The ACC recently came out with this great CVN video highlighting our recent Legislative Conference. In the video, I point out that the proposed cuts, the final version of which are soon to be announced, are distracting us from pursuing other noble health care reforms, such as promoting quality, reforming malpractice laws and increasing access. I've listed a couple of possible options for what else we COULD be focusing on right now if it wasn't for the Rule, but add your own suggestions in the comments section below.

On Tuesday, I received this e-mail over the ACC Board of Governors' listserv from ACC Nebraska Chapter Governor Michael Del Core about his experience during Hill visits at the 2009 Legislative Conference. 

After completing my office visits today, I noticed that the House Energy and Commerce committee was meeting, so I walked in to listen.  Lo and behold Kathleen Sebelius was there and answering questions from the representatives regarding H1N1... I suppose the topic of the meeting.  When it was his turn to take the floor Representative Walden from Oregon started off by telling the Secretary about the Gonzalez/Rogers letter that was sent to her [about the proposed 2010 Physician Fee Schedule] and asked her to give careful attention to the letter.  Of course he was called out of order but he made his point.  I am convinced that he brought up the letter today because of your efforts earlier.  Just thought you should know...it does make an impact!

Michael Del Core, M.D.
Governor, ACC Nebraska Chapter

Also, check out the ACC press release from the Leg Conference, which goes into more detail about what ACC members fought for on the Hill.

In its afternoon breakout session yesterday, the ACC held a panel on medical liability reform featuring James Paluskiewicz from the office of Rep. Michael Burgess (TX) and Dana Lichtenberg from the office of Rep. Bart Gordon (TN). So far in the 2009 Legislative Conference, medical liability reform has come up several times as an area that needs to be addressed in health care reform. The cost of medical malpractice (malpractice premiums and legal defense) is estimated by CBO to be at least 1 percent, or $22 billion, of overall annual health care spending in the nation.

However, the big number is the cost of defensive medicine. While the amount is controversial, it has been estimated by a number of legitimate sources (PricewaterhouseCoopers, etc.) to approximate $200 billion. Therefore, a little bit of malpractice relief could save a lot of money in reducing defensive medicine. If, for example, tort reform was able to save $50 billion per year in defensive medicine, it would add up to $500 billion over 10 years -- over half the projected costs of health care reform spending.

The ACC has long-held that caps on non-economic damages and other reforms, such as those contained in California’s MICRA, have the most significant impact on stabilizing malpractice premiums. However, realistically, there's a low likelihood such reforms would make it through the legislative process. Other options that could be included in reform or for demonstration projects:

• Health courts: Health courts are specialized administrative courts designed to handle medical injury disputes
  
  
• Certificate of Merit: Requirement to obtain a written statement by an appropriate licensed professional, certifying that there exists a reasonable probability that the treatment fell outside acceptable standards and that such conduct was a cause in bringing about the harm
  
  
• Collateral source rule: Eliminating the collateral source rule would allow juries to take into account payments from our sources when calculating awarded damages
  
  
• Periodic payments: Allows the defendant to make periodic payments of future damages over $50,000, if the court deems appropriate, instead of a single lump sum payment. It would ensure that funds continue to be available to the plaintiff to cover these future cost as they occur and avoiding the mismanagement of a lump sum payment
  
  
• Adherence to practice guidelines: This provision would offer limited liability protections to the physician or health care professional who offered care within nationally-accepted clinical guidelines
  
  
• Expert witness: Requirement that expert witnesses meet certain qualifications prior to testifying, such as must be a licensed physician and must be in the same or similar specialty as the defendant. Expert witnesses must also have been in practice within the past five years, which can include academic or clinical research programs.

The ACC supports the amendment offered by Rep. Bart Gordon (D-TN) to H.R. 3200 that would provide incentive payments to states for enacting certificate of merit requirements and early offers programs. There are many ways that we can begin to reform the malpractice system to reduce costs associated with defensive medicine. We just need to get started.

*** Image from Flickr (walknboston). *** 

Zia Roshandel, M.D., F.A.C.C., a cardiologist with Blue Ridge Cardiovascular Associates in Culpeper, Va., wrote in to the ACC shortly hearing about the proposed cuts. He's been featured in Cardiology and taped a CVN video (below), a version of which will be offered to Hill staffers during the 2009 Legislative Conference office visits by ACC members today. The post from below Dr. Roshandel explains why he took action.

**********************************************

Today, I’m going to Capitol Hill to fight for the continued existence of my cardiology practice in Culpeper, Va. My partner and I established the practice five years ago, but as the economy has struggled, the number of uninsured patients has grown and we struggle to cover our costs. Over the last year, we have taken many savings measures, including forgoing our salaries, reducing the number of employees, renegotiating our health insurance and reducing employee hours.

Given all that we’re done already to keep from closing our doors, when about two months ago I heard for the first time about the CMS cuts for 2010, I was stunned. My practice cannot withstand even a 10 percent cut, not to mention the 20 – 40 percent cuts proposed by this rule. I tried to contact my legislator in Virginia, but never got to speak to anyone. I sent them several e-mails to explain what effect these cuts would have on my small practice.  In addition, I took steps to educate myself on the cuts and talk to my colleagues. I urged them to take action, to educate each other and to educate CMS about the real life of a CV specialist in the community. 

Cardiologists need to band together to talk to Congress to inform them about the effects that the CMS cuts will have on cardiovascular practices. That’s why I’m here at ACC’s 2009 Legislative Conference. I hope to make lawmakers understand that if these cuts go through, practices like mine – that struggle as it is – will be forced to close and patients forced to look for care elsewhere. For patients in my small rural town, that means significantly longer drives to receive regular cardiac care and significant delays in treatment for every patient with chest pain, congestive heart failure, arrhythmia or any potential cardiac disease presentation as they are transferred to the closest hospital with a cardiac specialist, which is 45 to 50 minutes away.

Certainly, I’m not the only cardiologist who will be affected by these cuts. In fact, I would imagine that there are few cardiologists who won’t be affected by the cuts. Here is Washington this week, there are over 350 cardiovascular professionals fighting against the cuts, but while such a strong turnout is impressive, it will not be enough to prevent these cuts from taking effect. We’ll need every cardiologist and cardiovascular professional to step up, speak out and take action in determining your professional future before it is too late.

For more on my story, view the video below.

In the keynote speech at today’s 2009 Legislative Conference, grassroots advocacy expert Mike Dunn spoke to ACC members about the importance of grassroots lobbying and political action committees in influencing policy. He made very clear how much of an effect the two can have in influencing policy. If you want to do what you do (treating patients), you have to get involved in politics, he said. It doesn’t matter whether you like politics, he noted -- politics likes you. According to Mike, he who determines the rules, determines the care patients receive. Cardiovascular professionals have to be part of the equation of who determines the rules.

Mike also discussed a brief history of political donations. With the outlaw of soft donations, organizations like the ACC have a limited ability to influence lawmakers and form relationships. Because PACs and grassroots are the only two ways for us to influence policymakers legally, cardiovascular professionals must see themselves not just as medical professionals, but also as government relations professionals. Our strength is in our relationships with lawmakers, which we must bolster through our visits and through our donations.

He closed his presentation with some pointers for our Hill visits tomorrow:

• Don’t tell the history of cardiology or your own income concerns – your time is too short
  
  
• Emphasize the effects of the CMS cuts on quality of care and the viability of your practice
  
  
• Put in a word for tort reform. Health care reform should have tort reform – we won’t get Republican support without it
  
  
• Don’t ignore the staffer in the room

Mike started his presentation by saying, "Your house is on fire." Sadly, this is true. We got to use our advocacy efforts – even if you don’t like to get involved, even if you hate politics – to make sure we can put the fire out. Visit's ACC PAC's Web site here.

In the first session for today’s 2009 Legislative Conference, two important Congressional staffers joined ACC members to discuss “Health Care at the Crossroads: A View from the Hill.” The first was Wendell Primus from the Office of the House Speaker Nancy Pelosi (D-Calif.), who spoke about the opportunity we face to move to higher quality, lower cost care. Wendell noted that Congress needs our help in making this happen. He said: “We need you to work with your members of Congress and your Senators to make the point that we need to control costs, improve quality of care and increase access.”

Joining us from the House Ways and Means Committee was Geoff Gerhardt. Geoff discussed some of the highlights of the House bill (HR 3200), including coverage, payment reforms, prevention and public health, and medical education. Gerhardt talked at length about coverage – specifically the provisions in the House bill intended to expand coverage. Some of the items mentioned include an insurance exchange, protections for those with pre-existing conditions and protections against coverage rescissions. Geoff said that the hope is that people will have a real choice of insurance companies to go to.

The session also provided a lengthy question-and-answer session with members. Members covered a variety of topics, including expanding Medicaid coverage, combining Medicare Part A and Part B, using a unique patient identifier to track patients through registries to understand outcomes, implementing interoperability standards for health information technology, and much more.

Clearly, there are a lot of health care issues on the minds of ACC members. Hopefully over the next day, Legislative Conference speakers will be able to provide some clarity into many of these issues. The better we understand the issues that affect us, the better advocates we’ll be tomorrow during our Hill visits.

To kick off our 2009 Legislative Conference coverage, former ACC Texas Chapter Governor and current ACC Board of Trustees member George Rodgers, M.D., F.A.C.C. will discuss a recently released study on the impending cardiovascular professional workforce shortage, which appears in the Sept. 22 issue of Journal of the American College of Cardiology. Dr. Rodgers is president and chief medical officer of Biophysical Corporation, a company dedicated to advancing clinical knowledge through its research in the field of biomarkers, and a practicing cardiologist in Austin. As part of the release of the study, Dr. Rodgers and ACC SVP of Science and Quality Janet Wright, M.D., F.A.C.C., conducted a phone conference with reporters, which is available at the end of this post.

***********************************************************

There are many issues that cardiovascular professionals need to talk to lawmakers about to better inform health care policy and improve the health care system. As Margo Minissian, CCA, said in her post last month: Cardiovascular professionals are the “experts on health care and our lawmakers need us to get up-to-date on the different issues.” My commitment to advocacy is why I’m here in Washington, D.C., for the ACC’s 2009 Legislative Conference.

At this moment, two of the hot topics are payment reform and health care reform. However, an underappreciated advocacy topic for cardiologists, but one I feel is highly important, is addressing the cardiology workforce crisis. My colleagues on the ACC Board of Trustees Workforce Task Force and I on Thursday published in JACC the results of a survey finding that an inadequate supply of cardiovascular specialists will be available to treat the projected 20 million more Americans that will have heart disease by 2020.

Some of the study's findings:

• Currently there is a significant shortage of over 3,000 cardiologists in the workforce.  Only approximately 800 new cardiologists complete fellowships every year in the U.S.
  
• Forty-three percent of cardiologists in the current workforce are over the age of 55 – nearing the point in their careers that they might consider retirement. 
  
• There are going to be much greater demands in the next 20 years for cardiology services based on such drivers as population (baby boomers), the epidemic of obesity and the anticipated increase in prevalence of diabetes and concomitant cardiovascular diseases.
  
• Health care reform may further drive demands for more cardiovascular specialists.

Disparities
Not surprisingly, the report also found significant disparities in representation of women and minorities. Women represent about 12 percent of general cardiologists, 10 percent of interventional cardiologists and EPs and 30 percent of pediatric cardiologists; however, compare these rates to the rate of female medical students – 50 percent – and it’s clear how much room for improvement there is in encouraging women to pursue cardiology. Meanwhile, Hispanics and African Americans represent only 6 percent of the current cardiovascular workforce, compared to 25 percent of the general U.S. population.

What To Do About It
What does this all mean? In order to meet the growing demand for cardiovascular services, more is going to have to be done to recruit cardiologists and other nonphysician practitioners to the cardiovascular world. Part of this can be done through advocacy: we need more government funding for fellowship training positions in general cardiology. The government needs to help promote practice efficiency, such as subsidies for EHRs, a reduction in administrative burden and tort reform. Advocacy also will be needed to create more opportunities for under represented minorities, including shorter fellowship training and increased mentorship. We’re also able to meet the growing demand through increased use of team-based care, which will require more funding to train nurses and physician assistants on cardiovascular-specific care.

The shortage of cardiovascular professionals is a significant problem that will only get worse if no action is taken. Read more about the workforce study, and additional ways to reduce the shortage, in the most recent issue of JACC.

* Dr. Rodgers' post is part of a monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!

Beginning on Sunday, ACC members from all across the country will be arriving in Washington, D.C., for ACC's 2009 Legislative Conference. These members will be on the front line of educating Congress during this crucial time about the need to stop the proposed payment cuts and for health care reform. I'll have coverage of the conference here, with posts covering some of the sessions, videos where available, and entries from members attending the conference. Also, you can follow ACC's advocacy Twitter account, @Cardiology, for more coverage. If you're attending Leg Conference, share why in the comments on this post.