BIG news this morning from the ACC. After learning some lessons from our pilot program IC³, the ACC is launching the first-ever registry-based network for cardiology practices, called the PINNACLE Network. Its goal is to give practices the tools they need to be both innovative and high quality.  Learn more from the press release below or watch the CVN video.

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AMERICAN COLLEGE OF CARDIOLOGY LAUNCHES THE NATION’S FIRST
REGISTRY-BASED CARDIOVASCULAR PRACTICE NETWORK

Washington, DC – The American College of Cardiology today announced the launch of the PINNACLE Network, the first-ever registry-based cardiovascular network to link thousands of cardiology practices to each other and to the ACC’s National Cardiovascular Data Registry (NCDR), the preeminent cardiovascular data repository in the United States.

The PINNACLE Network™ immediately addresses the rapidly shifting business environment that private cardiovascular practices face with a wealth of practice management and financial management tools. The PINNACLE Network™ also builds a foundation for innovative, registry-based systems to reward practices for the high quality care that they provide.

“With the legislative and regulatory threats to traditional payment systems and the emergence of value-based payment programs, the ACC is in a unique position to develop and offer the PINNACLE Network™ with its suite of practice management tools to help practices not only survive but thrive,” said Alfred A. Bove, M.D., Ph.D., president of the ACC.

A comprehensive practice management system, the PINNACLE Network™ provides financial management tools to help practices thrive; workforce strategies to enable physicians to meet the increasing demand for cardiovascular care; guidance for the adoption of health information technology; and risk management education and strategies to lower the cost of liability premiums.

The PINNACLE Network™ will provide access to data management systems that translate data into clinical insights and leverages the power of the ACC’s national data registries to give practices negotiating power with payers for value-based payment systems.

“Embedding quality improvement and value-based payment in the natural flow of practice operations will be the foundation for a practice’s success clinically, financially and professionally,” said Janet Wright, M.D., the ACC’s senior vice president for Science and Quality. “By creating health information technology solutions for using ACC Guidelines and Appropriate Use Criteria at the point of care, the PINNACLE Network™ will show patients, colleagues and the health care community that we are delivering the right care for the right patient at the right time.”

The PINNACLE Network™ is powered by the PINNACLE Registry™, the nation’s first operational office-based data registry and will provide a centralized system for clinical practices to promote practice innovations and achieve clinical excellence.

The PINNACLE Registry™, designed by cardiologists, benefits from its two-year pilot phase as the IC3 Program and now will be integrated into the NCDR® to provide participants with access to both hospital and ambulatory patient-focused data. As one of the largest practice-level scientific efforts undertaken in the United States, the IC³ Program®, now the PINNACLE Registry™, contains hundreds of thousands of clinical patient records focusing on four common cardiac conditions -- coronary artery disease, hypertension, heart failure and atrial fibrillation.

For more information on the ACC’s PINNACLE Network™ visit www.pinnaclenetwork.org.

Yesterday I arrived in San Francisco for the TCT (Transcatheter Cardiovascular Therapeutics) conference, a yearly interventional cardiology meeting. Meetings like TCT provide an opportunity for interventional cardiovascular professionals to stay up-to-date on the latest science, technology and procedures. When it comes to cardiovascular education, the traditional paradigm is under attack and a new -- and more relevant -- platform is emerging. Not only are there new tools linking education and quality, but CMS, Congress and others are increasingly focused on education linked to licensing, certification and credentialing.

The ACC is actively addressing these issues by providing an integrated approach to life long learning. This includes developing opportunities for cardiovascular professionals to measure, track, and improve their performance, and, thus the quality of care they provide to patients. We are planning to help members meet and excel in the face of these new requirements. I like to think we’re leading the revolution in cardiovascular life long learning.

Meanwhile, we’re leveraging ACC’s quality resources like our registries, guidelines, performance criteria and expert faculty to facilitate this revolution. A great example of a new tool is our IC3 Program – our pioneering registry focused on the ambulatory setting. IC3 allows participants to benchmark their clinical performance, compare with others, and make adjustments where necessary -- and to participate easily in various new payment incentive models. 

All this talk of education and measurement isn’t going away anytime soon. We’ve got to adjust and take steps to thrive in a changing environment -- by directing and leading the change.

That said, if the frustratingly ill-crafted proposed CMS 2010 Physician Payment Rule is not taken off the table for cardiology, we’ll be diverted away from leading in the health reform charge in order to deal with a vestigial example of what's very wrong with the current environment and payment system. The proposed Rule would reduce practice revenues in outpatient cardiology by 20-40 percent, essentially devastating community cardiology practice. This is occurring in parallel to an opportuntiy for real and positive system change. What tragic timing -- and what a painful example of the problems and archaic nature of the current HHS and CMS systems (see my last post for more of my views on this). 

*** Image from Flickr (Paraflyer). ***

Electronic health records (EHRs) do not offer complete data to gauge performance, according to a new study in the Agency for Healthcare Research and Quality's Research Activities by Jeffrey Linder, M.D., of Harvard. Linder's research showed that EHRs were often inaccurate in determining the actual cause of a patient visit (688 encounters were billed as pneumonia, but chart reviewers found only 198 actual visits for pneumonia). A large portion of the data in the EHRs was not coded, which makes data extraction for care measures difficult.

This says to me that we’re on the right track with our NCDR registries, with their validated data elements, and with our advice that EHRs be integrated with data registries where possible.

In other registry-related news, the IC3 Program is growing by leaps and bounds! We added a whopping 100,000 patient records this week alone. Amazing. This kind of patient data in our ambulatory registry will really move the needle on quality of care.

Meanwhile, the IMPACT Registry Pilot is on schedule to launch in August for six months to test the usefulness of data elements and the feasibility for data collection. The official launch of the registry is slated for 2010. The IMPACT Registry will be the first national registry to provide data about the demographics, acute management and in-hospital outcomes for a comprehensive selection of patients undergoing diagnostic catheterization or catheter-based interventions for congenital heart disease.

Little is known about the population of patients with congenital heart disease, particularly with respect to the use and outcomes of catheterization and interventional procedures.  To date, most resources have been applied towards increasing the understanding of the anatomy and physiology of congenital heart disease, as well as the natural history of common defects.  National guidelines have been published which provide recommendations for the appropriate use of diagnostic catheterization, interventional catheterization and surgical treatments.  However, because studies performed in congenital heart disease are generally small in number, and because prior registries of congenital heart disease have been limited in scope, there is a paucity of data relating to the use of diagnostic catheterization and catheter-based interventions, and to the morbidity and mortality associated with these procedures.  Current national guidelines were derived primarily from expert opinion, and there is a strong need for data to allow optimization and refinement of the guideline recommendations.

As I discussed briefly last week, the Energy & Commerce, Education & Labor, and Ways & Means committees introduced their tri-comm health care reform bill, America’s Affordable Health Choice Act of 2009 (HR 3200, hyperlinked here for your reading pleasure). The President and others celebrated it as a landmark bill at the White House, while the Congressional Budget Office (CBO) Director, economist Doug Elmendorf, ruined their party by proclaiming the bill as an unsustainably expensive instrument that will destabilize the economy unless modified to reduce costs over time. CBO has always been the "skunk at the garden party" or worse, but this time they made House leaders and the President quite upset.  

What's In It
We strongly support access for all. But the CBO concerns are legitimate. Congress has espoused a set of worthy visions to improve quality and care coordination and efficiency, but the teeth for getting that done -- other than with the same old ineffective price controls -- aren’t yet there. A reform bill that works is certainly still possible after the debate gets going more openly. But, beyond the unspecified vision, the implementation strategies are not there. And, there are a lot of provisions in HR 3200 (many inspired by organized labor) that will alarm many of you if you read all the detail -- just understand this is a political process, and the House knows that most of that won’t survive the Senate’s scrutiny. One real concern for us is that there is no tort reform in this House version, and there probably won’t be anything to start with in the Senate health or finance versions either. 

We applaud the House for its commitment to provide access to health care to basically all US citizens, and in particular for eliminating the SGRrrr for the next 10 years. That’s huge -- $230 billion worth of what would otherwise be cuts to physicians. We praise their huge Medicaid coverage expansion, combined with taking the payment of that program away from states (which have paid on the CHEAP), and providing better payment to physicians. They put a good deal of new money into prevention and primary care, and they add money to offset physician workforce shortages. We also appreciate their establishment of a positive future Medicare physician payment updates (MEI) and favorable spending targets for updates in the future. We’re also well positioned with NCDR and the IC3 Program for their significant payment and delivery reform models, such as incentives for physicians and their expansion and improvements to the Physician Quality Reporting Initiative (although this program still lacks sufficient payment incentives ... a 2% "incentive" is close to useless for most practices). 

ACC President Fred Bove has expressed our praise of these positive elements to the three committees (that would infuse almost $300 billion of new dollars to delivery of patient care), but without praising or referring at this point to the elements of the plan that are undefined (the public option, for example), or to those we must work to amend because they are just plain bad policy (the imaging cuts, their attempt to undermine specialty hospitals, and their attempt to prohibit opting out of public coverage programs). We will work with House and Senate members to eliminate those elements -- none of which should survive Senate Finance scrutiny thankfully. The Senate will not buy the House’s income tax funding approach for HR 3200 as currently configured either. More...

ACC President Fred Bove, M.D., F.A.C.C., staff Senior Vice President of Advocacy Jim Fasules, M.D., F.A.C.C., and I attended the HHS Secretary Kathleen Sebelius’ testimony before the House Ways and Means Committee last week. She did very well and stressed the need for measuring quality, for choice of doctor and hospital and for reducing rising costs. She implied the choice of a "public plan" to compete with private insurance was an option still on the table.

We issued a response to her testimony: “Leaders in both parties and the health care community agree: The American health care system needs to change. What we heard from Secretary Sebelius and committee members is that change needs to come sooner rather than later. The ACC has long advocated for several of the reforms Secretary Sebelius testified about today including payment reforms and the development of a health information technology infrastructure.”

Sebelius also mentioned two annual reports HHS issued last week that all of us should take note of:

• The annual 2008 National Healthcare Quality Report — the highlights are that between 40 and 50 percent of patients do not receive evidence-based (guidelines, performance measures, appropriate use criteria) care in the average inpatient or outpatient encounter. Also, in terms of patient safety, huge gaps continue to be documented. For example, we could save $20 billion by reducing variation and eliminating preventable inpatient nosocomial infections (IHI has demonstrated this is possible).
  
  
• The annual 2008 National Healthcare Disparities Report — Health care is still doing an abysmal job of reducing and changing the disparities problem, despite all the related rhetoric. The ACC is working on a couple of things that would hopefully help this problem: ACC’s CREDO (The Coalition to Reduce Racial & Ethnic Disparities in (CV) Outcomes) project, which will provide new insights for how to solve this problem with respect to CV disease, and using the IC3 Program to improve adherence to guidelines and performance measures.

*** Official photo of Kathleen Sebelius. From Wikimedia Commons. ***

David Blumenthal MD will be the new ONC “Coordinator.” David, a professor at Harvard and physician working with Partners in Boston, is also a friend. He is interested in ACC ideas in information systems adoption, and in the National Cardiovascular Data Registry and IC3 projects, so it will be good to have him at the helm of the HHS Office of the National Coordinator for Health IT.

It’s amazing how fast things are moving in DC right now on both the system reform and the stimulus implementation fronts. There are hearings, major Congressional and White House briefings, press events, and high level policy meetings every day. ACC participated last week, for example, in:

The IOM, in partnership with AARP, and the ABIM Foundation sponsored an invitation-only meeting on physician payment reform. The chiefs of staff of key Senate and House health committees were there to receive feedback. I was there for ACC, and shared our views on how payment reform (linked to quality improvement) can reach out to practices NOT in large integrated systems through our proposed voluntary “quality first networks” and the IC3 program. This is increasingly received with excitement, and nicely dovetails with the Brookings Institution proposal for “Accountable Care Organizations” (ACOs) of physicians and patients linked together around risk sharing quality improvement strategies.

Senate Health, Education, Labor and Pensions Committee had a private invitation-only briefing on the current status of their joint drafting of the Senator Kennedy-sponsored health reform bill. They are making progress and wanted to share the outlines of the still-being-brainstormed concept. They reiterated that a “single payer” concept was not a politically viable option. HELP believes reform will pass this year, even if it takes several years to finance full implementation. ACC was invited, and I had a chance to share our quality improvement ideas there as well.

Senate Finance Committee held an invitational briefing on their proposal, being coordinated with the HELP proposal, and Sens. Baucus and Grassley are still optimistic reform will pass this year. We are giving feedback on all issues they are covering. The Senate’s goal is to have a bill drafted by June. ACC was there.

The National Coalition on Health Care (NCHC): this largest of the health reform coalitions met last week, and Drs. Weaver and Bove represented us with the major labor, employer, consumer group, and pension plan members.

Drs. Weaver, Bove, Brindis, and I met with influential House member Chris VanHollen (D-Md.) to discuss his sponsoring of  a “quality first” ACC Medicare pilot project proposal. There is growing interest in this kind of pilot.

House Ways and Means: held an invitational briefing on the status of their ideas about reform. WAM is holding roundtable informal hearings with members and guests from April to May, with the goal of a committee markup on health care reform legislation in June. Their focus this week was on coverage and affordability, much of which focused on the pros and cons of adding a public plan to compete with private health insurance. Health Subcommittee Chair Henry Waxman (D-Calif.) strongly supports this idea, which will be a deal killer for House Republicans as what they view to be a path toward single payer. WAM leaders Waxman, Charles Rangel (D-N.Y.) and George Miller (D-Calif.) sent a letter to President Obama committing to a bipartisan effort to pass health care reform before the August recess. ACC was there. More...

Wow. The President’s ultra-visionary speech -- and then the $3.5 Trillion budget proposal -- add up to a breathtaking agenda. On the other hand, if the economic crisis is worse than expected, or if anything else goes wrong in the world (like a Pakistan implosion, or worsened Mideast crisis, or deepening war in Afghanistan, etc), the economics of Mr. Obama’s proposals could be in the tank. That’s why it’s a bit like rolling the dice — there are big risks in the agenda, and in the budget proposal.

But, that said, why would the country not aspire again to a truly first class education system here for all citizens to build a powerful future economic base; or to a first class health system that covers everybody but doesn’t bankrupt the economy; or to a new green energy industry transformation that could further fuel a more entrepreneurial economy? This is a big vision, but a very appealing one.

The POTUS (President of the United States) certainly reiterated his support for health care reform last Tuesday night; and then he did so again Wednesday when put his money where his mouth is with the 10-year, $634 billion “reserve fund” to pay for 50 percent of the expected cost of a vastly reformed U.S. health care system. But, where does the other half of the health reform budgetary goal come from? That’s not clear, and is up to Congress to seek. This $634 billion fund will come largely from Medicare Advantage plans cuts; higher co-pays for wealthier seniors; cuts in home care; and other unspecified cuts to providers (along with new incentives for quality). Believe me, there will be devils in those details. But, we should all recognize that the present non-system IS unsustainable.

Speaking of unsustainable, what happens to the SGRrrr? That will cost over $400 billion to pay off over ten years (thereby eliminating the coming 40% cuts over that time; but by the way not increasing physician pay at all!). If we take injectable drugs costs out of Part B Medicare, the SGR pay off could be less -- supposedly about $329 billion. This amount is supposedly to be included somewhere in the budget -- but must be funded by cuts elsewhere. More...

Aneesh Chopra, health and technology advisor for Virginia Governor Tim Kaine, has been asked to participate on the Obama Transition Team to advise on health information technology (HIT). Chopra and ACC are partners in the Centra NCDR/IC3 project in Richmond.

Chopra is going to carry our message on HIT, quality reporting, IC3 and payment incentives further into the transition process where Jeanne Lambrew and others already are talking with us.

Chopra sees the potential of the IC3 program and wants to present it (and NCDR) as models of how the delivery system reforms to improve quality could proceed.

American College of Physicians has launched a campaign to use proposed “stimulus” dollars to finance an 18 month 10% payment increase in Medicare for FPs and internists. This is surely needed to protect the viability of primary care. It is tricky, however, because many specialties also treat chronically ill patients as their primary providers. ACP has asked ACC for our support of this effort on their part, along with American Academy of Family Physicians. The stimulus spending will be time limited to 18 months. ACP must assume that once such an increase is granted, it will not be rescinded later. If this is created, I would think it should apply to all E & M code patient-centered chronic disease management in other specialties.

We should talk with the primaries about also applying stimulus dollars toward a 10% increase for electronic reporting for quality measurement in a more effective “version 2” of the currently frustrating PQRI. This could provide specialists such as cardiologists a parallel positive update that could foster health IT adoption, IC3 activities, and improved care for patients, perhaps in association with low interest loans and grants for health IT.