ACC’s 2011 Legislative Conference had some great afternoon speakers on Monday, including health economist Len Nichols, PhD, and Nancy Nielson, MD, senior advisor to the Centers for Medicare and Medicaid Innovation (CMMI). Both Nichols and Nielson spoke about the need for cardiovascular professionals to get involved in payment innovation. We have the knowledge on how to make it work, they said. If we don’t get involved, someone else less knowledgeable will do it for us.

Nichols talked about the winding road that is payment reform, noting that the current unaccountable fee-for-service and third-party payment system has brought us to a place where the value of care per dollar is less than it could be, prices are above minimal costs and quality is not optimal for every patient. Failure to address these issues in a way that works for patients and providers will very likely result in across-the-board cost controls and/or utilization reviews or benefit cuts, he said.

According to Nichols, new payment models will require the alignment of care coordination outside of typical boundaries, and will involve a greater level of risk to providers than the current fee-for-service system. In addition any new model, outside of pure cost or benefit reductions, will require that patients be engaged in their own care through cost-sharing, wellness education and incentives to stay healthy. Decision support also will be critical in order to ensure that clinicians and patients have right the right incentives and information to make the most appropriate care decisions and facilitate risk sharing.

Nichols is the editor-in-chief of a newly launched website, the Community on Payment Innovation, which aims to bring great ideas together and highlight innovative payment models. By using the site, which is a joint venture of the ACC and the American Journal of Managed Care, we hope to generate ideas that we can bring to federal agencies, such as CMMI, to implement.

 

Nielson discussed the different payment pilots that CMMI has underway. The health care reform law authorized $10 billion in funding to study new ways to deliver health care, and that funding is what created CMMI, Neilson said. CMMI has a unique advantage over other agencies: waiver authority. This means it has the power to do things, like offer gain-sharing, that its parent agency, the Centers for Medicare and Medicaid Services (CMS), cannot. Some of CMMI’s pilots that you may have heard of: Partnership for Patients, Pioneer Accountable Care Organizations (ACO) and the CMMI bundling initiative.

The bundling initiative is interesting for a couple of reasons. It’s based on a CMS pilot, the ACE demonstration, which looked at bundling payments for acute care for certain cardiovascular and orthopedic procedures. CMMI took this base model and looked for a way to make it more flexible for a variety of different practice environments. What it ends up being, she said, is a way to get your feet wet with a new payment method if you’re not ready to be part of an ACO. You’ll still get a fee-for-service payment, but you may also get a gain-sharing payment on top of the fee-for-service payment. In addition, participants don’t need to go all-or-nothing; you’re able to try the payment method for one or two DRGs and see how it goes.

 

Both Nichols and Nielson stressed repeatedly that payment innovation WILL happen because we simply can’t afford not to. As Nielson said: “We are in a crisis. The cost of medical care is a major issue.” I couldn’t agree more. The pilots of CMMI, if implemented nationwide, may begin to address some of the issues. We’ll need to be leaders in this though. As Jack Lewin, MD, used to say frequently while the health reform law was being drafted: If you’re not at the table, you’re on the menu. Let’s get our thinking caps on a figure out what’s the best way to innovate our payment system.

By John Gordon Harold, MD, MACC, vice president-elect and former chair of the Board of Governors

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ACC’s Advocacy Steering Committee met early this morning to discuss our priorities for the next year. While new issues will likely arise, the following issues are ones where the College can proactively lead change or support cardiovascular professionals as they continue to provide quality care.

ACC Priority Issue #1: Reform Physician Payment.

This isn’t a new priority by any means, but with our health care system in flux under reform, this is our chance to enact the changes we’ve been pushing for over the past couple of years. This includes: repealing the sustainable growth rate; promoting alternatives to radiology benefit managers; providing guidance and testing for innovative new payment models that reward quality, cost-effective care; and mitigating the effects of Medicare/Medicaid rules on cardiovascular professionals.

ACC Priority Issue #2: Reform the Health Care Delivery System.

The health care delivery system is undergoing a much-needed overhaul. It’s us to up to make sure that whatever happens, the outcome allows for cardiovascular professionals to continue to provide high-quality care. This means we need to work with Congress, policymakers and other stakeholders to define what constitutes an accountable care organization, independent practice association and the patient-centered medical home. In addition, when it comes to the health reform law, we’ll need to improve the provisions that negatively impact cardiology and work with chapters on the state-specific health reform issues.

ACC Priority Issue #3: Tort Reform.

Definitely an ongoing issue, although one that is receiving more discussion this Congress compared to past. We’ll continue to support a bill from Rep. Phil Gingrey, M.D., an OB-GYN from Georgia, which would implement medical liability reform that ensure that injured patients are compensated quickly and fairly; improve provider-patient communications; and foster an environment for affordable and accessible medical liability insurance. Separately from this bill, we’ll work with Congress and state lawmakers to incorporate other reforms, such as health courts, certificates of merit and adherence to practice guidelines.

ACC Priority Issue #4: Health Information Technology.

There’s a lot going on federally with health information technology and we need to make sure ACC members are ready. For example, to avoid a penalty in 2012, physicians need to start e-prescribing between now and June. In addition, up to $44,000 per physician is available to providers who can demonstrate meaningful use of an electronic health record. We have to provide the resources to make sure ACC members are able to participate in these programs and capitalize on the financial incentives.

ACC Priority Issue #5: Regulatory Changes.

Regulatory changes are underfoot, and we need to get in now to shape the policies so that they don’t compromise high-quality patient care. Some issues that we’ll need to stay involved in: the transition to ICD-10 codes for medical diagnosis and inpatient procedure coding; new imaging lab accreditation requirements for Jan. 1, 2012; coding changes based on bundling trends; and the FDA focus on radiation safety and medical and device safety.

We’ve got our work cut out for us. What are your thoughts on these priorities? Are there any you would add?

The ACO concept -- while arguably still pretty foggy -- is certainly attracting a lot of attention in the health sector.  But, are ACOs going to eat up the non-integrated private sector?  Certainly not imminently.  But the ACO concept is worth some serious consideration by the profession. The ACC is certainly going to explore how the concept might be beneficial to some members and patient populations. There is potential here -- maybe.

Assuming the Affordable Care Act prevails in its legal challenges (and if it somehow does not, something similar to it needs to be created post haste to deal with the rising numbers of uninsured persons and costs of US health care), ACOs represent are a major element of the law, and the Secretary of Health and Human Services will have broad authority to provide financial incentives for them. Money is promised to flow here.

In fact, ACOs have become central to current thinking about how American health care might find ways to bend the cost curve and better organize health care. Huge conferences occur every week in DC it seems on what ACOs might be and how to build one. The idea is to bring doctors, hospitals, and health plans and Medicare (and Medicaid) together in ways that would hopefully streamline health care, improve patient health status and outcomes, reduce variation in care, and lower costs. Sounds like a fairy tale, doesn’t it? But, hospitals are wildly buying up physician practices to be ready to create ACOs. Health plans, particularly United and CIGNA, have already started buying up medical groups to build ACO networks and pilots -- health plans do NOT want to see hospitals predominate in this proposed transition of the delivery system. Even many physician IPAs and medical groups in California, Colorado, and elsewhere are similarly gearing up. All are hoping to land CMS “innovation center” grants.  ACO policy wonks and consultants are multiplying and are in evidence everywhere one looks.

This frenetic activity is all certain to keep churning along, driven by market forces, even if the ACA controversy drags on through next year. However, the ACA directs the Secretary of HHS and CMS to publish regulations on how ACOs will be structured and financed. The big question is -- where are the proposed regulations from CMS?  The ACO regulations were promised in January, then February, and now it’s mid-March. Whassup? 

Rumors are that the regs have gotten hung up over anti-trust concerns with DOJ and the FTC (Federal Trade Commission). Since ACOs will likely only be effective if they can bring physicians, hospitals, and health plans together to cover a large population and geography, issues around market dominance and anti-trust develop.  One of the ridiculous aspects of current US anti-trust policy that health plans are exempted from most market domination provisions. Hospitals and doctors are not. The Secretary supposedly has authority in the Affordable Care Act (ACA) to waive some anti-trust concerns for ACOs, and this is likely to be challenged by the FTC and the current Congress. So, the regs are in limbo. But that’s not stopping the action sans ‘regs.

Modern Health Care this week carried a story on an anti-trust debacle developing in Nevada as an ACO there tries to take shape. The Nevada attorney general's office and the FTC have launched an inquiry into a patient-care collaboration between Reno-based Renown Health and a local cardiology practice, Sierra Nevada Cardiology Associates. The alliance was the first step in forming an accountable care organization for the two organizations. 

"Their interest is not unexpected given the size of the transaction, and we've met and are cooperating and providing requested information," said Terri Hendry, Renown's spokeswoman, said in the article. "We are confident that this change is in the best interest of consumers and will result in improved coordination of heart services in the region." The ACC is monitoring this process and the entire process of the amazingly rapid changes occurring in the US health care delivery system around integration, physician employment, population based health systems, and payment reforms. Whew. A lot is happening, folks, despite what Congress thinks they can control.

What challenges will cardiology face in this politically tumultuous year? Read on. Last week the Coalition of Cardiovascular Organizations (CCO) met at Heart House to forecast, discuss, and seek consensus on what is on the horizon in 2011 on the congressional and state advocacy agenda. President Ralph Brindis, MD, FACC, President David Holmes, MD, FACC, and President-Elect Bill Zoghbi, MD, FACC, with ACC SVP of Advocacy Jim Fasules, MD, FACC, and I represented the ACC, along with the officers and staff leaders of Heart Rhythm Society, Society of CV Angiography and Interventions, American Society of Echocardiography, American Society of Nuclear Cardiology, Society of CV Computed Tomography, Society of CV Magnetic Resonance, Heart Failure Society of America, Society for Thoracic Surgery, the Association of Black Cardiologists, and Society of Atherosclerosis Imaging and Prevention. The Society for Vascular Surgery couldn’t attend.

It was a great exchange! Here’s my view of what we came up with as consensus priorities:

• Payment reform issues, including the getting rid of the SGR, are critically important to all. There was a general sense that we have to look beyond fee for service, and explore other bundling, episodes of care, and global budget opportunities, where an upside is conceivably possible, but certainly not easy to achieve. Some members will want to stay with fee for service, and we need to protect them as well. But re-aligning incentives and going where opportunities are is a big challenge for all of us. Business as usual is not going to work.
  
  
• Championing quality improvement is a major part of how we take on the above issues. We need our registries and accelerated abilities to continue to translate science into better clinical guidelines, performance measures, appropriate use criteria, and other tools to do that. This is how we will lead in cost containment and improving value.
  
  
• Addressing and monitoring workforce issues, including what the heck is really going to happen to primary care? What will the future role of specialists be?
  
  
• We need tort reform -- we have ideas here.
  
  
• Accountable care organizations and pressure for integration -- needs to be implemented such that physicians are not at a disadvantage to hospitals or insurers in the design and governance of such structures if they proceed. In some form, I believe, they will.
  
  
• Myriad specific issues: The RUC and CMS assaults on cardiology; precertification issues with insurers; RBMs; meaningful use, PQRS (formerly PQRI), fair e-Rx incentives and requirements; protecting private practice viability; adding value to hospitals where members are employed, consulting cuts, etc. We need to develop leadership skills too!

Doing all of this is tough in a zero-sum Medicare game; with ongoing disparities in evidence; with no respect for long-term value (VADs, transplants, TAVI); and docs not paddling together.

Let’s face it, nobody really loves change unless it doesn’t mess with your world or you are assured of being a big winner -- no risks, please. In most circumstances, the status quo is comfy. Change is pain. Okay, okay, I could rightfully be diagnosed as either a disruptive innovator or a being who is drinking too much coffee.  

While a majority of physicians and hospitals, and a good number of cardiology practices, are digging in their heels to protect against the looming and threatening-appearing changes afoot in health system reform, others are entrepreneurially moving forward to be positioned as winners in the future. Betting on those kinds of practices and innovators now will be the CMS' Center for Medicare and Medicaid Innovation (CMI) in the grants they will soon be awarding. They are already sponsoring a two dozen accountable care organization (ACO)-like pilot projects for group and solo practice volunteers.

And now, the Robert Wood Johnson Foundation, AHRQ (the HHS Agency for Health Care for Research and Quality), and the ONC (the HHS Office of the National HIT Coordinator) have teamed up in aligning their grant-giving to foster the same thing, but in this case the focus is on improving care and health status at lower costs in entire geographic communities, and in both private and public health care services.

David Blumenthal, Carolyn Clancy, & Risa Lavizzo-Mourey write about these plans as directors of ONC, AHRQ, and the RWJF in a Health Affairs blog this month. They point out that “if you’re looking for a transformation in health care, look first to America’s cities, towns and communities. That’s where it happens, among local men and women who deliver and receive care, and the employers and consumers who pay for it.”

They are together now funding more than half a billion dollars in various regions. They point out that money alone won’t improve quality and reduce costs. Rather, for that to happen, teams of local leaders from a range of perspectives must design and implement tailored changes in the way their region organizes, delivers and pays for health care. Each of the projects is thus different.

• RWJF’s Aligning Forces Program kicked off in 2006, and has engaged consumers and providers to measure the performance of docs and hospitals, reporting it publicly, and improving the quality, cost and equality of care being delivered. The Aligning Forces regions are beginning to explore payment reforms to help sustain and increase local improvements in quality.
• ONC’s Beacon Communities has joined the regional improvement effort with a large three-year grant, helping select regions use health IT as a community foundation on which to improve health and health care by being on the cutting edge of electronic health record adoption and IT-supported care coordination, quality improvement, payment reform and population health initiatives.
• Aid To Communities From AHRQ funds tools to build and sustain local collaborative leadership, engage the public and increase performance measurement, and create incentives for quality and improve preventive services. AHRQ’s Chartered Value Exchange project (CVE), in particular, is helping 24 select regions systematically improve the quality and value of health care provided locally.

If your practice, hospital, or community isn’t involved in one of these efforts, or isn't preparing for a CMI innovation grant, sitting around griping about change isn’t going to position you well in the future. The ACC is using NCDR and PINNACLE, FOCUS (imaging AUC), and other programs in CV care to give any of you who really are ready for needed change to be a the forefront on those communities and groups ready to get involved in creating a better future.

Accountable Care Organizations (ACOs) are as yet ill-defined integrated networks of doctors, hospitals, and payers proposed in the Affordable Care Act that will be eligible for large additional payment incentives for care of patients across defined geographies. A central feature of ACOs may be “patient centered medical homes” (PCMHs) that will eligible for additional capitated payment for coordinating care. A growing controversy within these discussions is whether PCMHs will be “gatekeepers,” that determine who will be able to see a specialist, or whether there will be both primary and specialty versions of PCMHs with some degree of patient choice of physician depending on the acuity of the diagnoses and chronic diseases requiring care.

A group of primary care associations—the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association—has released their Joint Principles for Accountable Care Organizations (.pdf).

The 21 principles describe important aspects to consider when building the administrative structure of ACOs, as well as how payment should be facilitated. The four organizations developed the principles through an extensive collaborative process to reflect those attributes they believe are essential for the effective implementation of the ACO model within the health care system. The principles state that primary care should be the foundation of any ACO and that the recognized patient and/or family-centered medical home is the model that all ACOs should adopt for building their primary care base.

The groups said in a joint statement that they sent their principles to CMS “to encourage their use as the agency outlines ACO demonstration projects, as well as to guide related ACO activities offered through the newly established CMS Center for Medicare and Medicaid Innovation.” The ACC agrees that primary care should be the typical basis for the PCMH, but disagree that a universal mandate to that effect will be harmful to seriously ill patients.

What do you think? Should specialties be allowed to participate in the medical home? Answer in the comments section below or in the Cardiology Discussions forum on CardioSource.