models will require the alignment of care coordination outside of typical boundaries, and will involve a greater level of risk to providers than the current fee-for-service system. In addition any new model, outside of pure cost or benefit reductions, will require that patients be engaged in their own care through cost-sharing, wellness education and incentives to stay healthy. Decision support also will be critical in order to ensure that clinicians and patients have right the right incentives and information to make the most appropriate care decisions and facilitate risk sharing.

Nichols is the editor-in-chief of a newly launched website, the Community on Payment Innovation, which aims to bring great ideas together and highlight innovative payment models. By using the site, which is a joint venture of the ACC and the American Journal of Managed Care, we hope to generate ideas that we can bring to federal agencies, such as CMMI, to implement.

 

Nielson discussed the different payment pilots that CMMI has underway. The health care reform law authorized $10 billion in funding to study new ways to deliver health care, and that funding is what created CMMI, Neilson said. CMMI has a unique advantage over other agencies: waiver authority. This means it has the power to do things, like offer gain-sharing, that its parent agency, the Centers for Medicare and Medicaid Services (CMS), cannot. Some of CMMI’s pilots that you may have heard of: Partnership for Patients, Pioneer Accountable Care Organizations (ACO) and the CMMI bundling initiative.

The bundling initiative is interesting for a couple of reasons. It’s based on a CMS pilot, the ACE demonstration, which looked at bundling payments for acute care for certain cardiovascular and orthopedic procedures. CMMI took this base model and looked for a way to make it more flexible for a variety of different practice environments. What it ends up being, she said, is a way to get your feet wet with a new payment method if you’re not ready to be part of an ACO. You’ll still get a fee-for-service payment, but you may also get a gain-sharing payment on top of the fee-for-service payment. In addition, participants don’t need to go all-or-nothing; you’re able to try the payment method for one or two DRGs and see how it goes.

 

Both Nichols and Nielson stressed repeatedly that payment innovation WILL happen because we simply can’t afford not to. As Nielson said: “We are in a crisis. The cost of medical care is a major issue.” I couldn’t agree more. The pilots of CMMI, if implemented nationwide, may begin to address some of the issues. We’ll need to be leaders in this though. As Jack Lewin, MD, used to say frequently while the health reform law was being drafted: If you’re not at the table, you’re on the menu. Let’s get our thinking caps on a figure out what’s the best way to innovate our payment system.

ACC members are headed to Capitol Hill today, armed with essential takeaways from yesterday morning’s “View From the Hill” session at the 2011 Legislative Conference. The session had an impressive line-up of panelists: Brett Baker, professional staff for the Committee on Ways and Means; Tiffany Guarascio, legislative director for Rep. Frank Pallone, Jr. (D-NJ); and Daniel Todd and Matt Kazan, both health policy advisors for the Senate Finance Committee. The panelists offered their candid views on health care issues that we are all too familiar with these days, specifically the sustainable growth rate (SGRrrr) and malpractice reform.

Panelists talked a lot about fixing the SGRrrr, and reiterated the bipartisan commitment to finding a permanent solution. Baker noted the importance of Congress securing a permanent fix to the SGRrrr this year and taking fiscal responsibility, so that we can finally put the “kick the can” attitude to rest. Todd stressed that at its core, fixing the SGRrrr is truly a bipartisan issue; however, the high price tag of $300 billion is the friction point that has kept the problem from being solved once and for all.  

Another friction point discussed is the polarization of the parties on medical liability. We already know that over 50% of cardiologists have been sued and 30% have been sued more than twice. Kazan cited the University of Michigan and University of Illinois’ seemingly simplistic approach of finding ways to avoid lawsuits in the first place. I pressed Kazan on the issue of tort reform and he suggested reiterating to Congressional members the imperativeness of reaching middle ground. He urged ACC members to ask lawmakers, beginning with today’s congressional visits, to prioritize this vital issue.

ACC’s Advocacy Steering Committee has ranked medical liability reform and SGRrrr repeal in our top priorities for 2011. As such, our advocacy staff has extensively communicated our positions to Congress.  We continue to support a bill from Rep. Phil Gingrey, MD, an OB-GYN from Georgia, which would implement medical liability reform that ensures injured patients are compensated quickly and fairly; improve provider-patient communications; and foster an environment for affordable and accessible medical liability insurance. We also actively advocate for a repeal of the SGRrrr and are dedicated to providing guidance and testing for innovative new payment models that reward quality, cost-effective care.

For those who attended the session, what was your biggest takeaway?

The ACC’s 2011 Legislative Conference kicked off last night with a full dinner program to benefit the College’s Political Action Committee. ACC President David Holmes, MD, FACC, welcomed the more than 350 attendees to the 20^th annual conference, urging them to take advantage of this time for the cardiovascular community to come together and speak with one voice.

Dr. Holmes was followed by a special tribute to 9/11 victims and U.S. military members. The ACC PAC made a contribution to the Yellow Ribbon Fund that was accepted by Captain Dan Berchinski, who lost both legs in Afghanistan. The Yellow Ribbon Fund is an amazing group dedicated to helping injured service men and women and their families while they are in recovery and it was an honor to have someone who benefited from this group with us.

General Stanley McChrystal closed the evening with a thought-provoking speech on “Plywood Leadership.” General McChrystal talked about the ways that plywood by itself is a cheap, flimsy wood, but put together it is strong and can be used to build just about anything. He reminded the crowd that alone we are like single sheets of plywood, but working together and bringing our own unique strengths we can lead change.

As I participate in a panel this morning on the “State of Cardiology” with Dr. Holmes and ACC BOG Chair-Elect Dipti Itchhaporia, MD, FACC, I am reminded of just how accurate this analogy truly is. As we react to the changing health care environment we need to understand both the national and state issues that impact the care we provide to our patients. It is going to take all of us as individuals coming together to lead the nation in shaping health care policy. Like plywood we also need to remember to be flexible and open to having our ideas torn down or modified as we move forward.

See the video below for discussion of the meeting from Bo Walpole, MD, FACC, ACC PAC Chair, and Jerry Kennett, MD, FACC, ACC Advocacy Committee Chair.

 

On Aug. 29, the ACC submitted comments on the 2012 Physician Fee Schedule proposed rule for Medicare.  This rule covered a wide range of policy areas.  While this rule covers payment rates for next year, we didn’t see any disastrous surprises like we did in the 2010 rule that caused half of our private practice members to sell off their practices to become employees, mainly of hospitals.  ACC comments on this year’s rule included the following:

• We opposed the Centers for Medicare and Medicaid Services’ (CMS) efforts to reduce payment for the technical component of imaging services provided by the same physician on the same day.  CMS considers expanding this policy to all services in the future, which we also opposed.
• We strongly encouraged CMS to propose changes in payment rates to existing services to avoid the debacle that was caused when payment rates for SPECT MPI were found to be incorrect in 2010.
• We strongly discouraged CMS to implement a penalty for not participating in the Physician Quality Reporting System (PQRS, formerly PQRI) in 2013 by adjusting payment in 2015.  We believe Congress intended this to be based on 2015 participation.

We supported the notion that cardiology groups should be compared against each other in public reporting programs and in payment adjustments, rather than comparing individual cardiologists to primary care physicians.  

For more background, a summary of the proposed rule is available on CardioSource. This year’s rule may be nothing compared to the damage that could very likely occur in the chaos around the Joint Special Committee $1.5 trillion cut. The SGRrrr could kick in as a 31 percent cut to docs Jan 1!

Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule on e-Prescribing last week. The final rule establishes the requirements for successful reporting of the e-prescribing measure, while also finalizing additional hardship exemptions for avoiding the 2012 e-prescribing penalty that begins on Jan. 1, 2012.

The ACC, along with the AMA and others, have had significant concerns regarding the implementation of the 2012 penalty and have urged CMS to reconsider the details and timing and to thoroughly consider the effects of this position on specialists such as cardiologists. Although the final rule does not extend the reporting time, it makes it easier for physicians to be eligible for hardship exemptions and addresses many of the concerns the ACC raised.

Under the rule, final hardship exemption categories for eligible physicians are as follows:

• Practitioners who have registered to participate in the Medicare or Medicaid EHR Incentive Program and have adopted certified EHR technology.
• Practitioners who are unable to e-prescribe due to local, state or federal law or regulation. (This proposed exemption is designed to address practitioners who primarily prescribe controlled substances.)
• Practitioners who infrequently prescribe. (For 2012, this means a practitioner must not have had the opportunity to e-prescribe at least 10 times between January and the end of June 2011.)
• Practitioners who provide services that are not included in the e-prescribing measures (e.g. does not provide office visits).
• Practitioners with practices located in rural areas without high-speed Internet access.
• Practitioners with a practice located in an area without sufficient available pharmacies for e-prescribing. (This includes natural disaster-caused disruptions.)
  

Physicians will need to request hardship exemptions by Nov. 1. The ACC is encouraging eligible professionals to apply for exemptions as soon as the CMS web-based portal is available. The College will provide more information on this timing as soon as CMS releases the dates. Meanwhile, it is important to note that these exemptions are very limited and the majority of cardiologists who did not report e-prescribing activity during the first half of 2011 will receive reduced payments in 2012. Read more about the e-prescribing penalty.

This post is written by Bill Oetgen, MD, MBA, FACC, and John Harold, MD, MACC, co-chairs of ACC’s Medical Professional Liability Working Group. 

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A recent article, “Malpractice Risk According to Specialty,” in NEJM provides interesting insights for cardiologists and CV surgeons. The study looks at all of the claims of a large physician-owned professional liability insurer from 1991 to 2005. Of 233,738 physician-years of coverage, cardiologists represented 1.8%, and cardiovascular-thoracic surgeons (CVTS) represented 1.6% of the experience. 

For all (40,916) physicians, the average annual medical professional liability (MPL) claims rate was 7.4%, with only 1.6% resulting in a payment to the plaintiff. Seventy-eight percent of claims resulted in no payment. For cardiologists on average, 8.6% were named each year in an MPL claim, and 1.0% had paid claims. Thus, cardiologists were at slightly higher risk to be named than were physicians in general, but they had a lower likelihood of actually paying any claim that was filed. For cardiologists, 88% of claims resulted in no payment. 

For CVTS, the numbers are less comforting. Annually, 18.9% of CVTS were named in a medical professional liability suit, and 3.8% had paid claims. Of the CVTS claims, however, 80% resulted in no payment, a proportion only minimally higher than all physicians. 

With respect to the amounts of payments made in 2008 dollars, the mean payment for all physicians was $274,887 and the median was $111,749. For cardiologists, the mean payment was $306,430, and the median was $145,886. For CVTS, the mean was $291,790, and the median was $161,452. 

CVT surgeons appear to be at higher risk for claims and have higher mean and median payments when compare to all physicians while sharing a ~20% risk of having to pay a claim that is brought.   

For cardiologists compared to all physicians, there is good news and bad news. The bad news is that cardiologists were slightly more likely to have a claim filed in a given year and that, if a payment was made, the amount was moderately higher that those paid for all physicians. The good news is that if a claim has been filed, cardiologists are less likely to make a payment than are all physicians. These results are in general concordance with the results of a study we led that was published last year in the American Journal of Cardiology.