The long-awaited U.S. Supreme Court ruling regarding provisions in the Affordable Care Act (ACA) was released yesterday. In a majority decision, the Court ruled that the ACA, including its individual mandate that virtually all Americans buy health insurance, is constitutional.

The ACA is the largest expansion of health care coverage since Medicare and Medicaid were initiated in the sixties. Having this decision behind us means that we can continue to move forward with supporting policies and provisions within the law that are in line with our overarching health care reform principles – particularly those that expand health care coverage, encourage preventive care, and foster innovative payment and delivery system models that reward quality and ensure value.

At the same time, the College will also continue to work with Congress and the Centers for Medicare and Medicaid Services (CMS) on provisions that affect cardiovascular care. Among those:

• Implementation of the controversial Independent Payment Advisory Board, a 15-member Board tasked with developing and presenting proposals to the president and Congress, starting in 2014, to extend the solvency of Medicare, slow cost growth, improve quality of care, and reduce national health expenditures. The College remains concerned by the authority granted to an independent body to determine payment cuts for only physicians, particularly in light of ongoing payment reductions as a result of the Medicare physician payment formula.
• Implementation of the Physician Payments Sunshine Act requiring that industry disclose payments to physicians and teaching hospitals, both direct and indirect. While the ACC supports the overarching objectives of the Act, the College has raised concerns regarding CMS’s interpretation and proposed implementation of the Act. Final regulations are expected in the coming months so stay tuned!

Outside of the ACA, there remains a lot of hard work before we can arrive at a sustainable health care system that emphasizes value and a strong patient-doctor relationship. In the coming months the College will actively be advocating for overarching payment and medical liability reforms that are critical for comprehensive health reform to be truly effective. In addition, our Advocacy team is focused on several regulatory proposals and legislative efforts that will have major impacts on cardiology. Among them:

• The 2013 Medicare Physician Fee Schedule (the proposed rule is expected any day);
• Additional cardiovascular coding changes as a result of continued bundling efforts;
• The annual battle to repeal/stop the flawed sustainable growth rate (SGR) formula used to calculate Medicare physician payment.

These topics, as well as life after the Supreme Court decision and the 2012 elections, will be the focus of the College’s annual Legislative Conference in Washington, DC, this September. (Registration is now open to all ACC members.)  Additionally, the ACC continues to be engaged with CMS, industry and other stakeholders as appropriate on all of these issues. It’s definitely a time of change for health care in the U.S. However, it’s this change that provides the most prospects for action. I’m excited by the opportunities not only for the College, but for the cardiovascular profession as a whole. Now is the time to leverage our successes over the last six decades in improving cardiovascular care and ensure that future policies and programs further these results. Let us work all together for this ultimate goal.

This post was authored by Manuel D. Cerqueira, MD, FACC, chair of the ACC’s Imaging Council.

Over the past eight years the ACC has developed Appropriate Use Criteria (AUC) for several imaging modalities with the goal of helping physicians choose the right test for the right patient.  As explained in a previous blog post, at one point usage statistics for diagnostic imaging was shown to have the fastest growth among all medical services covered by Medicare. Although this statistic has since declined, there is still generally room for improvement.

The AUC were developed to review patterns of care and serve as a framework for assessing appropriateness of care. As the terms for AUC (appropriate, inappropriate and uncertain) continue to be misconstrued by the media and payers, it has become increasingly important to educate these audiences about the effectiveness of AUC and the associated quality improvement tools in improving cardiovascular patient care.

Over the past few years, the College has advocated for the use of AUC as an alternative to prior-authorization based on arbitrary criteria, RBMs or “slash-and-burn” payment cuts (a great example of these efforts is in Delaware, which you can read about in a previous blog post here).  As payer’s use of AUC to determine payment becomes more prevalent, we have seen a deeper, more trusting relationships develop between insurance companies and physicians. The imaging community must continue to be stewards of AUC in order to maintain this level of credibility.

In addition, through Imaging in FOCUS, the College’s web-based Performance Improvement Module (PIM) based on ACC-developed AUC, physicians can track their appropriateness rates for radionuclide imaging (read more about FOCUS in a blog post here). The Imaging Council fully supports the use of FOCUS as a quality improvement tool in physician practices, hospitals and health plans, and we have identified promoting a PIM for echocardiography as a top priority for 2012. We urge other physicians and payers to adopt this tool as it provides real-time AUC benefit/risk calculations for individual patients and allows physicians and other organizations to track AUC patterns and exceptions over time.

The Imaging Council and Membership Section of the ACC will continue to represent the cardiovascular imaging community and work with ACC leadership to promote collaboration on issues facing cardiovascular specialists using imaging technologies to provide optimal patient care.

While an eye remains on the cardiovascular imaging community, it is my hope that through use of the AUC and these quality improvement tools, we choose the right test for the right patient, ultimately reducing waste in the health care system and improving care.

This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

For more information about the Imaging Council and Membership Section of the ACC and how to get involved, visit www.cardiosource.org/Imaging.

Do our patients know the signs of a heart attack and what to do if someone goes into cardiac arrest? When every minute counts, are we meeting the standards for door to balloon (D2B) times? These are the questions the ACC’s North Carolina Chapter has focused on over the past decade in collaboration with hospital systems throughout the state.

The Regional Approach to Cardiovascular Emergencies (RACE) project was developed in 2003 as a statewide system for providing rapid artery reperfusion for patients with ST-elevation myocardial infarction (STEMI). The RACE system is the largest state-wide STEMI system in the U.S. and incorporates the quality improvement efforts of over 100 hospitals, 700 emergency systems, and thousands of health care professionals working in a coordinated effort in order to improve timely reperfusion.

A recent study published in Circulation authored by NC Chapter Governor James Jollis, MD, FACC, who has been a champion on this issue, and colleagues looked at expanding regional coordination to the entire state of North Carolina. In doing so, rapid diagnosis and treatment of STEMI has become an established standard of care independent of health care setting or geographic location, and has resulted in improvements in timely coronary artery reperfusion.

Without a doubt, teamwork and grassroots efforts were needed to accomplish this streamlined effort. However, patient education and involvement is also a big component of helping to save lives.

The ACC, the NC Chapter and CardioSmart recently headed to Charlotte, NC, home of the NASCAR Hall of Fame, to participate in the Coca-Cola 600. As recently updated CPR guidelines recommend compression-only CPR, representatives from the RACE program were on-site to give CPR demos teaching race car fans about the 5 C’s (check, call, compress, continue, connect) and how to save a life. Cardiac arrest is a prominent issue in North Carolina and will affect an estimated 8,000 North Carolinians this year, of which only 1 in 4 will receive bystander CPR and only 1 percent will have an AED used on them.

In addition to the CPR demos, blood pressure screenings and fact sheets on CPR and heart health were given to thousands of race car fans. Dr. Jollis and Philip Iuliano, MD, FACC, also took the stage during the track walk alongside NASCAR racers and discussed tips for avoiding heart disease, keeping active and living a healthy lifestyle. CardioSmart’s partnership with Coca-Cola has given the College numerous opportunities to increase awareness of heart health and get out into the community.

I am encouraged by state-wide efforts such as the North Carolina RACE program that focus on coordinating and improving treatment times. It goes to show that by working together through quality improvement programs and initiatives we really can make a difference.

This post was authored by Kathy Jenkins, MD, FACC, Chair of the Adult Congenital and Pediatric Cardiology Council.

In the news this week, Max Page, the seven year old boy who played “Little Darth Vader” in the popular car commercial that debuted at the 2011 Superbowl, underwent open-heart surgery to repair a congenital heart defect.  He underwent surgery to repair a hole in his heart and replace his pulmonary valve.

A few days before the surgery in an interview on The Today Show, Max’s mom “discussed Max’s fear of his upcoming surgery and described how his family has been helping him prepare for the procedure.” She shared how days before the surgery he said, “Mom I don’t have a choice. I have to go through it. I don’t like it and it’s still scary — but I have to. So I think I might as well go through it with a good attitude.”

Max is a brave little boy well beyond his years, but unfortunately Max’s situation is not unique. In fact, congenital heart disease (CHD) is our nation’s number one birth defect, and nearly 40,000 infants in the U.S. are born each year with CHDs. Fortunately as medical care treatments have advanced, children born with CHD are living longer and healthier lives, even into adulthood.

The latest issue of Cardiology magazine focuses on CHD and the successes we have seen along the continuum of care. Congenital heart disease requires lifelong care, and the College’s Adult Congenital Pediatric Cardiology (ACPC) Section has been working to ensure patients with congenital heart disease have continuous cardiovascular care throughout their lives. There are now more adults living with CHD than children.

In the cover story, Gerard Martin, MD, FACC notes how there is a need for collaboration among adult CHD specialists, general cardiologists and pediatric cardiologists to educate each other, along with patients, on how to manage care over the course of a patient’s life. Moving forward, the College is fortunate to have leading national patient advocacy groups such as the Adult Congenital Heart Association, Children’s Heart Foundation and Mended Little Hearts as involved partners in providing patient and physician resources.

I also discuss how the ACPC Section has evolved over the years, what we have accomplished thus far, and what our plans are moving forward to improve care for CHD patients. If you haven’t done so already, I urge you to flip through the latest issue and learn about what the ACPC Council is up to.

We should all take Max’s word of advice for kids who have CHD: “‘If you use your FORCE and dream big, you can achieve anything. We may be small — but we’re mighty!’”

As a female cardiologist in a field of predominantly men I am aware of the challenges and opportunities faced by my female colleagues. An age-old issue has been potential gender salary disparities.

A study published this week in the Journal of the American Medical Association (JAMA) answered the gender salary disparity question and found that gender differences in salary exist among a group of physicians who perform similar work.

The disparity is still apparent after adjusting for a number of variables which authors hypothesized may be the cause for the difference. The variables include medical specialty, characteristics of the institution in which they work, work hours, and academic productivity and rank.

The findings show that if the salary disparity is constant over an entire 30-year career, a woman in the study group will earn $350,000 less than a man in the same group. Authors emphasize that the “cumulative difference” would be significantly larger if not controlled for the variables like specialty, rank and leadership.

The study authors suggest that additional research is needed to investigate why these gender differences in compensation develop and how to diminish their impact, due to their continued presence and “difficulty to justify.”

The ACC’s Women in Cardiology Member Section is also a great resource for women cardiologists with opportunities to strengthen their professional support system and skills through networking events, professional development and mentoring programs. These findings are sure to be a topic of discussion in the section.

In addition to gender salary disparities, there are also gender differences in cardiovascular outcomes. To look at this further, the College, in partnership with SCAI, has been participating in a Gender Data Forum series, which bring clinical trialists together from around the world to address these disparities.  The first forum, held this past December, focused on acute coronary syndromes (ACS) and acute myocardial infarction (AMI).  A white paper containing the findings and recommendations is expected later this year.  A second forum, which will address DES, revascularization and complex PCI is planned for September.

Awareness of women and heart disease also continues to be a major issue. I wrote in a previous blog post that 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 and women have a 28 percent increased risk of dying as compared to men to die within the first year after a heart attack. The statistics are staggering.

CardioSmart.org has a plethora of information for patients on women and heart disease, which was “once considered largely a man’s disease.” It has been said that once women place the same importance on preventing and detecting CHD as they do on their annual mammogram, we will be a much healthier nation.

I am proud to be a female cardiologist in a leadership position with the ACC. As these issues become increasingly important we must continue to support one another and encourage the up and coming female stars in the field.

Today the first Appropriate Use Criteria (AUC) for peripheral vascular ultrasound and physiological testing was released. Developed by the ACCF in collaboration with 10 other professional societies, the criteria help clinicians maximize the appropriate use of certain noninvasive vascular tests when caring for patients with suspected or known non-coronary arterial disorders.

It is estimated that more than 20 million adults in the U.S. have some form of vascular disease. Since ultrasound and other noninvasive laboratory tests can be essential tools to help clinicians evaluate vascular blockages and disease, the AUC were created in order to ensure the effective use of these diagnostic imaging tools.

The new criteria focus on indications where ultrasound and physiological testing is frequently considered. Of the 159 indications rated, 117 were rated as appropriate, 84 were rated as uncertain, and 54 were rated as inappropriate.

In particular, arterial vascular testing was found to be “appropriate” in about half of the clinical situations evaluated.  For example, there was “significant consensus regarding the appropriateness of cerebrovascular duplex ultrasound for evaluation of the patient with signs or clinical symptoms of cerebrovascular disease with 7 of 8 clinical indications rated as appropriate and 1 clinical indication rated as uncertain.”

Overall, vascular studies were deemed appropriate when clinical signs and symptoms were the main reason for testing. For example, it is reasonable to order a lower extremity vascular study for a patient who reports calf pain upon walking that resolves with rest. Tests that were conducted in patients with existing atherosclerotic disease or to establish a “baseline” after a revascularization procedure were also considered appropriate based on ratings.

Of the indications rated as “uncertain,” the panel noted variations in practice and important gaps in the evidence that made it difficult to determine appropriateness.  For example, there was uncertainty regarding the use of cerebrovascular duplex for assessment of the asymptomatic patient with risk factors or comorbidities associated with carotid artery stenosis, with 6 of 7 indications receiving an uncertain score. According to the writing panel, clinical and cost-effectiveness studies on non-invasive vascular testing are needed in order to gain more clarity.

Notably, one in five uses of vascular testing were determined to be “inappropriate” meaning that, although doing the test does not cause harm, the information gleaned would not further inform clinical judgment.

This new document joins the growing list of clinical guidelines that currently includes AUC for echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, cardiac radionuclide imaging, coronary revascularization and diagnostic catheterization. The intent of AUC is to “avoid over- or underutilization, thereby promoting optimal healthcare delivery along with justifying healthcare expenditures and promoting the best outcomes for patients with minimal risk.”

Over the past month here on the ACC in Touch blog, we’ve featured a special series – “Back to the Basics” of AUC – to discuss what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

Read more about the new AUC document on CardioSource here. Also be sure to check out my interview with CardioSource Video News on the new AUC document below. I invite you to leave any comments or thoughts below.

This post was authored by James Fasules, MD, FACC, senior vice president of Advocacy for the ACC.

Just when you thought you’d learned enough healthcare acronyms to understand what we should care about as cardiologists, they add another one. This time, it’s the UFAs – the User Fee Acts, the quick way insiders refer to the Prescription Drug User Fee Act (PDUFA), the Medical Device User Fee Act (MDUFA) and the new generic drug and biologic user fee programs. Collectively, these programs help to fund the congressionally-mandated mission of the Food and Drug Administration, which is necessary given the dichotomy between what is expected of the FDA and what Congress appropriates for the FDA to achieve those expectations. The first of the programs, PDUFA, came out of the HIV-AIDS crisis when it became clear that the FDA did not have the necessary resources to review new drug applications quickly enough. Industry pays certain fees to have their applications reviewed. In exchange, the FDA commits to reviewing and coming to decisions (approval or otherwise) within certain timeframes.

The programs, created by Congress, sunset every five years, and it is up to Congress to decide whether to reauthorize the program. Thus, without Congressional action, PDUFA and MDUFA are set to expire on Sept. 30. To put it in perspective, funding from the PDUFA program is so important to the Agency today that approximately 2,000 staff reviewers will lose their jobs in the event that PDUFA is not reauthorized and the application review process will come to a grinding halt. Because of differences between the two programs and the two industries, the expiration of MDUFA would lead to the loss of between 200 and 300 jobs for device reviewers.

So why should cardiologists care? After all, if it’s just about approvals for devices and drugs, shouldn’t that be industry’s problem?  Well, if you think the FDA is slow at reviewing applications now, imagine how slowing things would move without all of those individuals reviewing the applications. New devices and pharmaceuticals would take even longer to get to market and even fewer patients would have access to them. Just think about how much further behind Europe we would be. It’s not just about TAVR; it’s about all of the new interventions that have been developed in recent years and have helped to reduce mortality resulting from cardiovascular disease.

Over the last two years, ACC’s Advocacy team has been meeting with members of Congress and their staff on these issues, as well as agency officials, industry representatives, consumer groups and public health advocates. Additionally, the ACC is working with a number of physician organizations to promote the passage of the UFAs, as well as legislation pertaining to related issues.

Recently, both the House and Senate overwhelmingly passed their respective versions of bills reauthorizing the UFAs.  Over the next month, Committee staff from both chambers will work together to iron out differences between both House and Senate bills before voting on final legislation and sending to the president for his signature.  It’s an exciting time to be an UFA!

This post was authored by John Shuck, MD, FACC, governor of the Delaware Chapter of the ACC.

Over the past few years the issue of appropriate use and radiology benefit managers (RBMs) has been a “hot topic,” particularly in Delaware. Recently, the misuse of RBM's in denying cardiac stress imaging within the state came to national attention.  A Delaware patient was denied a cardiac stress test by an RBM used by a major health plan in Delaware. The patient was ultimately admitted to the hospital emergently for a catheterization and a lifesaving CABG was performed.  This patient's plight became well-publicized and sparked investigations by the U.S. Senate Commerce Committee and Delaware Insurance Commissioner as to why the test was denied.

Thanks to the efforts of many at the ACC national and state level, this past fall the Delaware Insurance Commissioner announced that the health plan will support use of the ACC’s FOCUS: Cardiovascular Imaging Strategies tool by Delaware cardiologists to make decisions about certain diagnostic imaging tests, as an alternative to RBMs. Unlike RBMs, the FOCUS tool engages providers in ongoing feedback reports and quality improvement activities. At the same time it reduces third-party costs to physicians and health plans (read more about FOCUS in a blog post here).

In January 2012 the FOCUS health plan product went live incorporating many of the same elements present in the FOCUS performance improvement module. Under the agreement, the health plan will pay for cardiologists in the state to use the online tool, which allows for consistent application of appropriate use criteria to determine when cardiovascular imaging tests are needed. Importantly, the program also provides feedback reports on the patterns of appropriate use to physician practices and health plans. FOCUS participants then use the reports to complete action plans and share best practices.

This model for managing medical costs by focusing on patient-centered decision making and quality care will hopefully be implemented by other insurers and within other states when it comes to ensuring appropriate use of medical imaging. I’m happy to see our efforts to implement this program in Delaware have not gone unnoticed as several other ACC chapters are currently in talks with health plans to implement this program at the state level.

For more information about Imaging in FOCUS, visit CardioSource.org/FOCUS. This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

I recently spoke with the Houston Chronicle, my hometown newspaper, about the need for physicians to take a more active role with our patients. I discussed how aligning incentives for physicians will provide better care for patients, the need to encourage health professionals to use technology, as well as the need to collaborate with other health care professionals to encourage prevention and to improve overall outcomes.

I also shared how obesity will start to cancel out some of the “wins” we’ve had in the field by bringing on high blood pressure and/or high cholesterol and diabetes at an earlier age if we aren’t proactive now and encourage lifestyle changes. This is why the ACC is partnering with groups like Million Hearts and are growing CardioSmart, which empowers health care professionals and patients to partner effectively to achieve better cardiovascular outcomes.

Lastly, I also touched on sudden cardiac arrest in student athletes and discussed how it is important to know about family history of heart and vascular disease. The ACC is offering a course, Sports Cardiology Summit: Protecting the Heart of the American Athlete, from October 19-20, which will help attendees enhance their knowledge in the practice of cardiovascular care for athletes. The program will examine screening programs that identify at-risk athletes and provide recommendations for safe participation, initiate research in sports and exercise cardiology, examine opportunities for cardiac care teams to enhance the cardiovascular care of athletes of all ages, and more. If this is an area of interest, you can also join the Sports and Exercise Cardiology Section of the ACC.

Check out the complete Houston Chronicle article here. We can each make a difference, engaging beyond our daily activities in our community and the population at large.

A new post on the New York Times Blog provides an interesting glimpse at the challenges we face as health care providers when it comes to involving patients in their own care decisions – a key tenet of patient-centered care.

“For over a generation now, efforts to make health care more patient-friendly have focused on getting patients and doctors to work together to make decisions about care and treatment,” writes Pauline Chen, MD, for the Times. “Numerous research papers, conferences and advocacy organizations have been devoted to this topic of “shared decision-making,” and even politicians have clambered aboard the train … But one thing has been missing in nearly all of these earnest efforts to encourage doctors to share the decision-making process. That is, ironically, the patient’s perspective.”

Chen cites a new article published in the latest issue of Health Affairs that explores the patient perspective. The article, which highlights the results of six focus-group sessions with 48 people in the San Francisco area, indicates that while the majority of people have a strong desire to engage in shared decision making, there are several obstacles that inhibit the ability to move from concept to reality. Key among these obstacles is the perception of physicians as authoritarian and fears of being categorized as a “difficult” patient. “This fear of retribution seemed related to both potential immediate and delayed effects,” the article notes. “A challenge to authority might modify treatment decisions as well as negatively influence the nature of the physician-patient relationship.”

Other findings from the focus groups, include the large amount of time spent by patients in conducting their own research regarding their disease state and/or treatment options, as well as the desire by patients to bring family, friends or other care providers with them to help compensate for any “social challenges” and time pressures “inherent in clinical consultations.”

Interestingly, these findings underscore the need for implementation of many of the elements identified as essential in the College’s recent health policy statement on patient-centered care. For example, focused education and training around patient–clinician communication incorporated as part of medical school and continuing education curricula could help providers learn how to best avoid the authoritarian perception. The health policy statement also calls for the development of easy-to-use decision aids that provide information about diseases, as well as risks and benefits of treatment or screening options. These have been shown to improve knowledge, reduce decisional conflict due to feeling uninformed or unclear about personal values, increase active participation in decision-making, and reduce indecision.

There is no denying that shared decision making poses challenges on both the physician and patient fronts. Chen is absolutely correct when she notes that “care organizations and doctors’ practices must be restructured to allow more in-depth conversations; clinicians need to be reimbursed for the time required for more meaningful conversations; and health care systems must adopt rigorous quality standards that measure and value real patient engagement in decisions.” However, there is also no denying the benefits to patients and to the health care system as a whole if we are successful. Cardiovascular disease is particularly well-suited as a testing ground for the concept, given the number of treatment options that exist for which small or no differences in outcomes exist. This allows for patients’ values and perspectives to play larger roles in the decision making process.

At the end of the day, the College is fully committed to patient-centered care. Our task is to learn from studies like the one in Health Affairs and continue to chart a course that ensures the needs of each patient and his/her family are met in the most appropriate, high quality and cost-effective fashion possible.  After all, a patient shouldn’t be afraid to speak up at the doctor’s office!