If you haven’t seen it already, check out this great coverage of reaccreditation published by the Associated Press this week. The reporter attended ACC.10 in Atlanta and writes extensively about the great work the College is doing to help our docs prepare for recertification. This is fantastic coverage of the College and one of its core areas of expertise.

I had a follow-up discussion this week with David Blumenthal, M.D., President Obama’s national coordinator for health IT. It was smart to have Blumenthal at the Atlanta ACC.10 meeting because he learned a lot more about NCDR, our appropriate use criteria projects and the commitment to quality of care. Given that the three basic overarching principles for “meaningful use” are e-quality improvement, e-prescribing and the ability to exchange data between various provider levels (hospitals, pharmacies, other doctors, etc.), Blumenthal is very excited about advanced quality of care projects using NCDR and PINNACLE.

He is not certain how many doctors will avail themselves of the stimulus money for health IT implementation beginning in 2011, although, like me, he hopes it will be universally applied for. As you recall, Medicare participants will be eligible for up to $44,000 over five years for health IT if they qualify for meaningful use, the requirements of which will be phased in. Medicaid participants will be eligible for $63,000 and those who participate in both programs will be eligible for $63,000. We need to get back to Blumenthal about ways to participate together as soon as the meaningful use process has turned into an official set of regulations.

The ACC was lucky enough to have two members, Westby Fisher, MD, and Sarah Clarke, MD, attend ACC.10 & i2 Summit and blog about their experiences. As their final post, they each addressed two patient scenarios all too common in the U.S. health system: one patient with good health insurance and one patient without (in the U.K., this translates into one patient with private health insurance and one with coverage from NHS). 

From the U.S. perspective, Dr. Fisher outlines the expected costs that Fictitious Patient #1 will incur. Thurgood Powell has a $5,000 annual deductible, which significantly defrays that $440,000 worth of medical care he receives after receiving a drug-eluding stent, elective bypass surgery, and finally ICD implantation and home monitoring.

Fictitious Patient #2 (humorously named Mortimer T. Schnerd) is not so lucky. Why? Because he’s uninsured. Without insurance to pay for his expensive bills, Schnerd receives his care at the public clinic with some coverage by Medicaid. If he’s “lucky” and it is determined that Schnerd is disabled enough by the heart condition, he could eventually qualified for Medicare, which would make it a lot easier (although by no means easy) to find a health care provider to provide follow up care. Because let’s face it, with the rate that Medicaid reimburses physicians, it’s like finding a pot of gold at the end of a rainbow to find a provider who will take a new Medicaid patient.

Meanwhile, over in Britain, things are a little bit different. Dr. Clarke writes about how during emergency situations (like, say, a heart attack) even with private insurance, patients are treated through NHS. The only difference in Powell and Schnerd’s care if that Powell “can choose his physician, ... will receive treatment more quickly and at a convenient date compared to the NHS” and “has a more comfortable stay in a private en-suite room in the private wing of the hospital.”

Thoughts
Drs. Fisher and Clarke’s analysis bring up some interesting points, given the historic health care reform bill that was just signed. To begin, Schnerd’s going to have more options for insurance from now on. Beginning in 2014, he’ll receive tax credits to help him purchase health insurance from an exchange, as well as help with his deductibles and copays. He won’t be expected to spend more than $695 to $1,096.20 on premiums, with maximum out-of-pocket costs for deductibles and copays capped at 15 percent of the total costs. If he doesn’t get any insurance though, he’ll be stuck paying a fine of about $695 per year. (See how the health insurance law will affect you with the Washington Post’s calculator).

Powell on the other hand, won’t see any changes under the bill. Based on this scenario, that seems to work out well for him. 

At least in the NHS system, as Dr. Clarke points out, no one has to pay to receive the treatment they need. They just need to have money if they want the treatment when they want it (as opposed to when the system wants to provide it) and for any luxuries. This delay can certainly lead to problems... problems getting timely access to care (which in CV care can mean the difference between life and death) and problems getting care at a time that works for your schedule. It’s a classic battle between cost and timely access. We’ve heard it over and over again during the health care debate.

Dr. Fisher is careful to avoid any discussions beyond the facts, but I think it’s important to note one other thing about Schnerd’s care: You can be sure that if Schnerd was an actual person without health insurance and he received $440,000+ worth of medical treatment, he went through A LOT of emotional distress thinking about how to pay for it. In this case, yes, he ultimately had his bills covered. For a lot of uninsured people though, this is not the case. They become saddled with thousands, if not tens of thousands, dollars worth of medical debt. That’s not a health care system, that’s a health care disaster.

Which is why the health reform bill passed. It’s far from perfect – and there are many provisions the ACC simply cannot support – but it’s a recognition that the system is flawed and needs reform. Rest assured, the ACC will be working with Congress, the President and Secretary Sebelius to seek amendments and push to add tort reform.

A Big Thank You
Finally, I want to close with a big “thank you” to Drs. Clarke and Fisher. Each did a spectacular job covering the science at ACC.10 & i2 Summit, providing a unique experience for readers. Covering three days of breaking trials and the latest science certainly isn’t an easy task, and after a long day of sessions, they both still managed to squeeze out several very thoughtful blog posts a day. All I can say is WOW. And of course, in my typical style -- THX!

Don’t forget to submit your photos of the meeting here for your chance to win an Amazon Kindle loaded with a year’s subscription to JACC. We’ve gotten some great submissions so far, but I know we can get some others before the contest closes March 26.

Well, folks, another great annual meeting has concluded. I think it’s safe to say we’ve covered all the major CV issues during these three crazy days, along with many not-so-major issues. I personally have enjoyed all the talk of health care reform (if it should ever happen) and of quality of care issues.  I’ve had the opportunity to meet with some true visionaries: U.S. CTO Aneesh Chopra, M.P.P., Anthony Atala, M.D., Richard Satava, M.D., to name a few, plus the many leaders of the international cardiovascular societies who travel great lengths to attend the meeting. I hope you’ve found the meeting to be enjoyable and have some clinical insights you’ll take back to your everyday practice. Make sure to mark your calendars now for ACC.10 and i2 Summit: April 3-5 in New Orleans.

I want to hear from you: What’s been your favorite part of the meeting? Answer the poll below and leave a more detailed response in the comment section below the poll.

There have been a lot of great LBCTs at ACC.10/i2 Summit. Which do you think was the best?

Some post-ACC.10 blog coverage to look forward to: Our ACC member bloggers will be giving their take on the differences in the US & UK health system in the form of two hypothetical CV patients, Thurgood Powell and Mortimer Schnerd. From Dr. Fisher:

We thought it would be interesting to compare and contrast two heart patients - one with insurance and one without insurance - from our two health care systems, to illustrate how these patients obtain health coverage, might be managed, and how things look from the patient's perspective.

...

For the purposes of the exercise, we'll take two patients, Mr. Thurgood Powell, a highly successful 57 year-old businessman making $250,000 (£166,128) per year with his company PoshPosh Entertainment, and Mortimer T. Schnerd, a pleasant 43 year old man who is unemployed but working part-time in the local K-mart, earning $17,400 (£11,562) per year. Both men will experience heart attacks, both men will present to Emergency Rooms in both countries, and both men with require 4-day ICD stays and require the implantation of an automatic defibrillator and follow-up for the first year after the heart attack. Beyond that, heck, who knows. But that will at least give us a starting point to discuss the good, the bad, and the ugly of both health care systems and to compare and contrast the two systems. We will purposely refrain from political commentary in our posts (that's for you to do in the comments section!). We only ask that the commentary discussion be respectful and civil. I would be thrilled to hear what the British think of their health care system/costs/etc. over on Sarah's blog and the U.S. perspectives on this blog.

So there you have it. Look to their blogs (Dr. Clarke and Dr. Fisher) for the full discussion, and I'll be posting my response here as well. 

Other posts from Dr. Clarke today:

• Want to know more about AF??!! See this new website and other trial results from the ACC!: The ACC and Heart Rhythm Society have launched a new website just for AF !!! Take a look!
  
  
• DAT post DES…how long??: The aged debate goes on! How long should we be giving dual anti-platelet therapy (DAT) after DES? Current guidelines suggest 12 months….
  
  
• Cryoablation for PAF: STOP-AF: Whilst anti-arrythmic drugs (AAD) are not without morbidity or mortality, and radiofrequency ablation requires mutliple lesions and can be associated with complications, cryoablation offers PVI with a single continuous cryolesion. But what are the complications?

Last year during ACC.09, I posed this question to blog visitors. Fifty percent said that pocket guides helped you the most in implementing guidelines into your day-to-day practice; 20 percent said it was the guidelines on CD; 15 percent liked wall charts best; and the rest answered “other.” With the TAD guidelines out today, I’m interested in seeing how and if these results have changed over the last year. Answer below!

Actor John Ritter’s sudden death in 2003 from a thoracic aortic aneurysm brought much-needed attention to thoracic aortic disease (TAD). TAD does not have to be fatal, but proper diagnosis and management are critical to allowing TAD patients to live long and healthy lives.  To address the treatment needs for this condition, the ACC and the American Heart Association this morning released new clinical guidelines for the diagnosis and management of TAD. The guidelines arguably deliver a powerful message to physicians and patients: Early diagnosis and treatment can save lives.

One of the most important messages in the guidelines is that TAD often runs in families. As a result, family history is a critical tool for uncovering undiagnosed cases of TAD. Here are other highlights from the guidelines:

• Imaging of the thoracic aorta by computed tomography (CT), magnetic resonance imaging (MRI) or, in some cases, echocardiography is the best way to detect TAD and determine future risk. A chest x-ray alone is not sufficient.
  
  
• Patients with genetic conditions that increase the risk of TAD should have aortic imaging at the time of diagnosis to establish the size of the aorta, with periodic follow-up imaging thereafter.
  
  
• All patients with a bicuspid aortic valve should be evaluated to determine whether the aorta is dilating, or widening.
  
  
• The symptoms of acute aortic dissection, which can mimic those of a heart attack or another cause of chest pain, often make it difficult to arrive at a prompt diagnosis and may delay life-saving treatment. Physicians should keep aortic dissection in mind when asking questions about medical history, family history, and the type and pattern of pain, and when examining the patient.
  
  
• Aortic dissection involving the ascending aorta (the portion nearest the heart) is a life-threatening emergency that should be treated surgically.
  
  
• Aortic dissection involving the descending thoracic aorta may often be managed with medications that control the blood pressure and heart rate, unless life-threatening complications develop. Additional medical therapy may include statins to lower elevated blood cholesterol levels.
  
  
• Minimally invasive endovascular techniques are an option in some patients with aneurysm or dissection of the descending thoracic aorta.
  
  
• All immediate relatives of a patient with thoracic aortic aneurysm or dissection, or a bicuspid aortic valve, should be evaluated by a cardiovascular physician and undergo aortic imaging to measure the size of the aorta and identify asymptomatic disease.

The new guidelines will appear in the April 6 issues of the Journal of American College of Cardiology (JACC) and Circulation: Journal of the American Heart Association, and is available online. They were developed in collaboration with the American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. and the American College of Physicians were also represented on the writing committee.

Yesterday I spoke at a session on practice management called “Practice Innovation: How to Reduce Costs and Increase Quality.” This session offered a high-level look at the many resources the College has available to help practices deliver high quality care while saving money.

The session had an all-star lineup: former (as of convocation last night) ACC President Fred Bove, M.D., M.A.C.C., and now current president Ralph Brindis, M.D., F.A.C.C., were the session chairs. Ralph gave a talk about the role of registries in a reformed health care system and how registries can help measure success, reduce health care disparities and serve as an important tool in comparative effectiveness research (similar to what I wrote about on Sunday).

ACC SVP of Science and Quality Janet Wright, M.D., F.A.C.C., talked about the various quality programs that ACC runs, such as the highly successful Door-to-Balloon campaign, the newly formed Hospital to Home program and medication adherence initiatives. Co-Chair of the Health IT Committee Jimmy Tcheng, M.D., F.AC.C., talked about health IT and the tools necessary to adapt to delivery system change. My presentation at the session covered ways of reducing variations in CV care through tools like appropriate use criteria.

This session goes to show all the different ways that the ACC offers members to improve quality in different areas. That said, CV practices around the country are struggling under the recent payment cuts put into effect by CMS to make fewer practice dollars go farther. It’s understandable that the thought of participating in a quality program might seem impossible at this point. However, even in economically distressing times, the ACC continues to promote quality programs because quality must be the core of what we as health care professionals do. At some point (hopefully!), practices will have the resources to fully commit and expand their participation in quality programming.

*** Image from morgueFile (jdurham). ***