Every year I come away amazed by the College’s Legislative Conference.  I have attended the conference for the past five years and in my opinion this was the best one ever. I want to take one more opportunity to thank all of the ACC staff, the Advocacy committee, the PAC Board, and anyone else I forgot to thank in person who had a hand in creating this outstanding conference.

We need to keep this momentum going forward, to recognize that advocacy is an ongoing effort, that relationships are key, and that multiple viewpoints can be expressed in a civil exchange of ideas. I encourage all of you to continue sharing your ideas and experiences on this blog and in the special Legislative Conference Forum on CardioSource Communities.  Also, CVN has posted a great overview video of the conference, which is below. You can view all the Leg Conference coverage on the blog here.

This post is from ACC Fellow in Training Justin Bachmann, MD, who attended the 2010 Legislative Conference earlier this week.

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Washington is something of an old friend.  I had the chance to get well-acquainted with the city during my Internal Medicine training at Johns Hopkins Hospital.  Now a Cardiology fellow at UT-Southwestern Medical Center in Dallas and the Fellow in Training representative for the Texas Chapter of the ACC, I return to DC several times a year.  This was my first year at the ACC Legislative Conference, and I was exceedingly impressed.  The ACC staff has clearly put a lot of work into helping us advocate for our profession through the most effective channel – as constituents.

I arrived at the Fairmont Hotel on Sunday afternoon.  The ACC Political Action Committee was kind enough to host a happy hour for Fellows in Training on Sunday night.  I had a chance to catch up with several other fellows that I met on the interview trail back when I was a resident.  The highlight of dinner that night was the Capitol Steps performance.  The Capitol Steps are an improv group known for their scathing wit, and every elected official is fair game.  The Pelosi/Reid tag team skit was particularly hilarious.

The next morning we got down to business.  The Texas delegation had a good turnout.  I sat with Dr. David May, the Texas chapter President, Dr. Rick Snyder, the immediate past President and Dr. George Rodgers, a former chapter President.  One of my fellow colleagues from San Antonio, Dr. Oscar Bailon, was also present.  The day started with an update on the legislative arena by ACC CEO Dr. Jack Lewin and the ACC advocacy staff.  Dr. Lewin then spoke about the effects of the recent CMS rule on cardiology practices throughout the nation, including trends towards hospital integration and the increasing strain on private practices.  I’d be lying if I said the picture was anything but bleak.

Luckily, we learned that Rep. Charlie Gonzalez (D-TX), one of cardiology’s most ardent supporters, was planning on introducing legislation to require that reimbursement cuts be phased in gradually instead of being implemented immediately.  Together with his prior legislation designed to reverse the severe cuts to cardiology services, Rep. Gonzalez’s efforts represent our profession’s best chance at protecting ourselves from the recent CMS rule.  Dr. Brindis fittingly honored the Congressman with the President’s Award for Distinguished Public Service later that evening.  Rep. Gonzalez received a standing ovation, and deservedly so.

Our appointments on the Hill on Tuesday started off in Kenny Marchand’s (R-TX) office.  We to moved on to visit with the staff of Pete Sessions (R-TX), Eddie Bernice Johnson (D-TX), Michael Burgess (R-TX), Silvestre Reyes (D-TX), and Solomon Ortiz (D-TX).  It’s clear that everyone is concentrating on being reelected and issues such as the sustainable growth rate (SGR) won’t be tackled so close to election day.  However, most of the offices seemed receptive to signing on to Rep. Gonzalez’s new legislation.  

As I look back on the Legislative Conference on my way home to Dallas, I’m grateful that the ACC has a highly motivated advocacy staff that is working to protect our legislative interests.  I’m particularly grateful to Dr. May and Dr. Snyder, with whom I spent the day on Tuesday during my Hill visits.  Dr. May and Dr. Snyder have been incredibly supportive of fellows in Texas and are skilled advocates for the profession.  I appreciate their mentorship and guidance.  Hopefully by next year Rep. Gonzalez’s legislation will be signed into law.  Either way, I’ll certainly plan on visiting the Hill with my colleagues from Texas in 2011.

The post below is by Mike McGuire, MD, FACC, governor of the ACC New Mexico Chapter.

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Things are changing in the practice of medicine, in case you hadn't noticed, and there is the distinct feeling in the air that we are seeing nothing but the faintest hints of the things that will be. 

As I thought recently about the sense of foreboding I was harboring inside about this, it occurred to me I was making a mistake I have made much too often in my life when events seemed (and sometimes were) out of my control.  While contemplating my navel and mentally transmogrifying the events (whether health care reform or any other sticky wicket ) into the collapse of modern civilization and the equivalent of nuclear winter, I was missing one opportunity after another to change my environment for the better and was making the people around me generally miserable. 

A very good friend of mine made a statement that seems to apply nicely to how physicians respond to stressful situations, like the current health care environment.  He said we are trained from our first year in medical school, and usually even before, to deal with difficult obstacles by bowing our necks and working harder, feeling this will either allow us to blast through the problem in front of us or, at least, find solace in stress relief until the issue resolves itself.  It seems to me that, for those of us in cardiology at least, there are better and more productive ways to deal with the concerns before us.

Arguing over facts already plainly understood is a distraction and an impediment to efficient problem solving.  Another good friend, Story Musgrave, a thirty year veteran of the NASA astronaut corps, begins his explanations of how he dealt with difficult problems in space by saying, "It is what it is."  While seeming trite, this mantra relieves the problem solver of the emotions surrounding both what used to be as well as wishful hoping for the future.  What is plain is that the confusion and not a little irritation that many of us feel about current events in the remodeling of health care delivery is actually due to senses of entitlement (i.e., the past: a generally reasonable expectation of the respect of our patients and their gratitude and payment for our long hours of preparation, toil and emotion) and of continuity (i.e., the future: the assumption that we will always be able to set our own courses, whether in incomes, work settings, provision of the newest techniques for our patients, etc.). 

While I believe there is a lot of validity to these views of the past and the future, they are not very helpful right now, due to the shift in control in large measure to people who don't care a fig for how many hours you spent away from your family last week.  It is what it is.  Coming to this understanding and accepting it is the exact opposite of fatalistic acquiescence, because it facilitates the formation of very large goals based upon solid, provable data.  The end result is the restoration to us of much more control over the areas in which we are the experts.  Harry Reid is not among this number.  

The risks we face in simply forging ahead and criticizing the decision makers without providing better options include the loss of trust of our patients.  We will only lose their esteem if we give it away, sell it cheaply or trample it underfoot.  They are not as easily fooled as some people in government and elsewhere have believed, and I think we are beginning to see this in the polls.  Unfortunately, we have not done a proper job of selling ourselves on an individual basis, as we have assumed our good works speak for us.  Society is now factoring in other considerations important to them, not the least of which are the economy and the public's view of its impact on them.  

Predicted shortages of cardiologists in the near future, the aging of America (not to mention the rest of the world ) and the recent leveling off of the last thirty years' decline in cardiac mortality ensure that we will remain in the highest demand, along with GI and Oncology.  Not only are we not going away, we are faced with the remarkable opportunity of figuring out how to care for more of our fellow citizens than we ever imagined.  We can see this as Feast or Unimaginable Burden, but living in the current reality frees us to imagine, help to design systems and set goals not even considered in the past.  While the current hot button is the genuine need for more primary care, it will be a very short time before the laudable initiative of expansion of access to care comes home to roost.  At that point, the systems necessary to provide cardiac care for so many people will be tested, and we have the opportunity now to be pacesetters and designers.

We believe the opportunity to make the health reform process tolerable and even useful is being offered to us.  Covering old ground is counterproductive and we can do better.  

This blog post is from Eugene Sherman, MD, FACC, vice-chair of the ACC Political Action Committee. For more updates from Dr. Sherman, visit his CardioSource Communities profile.

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The 2nd Annual PAC Luncheon during the ACC 2010 Legislative Conference was the highlight of today for the many ACC members lobbying on the Hill.  The PAC Luncheon is designed to bring a topical speaker, ACC Advocacy staff and donors. 

This years guest speaker was Karl Rove, well-known for his political activities and advisory role with President George W. Bush.  He even began his program by telling us about his experiences with James Carville, last year's speaker.  Mr. Rove was candid and entertaining in his Texas style with careful and detailed analysis of current President Obama based on recent poll data.  He critiqued both parties and their approach to this year's mid-term elections.  While not as much of a comedian as Mr. Carville, he was more analytic and factual and actually less opinionated in discussing the course of American politics as he sees it today.

His response to a question from former BOG Chair John Harold, MD, FACC, about 9/11 was insightful about the activities of that eventful day and the character of Mr Rove himself. For me, it was moving to hear his description of history and what those involved were thinking during the early minutes and hours after the attack on our country.

We are able to have this event and our Legislative Conference because of the leadership of the PAC under Bo Walpole, MD, FACC, who followed in the steps of Jay ALexander, MD, FACC, a leader who helped grow our PAC over the past several years.   Our PAC staff of Nick Morse and Kaycee Smith along with leadership provided by ACC CEO Jack Lewin, MD, and ACC SVP of Advocacy Jim Fasules, MD, FACC, has made ACC the envy of many specialty organizations.  

Please try to join us next year for the 2011 Legislative Conference and the 3rd Annual PAC Luncheon.  We will try find another top-notch political figure for 2011.

It was our pleasure yesterday afternoon to welcome to the 2010 Legislative Conference a pillar in the medical community – new Centers for Medicare and Medicaid Services Administrator Donald Berwick, M.D.  As I've said before, I believe it is important that we have both a physician and someone who understands quality at the helm of CMS. Berwick has been a long-time friend of the ACC and I believe his presence at the Legislative Conference highlights his commitment to listening to us and understanding our issues.

While he didn't go into great detail, Berwick spoke at a high level about his vision for the health care system and ways the physician community can work with CMS to bring this vision to fruition. He outlined what he sees as CMS’ three main jobs:

1. To run a very large insurance and financing system;
2. To implementing affordable care; and
3. To help change health care in the U.S. and make it become what it can be.

According to Berwick, the key to the third job is dependent on clinical leadership. “Only the people that give the care can actually change the care,” he said. “Without complete partnership with the delivery and clinical providers in this country, we will not realize the full potential of our health care system.”

When asked about his alleged interest in rationing, he replied that he believes every patient should receive all the care that will help them – he would not deny anyone the care they need. But, he said we should not be giving care that is unnecessary, unscientifically sound or dangerous.

He encouraged a focus on acute care, integrated care and effective prevention. He challenged participants and the ACC to take what they know and make it applicable to a broader audience. He cited the ACC’s D2B Alliance, Hospital to Home initiative and registry work as examples of ways the ACC is leading and doing just that.

Berwick also encouraged conference participants to define a common vision of the health care system that brings the “triple aim” of better health care (quality), better health and lower costs. He noted that government can’t build the health care system alone. “If we don’t work together, I don’t think we’ll get there at all,” he said.

He closed by saying “authenticity matters.” He urged change, not the creation of new names for old ideas. The applauded the ACC as being an inspiring leader and example when it comes to dedicated professionals working to improve the delivery of health care.  The 400 bipartisan attendees gave him a long standing ovation! He definitely turned a lot of potential skeptics into avid supporters.

In what ways can CMS and the ACC work together? Share your thoughts by commenting below.

Yesterday I presented to ACC’s Board of Governors about the health reform and its likely effects on payment models. There is a wide array of pressures affecting the health care system right now. For one, we’re hearing more and more talk about cost containment and remaining competitive in a global economy. Health care eats up 17% of the country’s gross domestic product and is growing at a faster rate than the GDP. Meanwhile, the rising cost of health care premiums (the ACC’s premiums for its employees are going up 18%) puts a strain on U.S. businesses to compete with other global businesses that do not have to pay for their employees’ health care, enabling them to cut costs.

To get costs down, a variety of changes have been proposed. This includes the integration and consolidation of physicians, hospitals and insurers to reduce overhead and duplicative services. There’s also purchasing power in large integrated systems. Some ways we might see this play out in the future is through the creation of more integrated systems (or accountable care organizations?). Integration can be horizontal (physicians aligning themselves with a hospital but not being employed by it) or vertical (where the physician is an employee of the hospital).

While either model could work out positively, the ACC and I would much prefer a future of horizontal integration of physician groups, independent practice associations, and other physician managed entities contractually aligned with insurers and hospitals. This protects physician autonomy, the patient-physician relationship and could even be ultimately a better strategy for hospitals and insurers than having them try to manage physicians as employees. The ACC continues to work hard to protect those physicians who choose to remain in solo or small group practice. These practices are more viable in some regions of the country than in others but, given that the vast majority of fellows seem to prefer employment at larger group venues, the movement toward integration is significantly driven by physician choice not health reform pressures externally.

There’s also the growing use of PATIENT incentives to keep down costs. Employers are increasing the burden of growing premiums by transferring costs to employees. Patients receive cheaper copays for visiting a primary care physician than visiting a specialist. Insurers are offering cheaper premium rates for staying within a “preferred” network of physicians.

Related to cost, there’s the problem of payment. See ACC SVP of Advocacy Jim Fasules’ write up earlier today about the SGR and its very expensive problems. Clearly, it’s not working. Because of this, we’re seeing a pressure to move away from fee-for-service reimbursement and toward models like the patient-centered medical homes and performance-based incentive programs. It remains to be seen what the best way of doing this is, but we know we need to find some way to pay for high-quality, patient-centered care.

The system is clearly struggling to implement delivery system reform. Never before have we seen such a pressure to implement electronic health records in a nationwide fashion. These systems enable better and easier care coordination, which can improve the patient experience by reducing duplicative testing and transferring of paper files. With widespread adoption of EHRs and care coordination, we could see a dramatic shift in how care is delivered. We’re also seeing a shift to focus on prevention, although much remains to be done on this front, in particular for cardiology.

The health reform law, or the discussions around it, is in large part responsible for bringing some of these changes to fruition. Whether or not you agree with the changes it’s bringing, they are here in large part to stay, even though ACC is working with other societies on “clean up” legislation should look. Cardiology must bring ideas to the table to portray ourselves as a specialty that the White House and Congress can come to for advice when finalizing the details over the next few years.

This post is written by ACC's Senior Vice President of Advocacy Jim Fasules, M.D., F.A.C.C.

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With ACC’s 2010 Legislative Conference underway, one of the main topics on the agenda is the ongoing battle over the sustainable growth rate (as Jack calls it, the SGRrrr). The SGR is one major part of the formula that is used to determine what rates Medicare pays physicians. Every year for the last 7 years, the SGR has been scheduled to be a “negative update” (meaning that physicians would be paid LESS for the same procedures than paid in the previous year). However, also every year for the last 7 years, the cuts have been overturned at the very last minute. This year, they actually were allowed to briefly take place. Retroactively reversed, the destabilizing force this placed on practices was palpable.  

Delays in addressing the SGR create an unacceptable situation for physicians. With the delays from haggling, we can’t know what our payment rates are going to be in advance, payments can be delayed and we’re put at extreme risk of negative updates in payments at a time when all practices are struggling to survive. Retroactive payment adjustments following claims holds are disruptive to physician practices and contribute to reduced access to care.

In December, the current short-term positive update will expire, leaving physicians facing a 23% cut. Is it likely that Congress will understand the issue and give us a 13-month positive update allowing us to work toward true payment reform? Sure. But more likely it will kick the can only a month or two down the road. Is this what we want ... Is this going to create stability in Medicare payment? No way.

Congress just doesn’t have the courage to fix the SGR, a mess they created. Given that we’re now entering election season, we’re even less likely to get the permanent fix we need. Although we’re unlikely to get a permanent fix, we are working with the AMA and other medical societies on a long-term solution. A 3-5 year SGR temporary patch fix would give us the time we need to test and try payment reforms that improve quality, promote patients, and allow the profession to remain viable for current members and future physicians. The ultimate goal is to repeal the unsustainable formula and install a new and more stable physician payment system. There is little more important than this effort to maintain practice viability.

A new ACC survey of more than 2,400 practices was presented today during the 2010 Legislative Conference. The survey provides a comprehensive snapshot of the current state of cardiology given the changing health care landscape. Respondents from 49 states and Puerto Rico provided valuable insight into the various ways the changes are forcing many private practices to take drastic actions to remain viable. 

Over the last year, the survey found that more than half of all practices have taken some form of cost-cutting action as a direct result of the cuts in reimbursement for cardiovascular services included in the 2010 Medicare Physician Fee Schedule. The first and largest wave of activity is directed at the staff level, with half (50 percent) of cardiovascular group practices reporting a reduction in staff to save expenses. In addition, 40 percent of survey respondents said they have reduced staff benefits, while 45 percent have reduced salaries for physicians and clinical staff (28 percent). The second wave of actions more directly impacts patients. Survey participants reported limiting services (18 percent), reducing hours and availability (10 percent), and limiting the number of new Medicare patients (9 percent).

Private group practices are significantly more likely to have initiated cost cutting activities. Patients are being pushed to hospitals to receive services which results in higher co-pays, longer turn-around in treatment, and increased costs of care. If the pocketbook continues to be tightened, practices will be forced to further limit patient services.

Private practices have also been forced to re-evaluate their business models and look for options that improve the quality and efficiency of their practices, while also providing additional revenue. This has resulted in a trend toward hospital integration or practice mergers. According to the survey, nearly 40 percent of private group practices are currently integrating with hospitals or merging with other practices. Meanwhile, 13 percent of all cardiovascular practices are considering hospital integration or a merger in the next three years to help stem the financial burden.

The ACC will be using the survey data to help determine next steps in terms of meeting member needs in terms of team-based care, quality improvement tools, educational tools and other resources. The survey results will also help inform advocacy efforts related to payment reform and health care reform implementation.

The changing practice structure has the potential to profoundly affect the physician/patient relationship, patient care and costs. These changes also will have impacts on professional societies like the ACC. Our job will be to continue to track the changes in cardiovascular practice and use the results to have in place the needed support and tools for our FACC constituency to ensure patient access to quality, evidence-based care.

* The ACC’s 2010 Practice Census was conducted from May 5 through August 9 by email and telephone. A total of 2,413 unique practices from 49 states and Puerto Rico participated in the study. The response rate was 31 percent.

As Cardiology continues to change, the goal of the ACC and its Chapters is to keep members informed of the national and local trends that are impacting the practice of cardiovascular medicine. On Sunday, the College’s Board of Governors met for its third and final regularly scheduled meeting of the year to discuss these trends and learn about ACC efforts to help members meet the challenges associated with these trends head on.

The meeting kicked off with a first look at the recent ACC 2010 Practice Census. More than 2,400 respondents from 49 states and Puerto Rico provided valuable insight into the various ways changes have forced many private practices to take drastic actions to remain viable.  Heading into the 2010 Legislative Conference over the next two days, the Practice Census results will be crucial in discussing state-based impacts of health care reform and ongoing Medicare payment cuts.

The survey found that over the past year more than half of all practices have taken some form of cost-cutting action as a direct result of the cuts in reimbursement for cardiovascular services included in the 2010 Medicare Physician Fee Schedule. In addition, the survey found that private practices have also been forced to re-evaluate their business models and look for options that improve the quality and efficiency of their practices, while also providing additional revenue. According to the survey, nearly 40 percent of private group practices are currently integrating with hospitals or merging with other practices.

Other issues of importance to states include local coverage determinations, radiology benefit managers and the public reporting of PCI data. BOG members were able to discuss these issues in detail and provide first-hand feedback in terms of challenges and successes. Also key, BOG members were given inside looks into ways the College is paving the way to address national and state-based trends. Whether it’s harnessing technologies that put guidelines at the bedside, working with health plans to develop a tool that focuses on ensuring appropriate use of medical imaging, or developing a “Cardiovascular Practice Improvement Pathway” that recognizes quality, evidence-based care, the College has a number of new initiatives underway to meet the needs of members. In addition, the PINNACLE Network and Registry are working to ensure data-driven system development, increased adherence to practice guidelines, provide lifelong learning opportunities and ensure appropriate payment and recognition.

Guest speakers, including Joshua Seidman, Ph.D., director of the Meaningful Use Group for the Office of the National Coordinator, were also on hand to provide insight into other areas of interest to cardiology. Seidman provided answers to questions about the new federal EHR incentive program. In addition, George Diamond and Sanjay Kaul of Cedars Sinai  spoke on the subject of “From Clinical Trial Evidence to Practice Guidelines: Lost in Translation.” Their presentation encouraged discourse around the challenges associated with the development of clinical guidelines.

The College has many opportunities to lead and help shape the new health care landscape. Much of the work in terms of implementation will take place at the state level. Coming out of this meeting – on football Sunday no less – I believe the College is prepared to carry the ball into the end-zone.

Which reminds me, your chance to choose your next ACC Governor is coming up. BOG elections will be open from Oct. 19 to Nov. 16.  the Board of Governors (BOG) and Cardiac Care Associate (CCA) Liaison elections are open from Oct. 19 to Nov. 16. Visit www.CardioSource.org/Elections for more information and details on the election process, or contact your National ACC Chapters staff at 202-375-6657.

The past several weeks have been frustrating for any physician in the United States, and perhaps even worse for cardiologists trying to run small businesses. Congressional gridlock is at its best as the debate over the sustainable growth rate (SGR) continues. The so-called “patch” keeps getting smaller and smaller and, as of right now, it looks like it will be Groundhog Day all over again come November.

As things currently stand, the Senate last Friday passed a six-month patch that would give doctors a 2.2 percent payment update through November. The agreement is now before the House, which could vote as early as tomorrow.

The ACC’s Legislative Conference in September will definitely be interesting if nothing is done before November to find a longer-term solution. The continued state of limbo is making it difficult for practices already struggling with reduced payments. You can’t plan for the future when the “future” changes every 30 days. To make matters worse, the 2011 Proposed Medicare Physician Fee Schedule is expected out later this month and, while we don’t know all that’s included, we do know the second year of the phased-in practice expense cuts will hit cardiovascular practices. There will also be additional SGR cuts.

I think it will be critical to use our face-to-face time with members of Congress to educate them about the current state of cardiology and what needs to be done in terms of payment reform and health reform implementation. We must also use this time to have a frank discussion about the value of cardiology as a specialty. We come to Congress as an association of cardiovascular professionals. We can proudly point to innovations that have led to meaningful reductions in cardiovascular death and disability. We also remain committed to the appropriate and safe use of imaging, the reduction of readmission rates and the prevention of cardiovascular disease.

In the meantime, it’s important to note that CMS as of June 18 is processing June claims at rates that reflect the 21.3 percent SGR cut. If the House and Senate act to avert the cut, claims will be processed as follows: (1) where the submitted charge is higher than the new rate, the contractor will automatically reprocess the claim; and (2) if the submitted charge is lower than the new rate, the physician should call the contractor. According to the AMA, no one is going to be reviewing the limiting charge for the period that the cut was in place because CMS assumes Congress will ultimately make the fix retroactive.