Last week I had the chance to attend the Cardiovascular Summit: Solutions for Thriving in a Time of Change, held in Las Vegas. The CV Summit started last year with much success and continued this year with more than 400 attendees!  It was a superb meeting that left participants with more knowledge, solutions, and next steps to thrive as physicians in a time of uncertainty and continuous change.

The meeting kicked-off with sessions on the status of health care reform in the U.S. and the potential impact on cardiovascular medicine over the next few years. The keynote address, given by Harold Miller, executive director of the Center for Healthcare Quality and Payment Reform, taught us ways that physicians can lead the way to a new reimbursement system that rewards quality, rather than quantity, while saving money for the health care system.

The following day covered data management and the cardiovascular service line, essentially how to work better with each other and using data to connect the dots, as well as how to implement a solid infrastructure from the get-go.

In a special workshop for congenital heart disease professionals, ACC Senior VP of Advocacy Jim Fasules, MD, FACC, shared Medicaid changes expected as a result of the Affordable Care Act, as well as widely anticipated value-based purchasing programs and their potential effects on pediatric cardiology.

In addition, due to the massive coding changes this year stemming from the Medicare Physician Fee Schedule, a pre-conference session discussed appropriate documentation for those codes and concerns about audits.

Finally, the Summit appropriately concluded with sessions on leadership and governance. Workshops on finance and evolving payment models discussed contracts, horizontal integration, incentivizing physician and MLP compensation, and more, and left attendees with ways to deal with the new, evolving environment – things that they don’t necessarily teach you in medical school.

In the session on strategic change and how to keep your organization from becoming irrelevant, W. Martin, MD, eloquently stated that change never stops. There may be a reprieve between changes, but a broader vision requires a next evolution, another change. I couldn’t agree more, and it is our duty to educate ourselves and lead the change.

Special thanks to everyone involved for making this meeting a huge success, especially Howard Walpole, Jr., MBA, MD, FACC, course director of the ACC Cardiovascular Summit, and Pamela S. Douglas, MD, MACC and C. Michael Valentine, MD, FACC, course co-directors.

Be sure to check out ACC’s Facebook page for photos from the CV Summit.

Stay on top of 2013 changes and efficiently and accurately report cardiovascular services and procedures with the updated 2013 CPT® Reference Guide for Cardiovascular Coding. Visit CardioSource.org/CPT to order your copy.

Earlier this week the nation waited in anticipation as the American Taxpayer Relief Act of 2012 was passed through the Senate, and eventually through the House late New Year’s Day, therefore averting the so-called “fiscal cliff” from taking effect. The bipartisan deal included a one-year patch of the flawed Sustainable Growth Rate (SGR) formula, preventing Medicare payment cuts of 26.5 percent that were set to kick-in on Jan. 1. Across-the-board sequester cuts of 2 percent were also delayed, keeping Medicare reimbursement safe for another two months.

Throughout the past year, ACC leadership and staff helped lay the groundwork for several quality-related provisions in the new law through ongoing dialogue with congressional committees about ACC’s quality improvement tools, including registries. Included in the legislation, was an extension of the Geographic Work Adjustment through 2013 and reauthorization of funding for measure endorsement for another year. The ACC worked with the Stand for Quality coalition, including the National Quality Forum and the American Medical Association, to advocate for extension of this funding.

Also thanks to the incredible efforts of ACC’s Advocacy team, a provision to qualify registry programs to meet Physician Quality Reporting System (PQRS) reporting requirements was included. Professional society clinical data registries, such as the ACC’s National Cardiovascular Data Registry, collect robust data that are used to provide feedback to physicians and enhance performance. This focus on quality, evidence-based care by itself is an effective way to reduce overall costs while enhancing quality of care. Registry participation is a more robust performance improvement method than the current PQRS, and now that more physicians can meet PQRS requirements, physicians can avoid future penalties under the program. This provision was the result of discussions between ACC, the American Society of Clinical Oncology, the Society of Thoracic Surgeons, and a few other organizations with bipartisan staff for the Senate Finance Committee and House Ways and Means Committee in the summer and fall.

The College also played a key role in a provision to enhance the quality of data needed for new delivery and payment models. The law now requires the Secretary of HHS to develop a strategy to provide data for performance improvement to physicians in a timely manner. This provision is the direct result of testimony by physicians, including ACC Past President Doug Weaver, MD, MACC, before the Senate Finance Committee this summer as well, as a roundtable discussion between committee staff, ACC and several other specialties this fall.

While the offsets used to pay for the $25 billion SGR patch do result in an increase in the equipment utilization rate for advanced imaging modalities that is limited to CT/MR/PET, which will mean reduced payments, but fortunately ACC staff were able to keep prior authorization and changes to the in-office ancillary services exception kept out of the agreement.

Moving forward, ACC’s Senior Vice President Jim Fasules, MD, FACC, said it best when he told the ACC presidential team earlier this week  that while “the work now shifts to the spending cuts debate with a big spotlight on entitlements … right now we get to stop holding our breath.” It is now more important than ever that the cardiovascular community and the rest of the house of medicine build on the momentum from these efforts and continue to push for a permanent repeal of the SGR. As I mentioned in my blog post last week, 90 percent of ACC PAC-supported candidates (104) won their respective elections in November 2012, strengthening the College’s allies on Capitol Hill. These relationships and grassroots efforts have and will continue to be increasingly important as we work towards a permanent repeal over the next year. The ACC stands ready to work with Congress as it confronts the challenges and opportunities within Medicare.

Stay tuned to the ACC Advocate and CardioSource.org for additional details in the coming months.

This post is authored by Stephen R. Ramee, MD, FACC, chair-elect of the Interventional Scientific Council.

The 2013 Medicare Physician Fee Schedule continues the Centers for Medicare and Medicaid Services' (CMS) campaign to reduce payments for complex procedures and diagnostic tests in order to redirect resources to other services. An agenda that began with crippling cuts to echocardiography and SPECT and continued with implementation of faulty practice expense data that cut cardiology services across the board has now targeted EP procedures and PCI.  Although the cuts result in large measure from decreases in the amount of time needed to perform the typical EP study and ablation or PCI (note that the system for determining RVUs is heavily driven by procedure time), CMS payment policy decisions have made things worse. By unilaterally rejecting recommendations from the physician community that would provide opportunities for cardiologists to accurately report more complex procedures, CMS is preventing physicians who care for the most challenging patients from being fairly compensated. ACC will be vigorously opposing CMS’s decisions and working with the Society for Cardiovascular Angiography and Interventions (SCAI) and the Heart Rhythm Society (HRS) to rectify these decisions. Unfortunately, no changes to the fee schedule can happen before 2014.

Our practices that have already experienced precipitous cuts in payment for core services now face payment reductions on the order of 27 percent for EP studies/ablations and 20 percent for PCI. Many of us, myself included, are astonished that the reward for a relentless focus on quality that has brought about a 27-percent reduction in mortality from heart disease is a payment cut.

While the cardiovascular field is justifiably angry about the latest round of payment cuts, it’s important to recognize that this is the byproduct of a broken system for physician payment. Congress’s inability to fix the Sustainable Growth Rate (SGR) has meant a decline in real terms in the resources our nation devotes to paying for the physician services Medicare patients need and deserve. Rest assured that ACC will be doing everything possible to reverse CMS’s bad decisions and to stop the SGR cut from going into effect. But we will also be redoubling our efforts to make sure policymakers understand the value of the lifesaving work cardiologists do every day and to move toward a payment system that supports and rewards our specialty’s dedication to improving care and outcomes for patients with heart disease.

For full coverage of the 2013 fee schedule and coding changes, visit CardioSource.org/PhysicianPayment. Stay tuned to The ACC Advocate for updates on ACC’s action. Be sure to follow @Cardiology on Twitter for the latest advocacy and health policy news.

This post was authored by Bo Walpole Jr. MD, MBA, FACC, chair of ACCPAC.

It’s that time of year again, where we’re on the edge of our seats wondering what next year will bring for physician payment. On Nov. 1, the Centers for Medicare and Medicaid Services (CMS) released the 2013 final Medicare Physician Fee Schedule, which sets payment rates and related policies for next year. While 2010 was a particularly uprooting year, one that we haven’t quite recovered from yet, each year brings its own challenges.  

So what’s in store for next year? In addition to the 26.5 percent cut stemming from the flawed Sustainable Growth Rate (SGR) and across the board cuts of 2 percent associated with sequestration provisions of the Budget Control Act of 2011, we face an overall -2 percent impact on cardiovascular medicine.

Next year, PCI is also in the line of fire. We’ll see physician work RVU reductions of roughly 20 percent to the family of PCI codes and roughly 27 percent to the family of EP/ablation codes. Another concern is CMS’ decision to expand a multiple procedure payment reduction (MPPR) to cardiovascular services, resulting in 25 percent reductions in certain cases. Unfortunately, CMS decided to move in this direction despite the ACC, other stakeholders and 60 members of Congress voicing strong objection earlier this year. (See congressional sign-on letter.)

Additionally, the final rule lays out details for the Physician Quality Reporting System (PQRS) and e-prescribing, and Value-Based Payment. In each of these cases, there are definitely incentives for successful participation, however, we are now entering the phase where many of these programs are transitioning to penalties for non-participation. It’s important that we all stay on top of the varying deadlines for these programs and weigh the costs and benefits associated with not participating. The College has resources for members in the Physician Payment Resource Center in the Advocacy section of CardioSource.org and includes frequent reminders about deadlines in the weekly ACC Advocate newsletter.

These are challenging times across the health care spectrum, with sequestration, the fiscal cliff and the debt ceiling looming over the country, and we must continue to work together to ensure the voice of cardiology is heard loud and clear on the Hill. The good news is that 104 out of 122 ACCPAC-supported candidates won their elections last week. That’s an astounding 90 percent success rate and means, at the very least, that we have potential allies on both sides of the political spectrum as we work to encourage health policies that allow us to provide quality, cost-effective care to our patients!

Now is the time to foster partnerships with these lawmakers through legislator practice visits and other grassroots events. We can provide them with first-hand perspectives of how their decisions impact health care for patients with cardiovascular disease; facilitate the delivery of high-quality, cost-effective cardiovascular services; and fund cardiovascular research and prevention.

I also urge you to check out the agenda and register for the Cardiovascular Summit that will take place Jan. 10 – 12 in Las Vegas. The Summit will bring together health policy leaders, payers and other stakeholders who will delve into the impact of the elections, health reform implementation, evolving payment models, coding and documentation and more. There is no better time to be involved in these conversations!

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Stay tuned to The ACC Advocate, CardioSource.org and the Nov./Dec. issue of Cardiology magazine for more information on the implications of the 2013 Medicare Physician Fee Schedule on cardiology. You can also hit the ground running in 2013 by preparing for coding changes now.  The ACCF/AMA CPT Reference Guide for Cardiovascular Coding is your one-stop resource for understanding significant new code revisions; efficiently and accurately reporting cardiovascular services and procedures; brushing up on CPT guidelines; and guidance on general intent and use of radiological and cardiovascular diagnostic and therapeutic procedures and services. In addition, a special webinar on Nov. 28 from 3-5 p.m. ET will explore major coding changes for 2013. Learn directly from those who presented the codes and sat at the table during the CPT and RUC processes. Register now.

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

This week more than 350 ACC members were in our nation’s capital for the College’s 21st Annual Legislative Conference. ACC’s leaders, FACCs, FITs, CCAs, Practice Administrators and even international members were all on hand to participate in briefings on the critical health policy issues facing medicine today.

The conference kicked-off on Sunday with a special reception and dinner celebrating the 10th Anniversary of ACC’s Political Action Committee. During the keynote speech, Pulitzer Prize winner and syndicated Washington Post columnist George Will shared his insider’s perspective of the current political climate and the impending presidential election. Filled with facts and baseball references, Will was able to engage a packed room full of attendees from both sides of the aisle.

On Monday members heard from ACC President William Zoghbi, MD, FACC, who presented results from the 2012 Practice Census, (read more about the results on CardioSource.org), as well as from a range of politicos including an election outlook from Ronald Brownstein.

Earlier today Rep. Michael Burgess, MD (R-TX) was presented with the President’s Award for his distinguished public service and support of the College’s health policies that promote high-quality patient-centered care.  Soon after, conference participants headed to Capitol Hill for a day full of pre-arranged meetings with their members of Congress. Given the current health care landscape, members stressed the importance of Congress avoiding further harmful spending cuts and reforming the Medicare payment system. With 295 separate legislator meetings scheduled, the ACC’s commitment to quality and patient-centered care was heard loud and clear on the Hill.

Our actions and advocacy efforts this week are important for many reasons. We are dependent on Congressional action to prevent upcoming cuts from the sustainable growth rate (SGR). In addition, the Centers for Medicare and Medicaid Services (CMS) has already proposed an array of new policies for the 2013 Medicare Physician Fee Schedule (read ACC’s comments on the proposed rule here) that include both threats and opportunities for cardiology. These proposed policies include:

• The final year of transition to new PE RVUs causes small reductions to most cardiology services.
• A proposed multiple procedure payment reduction for a wide range of diagnostic cardiology services (e.g., echocardiography, stress tests, vascular ultrasound) would reduce the technical component payment for the second and any subsequent service by 25 percent if performed on the same day.  ACC has vigorously opposed this proposal.
• Medicare has proposed for the first time to pay for transitional care services for patients discharged from hospitals or skilled nursing facilities. Physicians providing care coordination services within the first 30 days of discharge would have the opportunity to bill Medicare for these services. The ACC sees this as an important step forward for Medicare, but expressed some concerns about the specifics of the proposal. We’re hopeful that CMS will make some changes to ensure that patients with cardiovascular disease benefit from the new policy.
• If CMS goes forward with its proposed rules, physicians in groups with 25 or more practitioners will be the first to be subject to the value-based payment modifier established in the Affordable Care Act. Also, beginning in 2015, groups of 25 or more will be subject to a 1 percent penalty or may be eligible for bonus payments based on PQRS participation and performance on quality and cost measures in 2013, and practices with 25 or more physicians and other practitioners will need to take action in the first quarter of 2013 to avoid the penalty and ensure potential eligibility for bonus payments.

Not included in the proposed rule, but of great significance to cardiology, we also expect 2013 coding and valuation changes to result in cuts of 20 percent or more for EP/ablation services and some PCI services, but exact impacts will not be available until Medicare releases payment information on Nov. 1.

Although CMS will review comments and release final decisions on these proposals soon, our efforts on the Hill this week will inevitably help raise awareness of the issues facing cardiology today. Stay tuned to the ACC Advocate and CardioSource.org for updates this fall. Also stay tuned for individual perspectives from Legislative Conference here on the blog in the coming days.

This post was authored by ACC Past President W. Douglas Weaver, MD, MACC.

Wednesday was an exciting day in Washington, DC, where I testified on behalf of the ACC before the Senate Finance Committee hearing regarding Medicare physician payments. The hearing addressed problems plaguing the current Medicare physician payment system and sought to identify new payment models and quality initiatives that incentivize high-quality and high-value care at reduced costs.

Following recent discussions with former Centers for Medicare and Medicaid (CMS) administrators and insurers, the ACC, along with the American Medical Association, American Academy of Family Physicians, American College of Surgeons and American Society of Clinical Oncology, was invited to share lessons learned on effective physician payment approaches. This was a vital opportunity to reiterate our long-term dedication to exploring innovative payment models in Medicare and share how our many quality programs and evidence-based measures are working to improve the delivery of high quality, affordable care.

I cannot stress enough how critical the discussion on Medicare physician payment is to the sustainability of our health care system. Congress must avert scheduled reimbursement cuts just released in the proposed 2013 Medicare Physician Fee Schedule, repeal the SGR, and provide stable payments for several years to allow the development of new delivery and payment models. They know this, but just don’t know how to do it. Although I was prepared to provide suggestions to improving value over the next several years; I was surprised to be asked about what we can do this year which will dramatically reduce Medicare costs beginning in January.

The SGR has been a problem for years and a key issue I faced during my tenure as ACC President in 2008. The current uncertainty in the future stifle both our practices and our hospitals in making real investments aimed at improving integration and reducing the current fragmentation of care and reducing waste. It is discouraging that Congress has yet to come up with a solution, but I am hopeful that we can develop a system that aligns compensation with performance of evidence-based medicine and higher value, appropriate health care.

During my testimony, I had the opportunity to discuss several of the College's exciting innovations currently underway, such as our clinical registries which can be used to increase quality far beyond the PQRS quality measures of CMS. We also have appropriate use criteria embedded into Cath PCI-which has begun to lower the number of patients getting unneeded revascularization.  I asked them to incent doctors to use these tools and incent EMR venders to incorporate them into their products which also need to be made interoperable among all of the suppliers.

I also told them they need to support care management in the out-patient setting, which is paying primary care docs and specialties such has ours in which the vast majority of our patients are billed under primary care diagnoses (eg, heart failure, coronary disease, hypertension). These extra dollars allow us to fund the needed physician infrastructure to keep these patients on a care plan, and to reduce emergency visits and hospitalization.

The bottom line is that ACC knows how to improve quality and efficiency use our registries and other specialty specific tools. If Medicare promotes these activities by incentivizing their use and helping pay for the efforts, I believe the current improvements that we are witnessing will accelerate.

Read more about the ACC's involvement in the Senate Finance Committee roundtable on Medicare Physician Payments on CardioSource.org including the submitted testimony. Also read a statement from ACC President William Zoghbi, MD, FACC on the hearing.

(pictured top: Dr. Weaver testifying before the Senate Finance Committee; pictured bottom: Senator Max Baucus (D-Mont.) and Dr. Weaver)

• We opposed the Centers for Medicare and Medicaid Services’ (CMS) efforts to reduce payment for the technical component of imaging services provided by the same physician on the same day.  CMS considers expanding this policy to all services in the future, which we also opposed.
• We strongly encouraged CMS to propose changes in payment rates to existing services to avoid the debacle that was caused when payment rates for SPECT MPI were found to be incorrect in 2010.
• We strongly discouraged CMS to implement a penalty for not participating in the Physician Quality Reporting System (PQRS, formerly PQRI) in 2013 by adjusting payment in 2015.  We believe Congress intended this to be based on 2015 participation.

The proposed 2012 Medicare Physician Payment Rule (formally called the Physician Fee Schedule) was issued just before the 4th of July weekend at 4:15 p.m. Friday. Why? So nobody will have time to read it and comment and complain until this week. The 2010 payment rule was devastatingly bad. The 2011 rule was nowhere near as bad as that, and this one for 2012 is not full of apparent surprises. The 2012 rule has the third year of residual cuts that originated in 2010, but the impact next year averages out about negative 1%. The big impact would be the SGR cut of 29.5% if it were not waived -- which it will be for a year at least I presume.

Here are some of the highlights from our initial review (more coming later this week):

• Imaging Payment Reductions: CMS proposes to reduce the payment by 50 percent for the professional component of certain imaging services provided at the same session on the same day by the same physician.
  
  
• Electronic Prescribing Penalty: By law, CMS is required to reduce Medicare payments to those practitioners who do not electronically prescribe and for whom at least 10 percent of their Medicare payments are associated with certain types of office visits. As part of the 2012 proposed rule, CMS is considering providing practitioners with an additional opportunity to avoid the penalty.
  
  
• Potentially Misvalued Services: CMS identifies three cardiology codes for review as potentially misvalued. Data for cardiovascular stress test (93015), extracranial study (93880), and complete electrocardiogram (93000), will be reviewed by the RUC for presentation to CMS before July 2012.
  
  
• Physician Compare and Value-Based Purchasing: CMS proposes another step towards the required implementation of value-based purchasing in 2015. In the proposed rule, CMS includes a series of claims-based measures that will be used to report on physician quality using the new Physician Compare website. In addition, CMS proposes a series of quality measures that will be used to adjust payment based on quality starting in 2015.
  
  
• Physician Quality Reporting System (PQRS) and Maintenance of Certification (MOC): CMS proposes some changes to PQRS but largely keeps intact the registry reporting that is commonly used by cardiologists. Physicians that successfully participate in PQRS in 2012 will receive a 0.5 percent bonus of Medicare payments.
  
  
• Coding: CMS, as expected, continues to move forward with bundling payments for certain services. Specific changes will not be available until November.

Read the full initial review on CardioSource.

Health and Human Services Secretary Kathleen Sebelius chatted recently with MedPage Today about President Obama’s proposed 2012 budget and the provisions of interest to physicians. As Jack wrote last week, the proposed budget contains enough funding to freeze physician payment under the sustainable growth rate at current 2011 levels for two years. While this certainly is an improvement over having to fight off the massive draconian cuts that the SGR full enactment would entail every year (or every few months, as has happened the last couple of times), this is hardly the permanent fix that the ACC has been pushing for. Sec. Sebelius explains what she feels is the rationale for this limited freeze: pass the 2-year freeze to “start a conversation with Congress,” and then immediately work on a permanent solution. Sebelius notes that there is nothing more important than having doctors in Medicare, and acknowledges that physicians are getting weary of going year-to-year having their pay jeopardized.

She’s right there. There have been several reports in the media of physicians dropping out of Medicare as a result of cuts present in the Physician Fee Schedule and the constant uncertainty of the SGR. However, it’s a little unclear if passing a two-year fix will actually give Congress two years to work on an innovative payment system that rewards high-quality care (what the ACC and other medical societies would like) ... or two years to avoid dealing with the massive cost this type of effort would likely require. I hope that Congress steps up to the plate to truly solve the SGR dilemma for us physicians over the next two years.

Check out the video on the KevinMD blog for Sec. Sebelius’ take on other health care issues, including health IT, the Affordable Care Act, fraud and abuse and the medical loss ratio.

CMS Administrator Donald Berwick, MD, and CMS Chief Actuary Richard Foster testified before the House Ways and Means Committee last week at a hearing titled, “The Impact of the Affordable Care Act on the Medicare Program and Medicare Beneficiaries.” We were there.

In the fall, Dr. Berwick testified before the Senate Finance Committee but this was his first time in front of a House committee. After discussing his background in medicine and what he views to be the many the benefits of the Affordable Care Act (ACA), Dr. Berwick held his own during tough questioning. This was also a ‘sniff him over’ process, given he has been promoted for confirmation again.

In his opening statement, Chairman Dave Camp (R-MI) noted the contrast between Dr. Berwick’s optimism on the ACA and Mr. Foster’s bleak outlook for Medicare due to the ACA. Foster has disagreed with others and the Congressional Budget Office on ACA savings, which Foster thinks are unlikely to be achieved. Democrats used the hearing to try to “shatter the myths about reform,” as stated by Ranking Member Sander Levin (D-MI) during his opening statement. Democrats repeatedly pointed to what they view as the most popular provisions of the law and what would happen if the law was repealed. In other words, this was a genuine partisan circus event.

There were plenty of controversial questions and answers. On tort reform, Dr. Berwick said he supports “exploring a national solution” on medical liability but would not comment on non-economic caps. Rep. Vern Buchanan (R-FL) told Dr. Berwick about a letter he wrote to CMS regarding concerns of Florida cardiologists with Medicare payment cuts for cardiology services (this "2010 Rule" issue preceded Berwick’s coming to CMS, but he’s sure hearing about it). When  Rep. Sam Johnson (R-TX) described physicians no longer participating in Medicare and having to reduce staff, benefits and charity care, Dr. Berwick stated that enrollment in Medicare is the highest ever for physicians. Poor Dr. Berwick -- he wants to talk about improving quality and patient safety and lowering costs in those ways, but there was no chance of that. Too bad he couldn’t just speak his mind, though. He had a lot of constructive non-partisan things he could have shared there, but that wasn’t what this hearing was about.

What did we and the nation learn from this hearing that we don’t already know? Nothing.