Congress has given us all a holiday gift and has passed an amended version of the Senate's $30 billion package that would, in part, delay the Jan. 1 Medicare physician payment cut for two months. The amended language calls on Senate leadership to agree to a conference early next year to negotiate a full-year extension of current Medicare reimbursement rates and the payroll tax holiday. This measure cleared both chambers by unanimous consent and President Obama has already signed the legislation into law.

I hope you all enjoy the holiday season and rest assured that we will come back in full force in 2012 to work for a permanent fix so we won’t have to deal with this never-ending SGR madness.

As 2011 comes to a close we can look back with pride on all of the accomplishments in the field of cardiovascular medicine over the year. Whether it was all of the great science presented at ACC’s scientific session in New Orleans; development of new and/or updated guidelines reflecting how to best use new treatments or drugs; participating in the United Nations Summit on Non-Communicable Diseases; or partnering with public and private entities on the Million Hearts Initiative – we have made great strides. Our field can be a challenging one at times, but the end results are well worth the battle.

One of the accomplishments I am most proud of, however, is our work related to transcatheter valve therapy (TVT). Early 2011 brought us the PARTNER Cohort A trial, which looked at this transformational procedure that had been used in 40 other countries outside the U.S. until this year. Soon after, The Society of Thoracic Surgeons (STS) and ACC together developed a high-level societal overview on TVT to ensure safe introduction of the therapy into the U.S.  Michael Mack, MD, president of STS, and I testified at a Food and Drug Administration (FDA) committee hearing about the importance of a team-based approach when implementing this procedure.

In the past few months, not only has the FDA approved this new technology, which has the promise and potential to significantly affect the management of patients with severe aortic stenosis, but the Centers for Medicare and Medicaid Services (CMS) has opened up a National Coverage Determination analysis at our request. We are ending this year with the official launch of the STS/ACC TVT Registry^TM, which will track patient safety and real-world outcomes related to the newly introduced transcatheter aortic valve replacement (TAVR) procedure. The Registry is a great example of teamwork between professional societies as we worked closely with STS, the FDA and CMS, with input from The Society for Cardiovascular Angiography and Intervention (SCAI) and The American Association for Thoracic Surgery (AATS). We are continuing to work closely with these stakeholders on the development of future clinical documents and educational programming to ensure appropriate use of this new therapy. It is our hope that our efforts now will serve as the model when new devices or therapies are developed in the future.

We’ve had quite an exciting year, and as we head into 2012, I am excited for what this next year will bring!

What do you think were some of the great innovations of 2011?

In this last week of Congressional action in 2011, on Saturday it seemed as though Congress at the last second would approve a package funding the government into the next year, and in a parallel last-minute decision, the payroll tax cut extension and the SGRrrr (the un-Sustainable Growth Rate Medicare physician payment formula expressed as a growl) seemed to have been saved by the U.S. Senate for two months (through February 2012).

But unbelievably this afternoon the House rejected the two-month extension since they want a longer extension instead. The Senate has already adjourned for the holidays and it is unlikely an alternative resolution to prevent the pending SGR cuts will be resolved before the Jan. 1 deadline. This is a clear failure by Congress and its impacts will be felt by practices and patients as we head into the new year. Once again physician practices are subjected to financial uncertainty and disruption of business. Most importantly patients' access to life-saving quality health care is on the line.

The Centers for Medicare & Medicaid Services (CMS) announced that if Congress hasn’t acted by the start of the new year it will hold claims until Jan. 17 before they start the automatic Medicare payment cuts.

This circus has played itself out. We are in serious trouble if both parties are unable to abandon partisanship to seek a middle ground to solve the huge problems and risks we face. We’re certainly not the shining example of how democracy should responsibly function for Egypt to emulate, or for mentoring any emerging democratic nation. Our Congress is currently broken. We need the next generation of leaders to work on fixing this never-ending SGR ping pong match.

It’s been a while since we’ve heard about the Physician Payments Sunshine Act, (read previous blog posts here and here) but this week the Centers for Medicare & Medicaid Services (CMS) released the long-awaited proposed regulations.  A requirement of the Affordable Care Act, the Sunshine Act requires drug and medical device companies to publicly report their payments to physicians.

CMS had missed their deadline of October 1, but after some pressure and criticism from lawmakers and industry, the agency released the rules just in time for the holidays. Since the rules are late, data collection will not begin until the final regulations are issued.

The ACC has a stringent position on conflicts of interest and relationships with industry, and while we strongly support transparency in physician and physician organization relationships with industry, we believe that it is critical this information be placed into the proper context, and made publicly available in a format understandable by the average consumer.

The College will be submitting comments on these proposed regulations to make sure the Sunshine Act process is as transparent and accurate as possible. View the comments submitted to CMS earlier this year here. For more information, visit www.cardiosource.org/Advocacy.

A recent article in Health Affairs examined the supply and distribution of the cardiology workforce across the country given “a sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease.”  The paper was co-authored by Harlan Krumholz, MD, FACC, a member of the ACC Board of Trustees and professor of medicine and epidemiology and public health at Yale University School of Medicine.

The results showed that there has been a modest increase in the cardiology workforce over the past 12 years, whereas the primary care physician and entire physician workforce shortages are more pronounced. But there’s also a big disparity in the geographic distribution of cardiologists across the country, specifically in rural and socioeconomically disadvantaged areas.

As the U.S. “baby boomer” population becomes older, it is clear we will need to rely on team-based practice models to deal with the cardiovascular demands on the U.S. health care system that are certain to increase. A team-based model will enable delivery system and quality of care improvements as it offers solutions to the workforce shortage, and will expanded physician productivity, and improve job satisfaction by reducing workloads and preventing burnout.

According to the CDC, since 1950, age-adjusted death rates from cardiovascular disease have declined 60 percent, representing one of the most important public health achievements of the 20th century. Despite this huge reduction in morbidity and mortality, just imagine what we can accomplish when we work together in a team-based setting using NCDR^® and PINNACLE Registry^® data to systematically improve patient outcomes, and simultaneously improve efficiency and value.

We still have a long way to go in fighting the leading cause of death in the U.S., so let’s get to it!

The ACC has joined the ABIM Foundation’s Choosing Wisely^TM campaign along with eight other leading medical specialty societies and Consumer Reports to help physicians, patients and other health care stakeholders think and talk about overuse or misuse of health care resources in the U.S.

According to the Organization for Economic Co-operation and Development, decade after decade the U.S. spends more money per capita on health care than any other developed country with little progress in quality or value to show for it. The Congressional Budget Office estimates that up to 30 percent of care delivered in the U.S. goes toward unnecessary tests, procedures, medical appointments, hospital stays and other services that may not improve health. Coupled with the fact that the Centers for Medicare & Medicaid Services estimates U.S. health care spending will reach $4.3 trillion by 2019, it is clear that our current health care system is unsustainable and in need of an intervention.

As part of our longstanding effort to play an active role in addressing the quality of care, the College is joining the campaign to encourage open communication about the risks, costs and benefits of tests and treatments so that our patients can be informed partners when making important decisions about their care. We believe that partnerships between patients and health care providers are crucial to achieving better outcomes and lowering health care costs. From our CardioSmart^TM National Care Initiative, aimed at helping patients better understand and/or prevent heart disease, to our state-of-art educational programing and decision-support tools that place evidence-based guidelines at a clinician’s fingertips, we have been and will continue to be committed to ensuring the most appropriate, cost-effective care.

Over the course of the multi-year campaign, we will be working with the ABIM Foundation to identify and reduce waste in the health care system. With the medications, devices and imaging technology available to cardiologists today, we can save and improve the lives of patients who would not have had a chance just 15 years ago, but we also have a responsibility to use these powerful tools effectively and make sure we are choosing wisely.

To learn more about the Choosing Wisely campaign visit, www.ChoosingWisely.org.

This post was authored by Dipti Itchhaporia, MD, FACC, chair elect of the ACC’s Board of Governors.

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According to WomenHeart, heart disease is the leading cause of death of women in the U.S. Nearly five times as many women will die from heart attacks alone this year than will die from breast cancer. Women have a 28 percent increased risk of dying as compared to men to die within the first year after a heart attack. Unfortunately, the vast majority of cardiovascular research has been performed on men and/or data have not been separated out based on gender.  Where men and women have been studied separately, some important differences have been identified.

Yesterday the ACC co-hosted a Gender Data Forum with the Society for Cardiovascular Angiography and Interventions’ (SCAI’s) Women in Interventions, to explore the information and statistics that are available. The forum featured primary investigators from major clinical trials who discussed gender data differences in their trials that specifically looked at anti-platelet and anti-thrombolytic therapies in Acute Coronary Syndrome (ACS). Studies included PLATO, TRITON, CURRENT OASIS, GRAVITAS, HORIZONS/ACUITY, ATLAS ACS, Fondaparinux, Integrellin, Abciximab, CHARISMA and CURE, and FRISC II.

By examining and discussing the results from these studies and commenting on the comparative effectiveness, the goal was to hone in on the differences in these studies that we could further explore and better understand as we think about future research and trials examining differences in gender. A further goal is to increase gender specific data in future studies.

Overall the forum was successful and there were several ideas that resulted from the discussions as we look to impact regulatory agencies, industry, physicians and patients to reduce health disparities.  Our hope is to compile our learnings from the forum into something that can be useful and more widely distributed, so stay tuned for more information. In the meantime look for upcoming ACC educational sessions on women’s health disparities, including the Heart of Women’s Health meeting in January and hot topics at ACC.12 in Chicago.

The College is fortunate to have wide representation of its Board of Governors from all 50 U.S. States, Canada, Mexico, the Army, Navy, Air Force, Veterans Affairs, and Public Health. We have much to learn from one another, as there are several inherent differences between our health care systems.

Our colleagues from Canada share with us “a day in the life” in latest issue of Cardiology magazine. We learn that there are a few similarities and several differences between Canada’s health system, which covers 100 percent of the nation’s citizens, and the U.S. traditional practice system.

Cardiologists in Canada work in an independent and autonomous practice style environment which includes autonomy in diagnostic testing and treatment. Emergency and acute care, including state-of-the-art STEMI care, as well as readily available access to urgent testing and procedures are hallmarks of the Canadian health system.

The private practice in Canada is similar to the U.S., as cardiologists are responsible for their office operation, overhead, staff, professional dues, and development. There is no pension plan for private practice physicians, but there is the option of professional incorporation in some provinces, which takes advantage of the small business tax program, and taxes the first $500,000 of income at approximately 15 to 16 percent.

Billing for clinical services in the Canadian system goes to a single payer, which is a provincial government agency, with some exceptions including services rendered to armed forces. The system is electronically based, taking only two to three hours per week per physician. Correct submissions receive virtually immediate payment and there is no pre-authorization required.

While the U.S. engages in the tort debate, Canadian physicians are defended by the Canadian Medical Protective Association (CMPA) which provides medical assistance, defense, and advice to physician members in times of medical malpractice disputes. Only about one out of every 10 cases go to trial, and when they do, CMPA’s defense success is about 90 percent. Thanks to provincial reimbursement programs, the cost of CMPA coverage for individual cardiologists is extremely modest.

Canadian health care does have issues of concern. Hospital bed availability, emergency room overcrowding, and long waiting lists for some non-urgent care and testing are areas in need of improvement. To address the negative impact of long waiting lists, the Canadian Cardiovascular Society (CCS) developed a set of National Waitlist Guidelines. The Canadian Medical Association’s Wait Time Alliance has adopted these benchmarks and they are increasingly used in system planning and goal setting.

Budgetary limitations also tend to stifle the ability to introduce new programs, particularly new technology to hospitals. Program and patient needs sometime come into conflict with the limitations imposed by fixed funding streams from provincial governments to hospitals. Canadians see the need for improvements and in a survey taken by the Institute of Research on Public Policy in June 2011 of more than 1,200 citizens, working with the provinces on health care ranked highest in a list of possible priorities for the federal government.

Thanks to our friends Christopher Simpson, MD, FACC, Rodney Zimmermann, MD, FACC, and G.B. John Mancini, MD, FACC, for giving us a closer look into their Canadian health system.

View the Nov/Dec 2011 issue of Cardiology Magazine here. More information about the ACC’s Chapters is available at CardioSource.org/Chapters.

The announcement of the resignation of Don Berwick, MD, administrator of the Centers for Medicare and Medicaid Services (CMS), came a month earlier than expected. President Obama had appointed him without Senate confirmation a year ago during a Congressional recess, and such appointments expire within a year.

Berwick has been a visionary CMS Administrator with his “triple aim” of better care for individuals, better health for populations, and slower growth in costs through improvements in care. A pediatrician by training, he has been a good friend of the ACC, and most of the House of Medicine will be sorry to see him go before he had a chance to move needed delivery system and payment reforms ahead.

During his tenure at CMS, Berwick helped implement a number of key provisions of the Affordable Care Act (ACA), but unfortunately, Berwick has been a scapegoat for Republicans who are mad about the ACA, and he steps down from his CMS position after having run through a gauntlet of criticism in Congress as well as the conservative blogosphere.

As I stated in a recent interview with Medscape Medical News: I credit Dr. Berwick with having listened to physicians in the process of reforming the healthcare system. When organized medicine panned the first version of the Accountable Care Organization (ACO) rules, Dr. Berwick went back and changed them significantly. CMS is trying to do its job as a regulatory agency, but facilitate innovation at the same time. They're partnering with us. That's clearly part of Don's legacy. It's been a great era.

Berwick’s CMS Deputy, Marilyn Tavenner, RN, MHA, a highly respected nurse and former Virginia health administrator, has been named to replace him. Although Berwick will surely be missed, we’re well situated to work with Tavenner and look forward to continuing a strong relationship with our friends at CMS as we work together to better the U.S. health care system.

This post was authored by Carolyn Bridges, MD, Associate Director for Science, Immunization Services Division, National Center for Immunization and Respiratory Diseases (NCIRD), Centers for Disease Control and Prevention (CDC).

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If you don’t make a strong recommendation for your patients to get a flu shot—who will?

Every year, CDC reminds physicians and the public that people with high risk conditions—including people with heart disease and stroke—need a flu shot to help prevent hospitalizations and even deaths from complications from influenza.
But every year, only about 40% of patients 18 to 64 years old with cardiac disease get vaccinated.

You can change that.

Some cardiologists may have traditionally felt that vaccination discussions should take place under the aegis of primary care providers or other clinicians.  And, many specialty providers may not have the staff or facility to support patient vaccination programs in their office, or they may not see their patients regularly during flu season.

It’s time for a new tradition. Studies show that a physician’s recommendation and offering flu vaccine are strong predictors of patient vaccination. In other words, if you strongly recommend a flu shot—your patients will get vaccinated.  These days, if you don’t carry flu vaccine in your office, there are multiple options for your patients to get flu shots. You can write them a ‘prescription’ to remind them and emphasize the importance of preventing severe illness from influenza.

Why is it so important for your patients?

People with heart disease are at high risk for developing serious complications from flu. In fact, among adults hospitalized with influenza, cardiovascular disease is one of the most common chronic conditions.  And, among adults that died from 2009 H1N1, cardiac disease was second only to chronic lung disease among existing co-morbidities.

Need more convincing? Having cardiac disease is estimated to increase the risk of influenza-related hospitalization by almost 3 fold. (*references 1-9)

There’s further incentive—of a positive nature: randomized studies of influenza vaccination of patients with existing cardiovascular disease show that flu vaccination decreases the risk of acute coronary syndrome and cardiovascular disease-related deaths. (*references 10-12)

Based on the risk of severe illness from influenza and the benefit and known safety of influenza vaccination, both the American College of Cardiology, American Heart Association, and the Centers for Disease Control and Prevention recommend the flu shot for patients with cardiac disease. (*references 13-14)

You’ve got both the carrot and the stick in your hands. It’s time for a new paradigm—where all cardiologists take a more active role in ensuring that their patients are vaccinated against influenza each year.  This goes beyond asking patients “So, did you get your flu shot?”  It goes beyond merely suggesting that a flu shot might be a good idea.   Your strong recommendation and instructions to patients about where to get their vaccine, if you don’t offer vaccination in your office, are needed to protect your patients against influenza.

For more information, visit the CDC website. You can order free materials, review the ACIP guidelines, or find further information for yourself, staff, and patients.

The CDC and the ACC have partnered with QuantiaMD to bring you a succinct 5-minute presentation covering recommended Immunization Practices for these high-risk patients. Please note a free QuantiaMD registration is necessary to view entire presentation.

Other resources available on the ACC’s patient-centered website, CardioSmart.org, include patient fact sheets in both English and Spanish. Follow the ACC on Twitter and Facebook for additional tips and information and participate in the Forum Discussion on Prevention in the CardioSource Communities.

*View all references here.

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Please note that statements or opinions expressed herein reflect the views of the contributor, and do not reflect the official views of the ACCF, unless otherwise noted.