This post was authored by Kathy Blake, MD, FACC, member of the ACC’s Advocacy Steering Committee.

A recent article in the Wall Street Journal, “Same Doctor Visit, Double the Cost” (subscription required) detailed the shift we have seen across the country of hospital systems acquiring private practices, often leading to higher prices of services.
The article notes that “as physicians are subsumed into hospital systems, they can get paid for services at the systems’ rates, which are typically more generous than what insurers pay independent doctors. What’s more, some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost. The result is that the same service, even sometimes provided in the same location, can cost more once a practice signs on with a hospital.”

The article lays the groundwork for much of what the College has been advocating for over the past few years: the need for payment reform. The payers have noticed. The patients have noticed. The Centers for Medicare & Medicaid Services (CMS), as the article suggests, may have its hands (somewhat) tied by statute. The love affair with independent practice ended a long time ago. The infatuation of business with private payers and HMOs died awhile back. The current love affair, with integrated systems, is looking a bit tattered. The reality suggests that a variety of offerings across the full spectrum probably leads to a healthier delivery ecosystem, especially if there is transparency about cost and quality, and real competition based on accurate determination of value.

The article is timely as the 2012 Legislative Conference is right around the corner and will be touching on issues such as the College’s ongoing payment reform efforts, including advocating for the repeal of the sustainable growth rate (SGR) and instead focusing on quality-based delivery and payment models. Also at Legislative Conference Dr. Zoghbi will give an update on the “State of Cardiology” with results from this year’s Practice Census (we remember the results from two years ago that started documenting this shift in private practice).

The current fee-for-service system in integrated models is not sustainable, and it is up to us to steer the payment reform decisions in the right direction.

This post was authored by Eric Stecker, MD, FACC, member of the ACC’s Clinical Quality Committee.

Last week I made the argument that value (efficient provision of quality care) is a critical but under-recognized component of successful health care reform. Today we’ll briefly address several potential elements of health care reform that cardiologists should be facile with.

How do you measure quality care?
It is no longer sufficient to say we provide high quality care; we must demonstrate it objectively. Quality metrics remain imperfect but will improve over time and provide important information for patients and policymakers. Patients who see cardiovascular physicians participating in programs like ACC’s Imaging in FOCUS, and using registries such as those that fall under the ACC’s NCDR^® umbrella, can be assured the appropriateness and quality of their inpatient and outpatient care is being monitored and in most cases continuously improved.  The ACC’s clinical publications, including practice guidelines, consensus documents, appropriate use criteria, data standards and health policy statements are also excellent resources when it comes to guiding the most appropriate, evidence-based care.

Financial incentives for providers and patients
Medicare has initiated “value-based purchasing” programs to incentivize health care systems to improve quality. These programs could expand considerably in the future if proven successful. Individual health systems and insurers have experimented for many years with various financial programs to incentivize physicians to improve quality metrics or outcomes. The impact of these pay-for-performance programs has been mixed, but as pointed out by Ryan and Blustein, appropriately targeted and scaled monetary incentives are likely to have an impact.  Programs to incentivize patients by lowering or eliminating copayments (“Value-Based Insurance Design”) have proven very effective and are critical to aligning both the “supply” and “demand” aspects of high value care.

Managing individuals versus managing populations
Physicians are accustomed to caring for individual patients who engage them in the clinic, emergency department or procedural suite. However, by necessity the measure of a population’s health is made at the population level, not the individual level. Federal, state and local governments as well as businesses and employers have become more sophisticated and motivated to track aggregate health measures.  As a result cardiologists will become increasingly responsible for reporting and improving the health of all of the patients in their practice as a whole.  It will be important for cardiologists to gain the familiarity and skill to manage populations, but also retain sensitivity to issues that could harm individual patients so that policies and metrics can be modified accordingly.

If health care reform efforts are appropriately structured, cardiologists can thrive by focusing on efficient provision of high quality care for individuals and populations.  This will be best achieved when cardiologists align with and achieve leadership roles in health systems that focus on and incentivize quality systems of care.

This post was authored by John Shuck, MD, FACC, governor of the Delaware Chapter of the ACC.

Over the past few years the issue of appropriate use and radiology benefit managers (RBMs) has been a “hot topic,” particularly in Delaware. Recently, the misuse of RBM's in denying cardiac stress imaging within the state came to national attention.  A Delaware patient was denied a cardiac stress test by an RBM used by a major health plan in Delaware. The patient was ultimately admitted to the hospital emergently for a catheterization and a lifesaving CABG was performed.  This patient's plight became well-publicized and sparked investigations by the U.S. Senate Commerce Committee and Delaware Insurance Commissioner as to why the test was denied.

Thanks to the efforts of many at the ACC national and state level, this past fall the Delaware Insurance Commissioner announced that the health plan will support use of the ACC’s FOCUS: Cardiovascular Imaging Strategies tool by Delaware cardiologists to make decisions about certain diagnostic imaging tests, as an alternative to RBMs. Unlike RBMs, the FOCUS tool engages providers in ongoing feedback reports and quality improvement activities. At the same time it reduces third-party costs to physicians and health plans (read more about FOCUS in a blog post here).

In January 2012 the FOCUS health plan product went live incorporating many of the same elements present in the FOCUS performance improvement module. Under the agreement, the health plan will pay for cardiologists in the state to use the online tool, which allows for consistent application of appropriate use criteria to determine when cardiovascular imaging tests are needed. Importantly, the program also provides feedback reports on the patterns of appropriate use to physician practices and health plans. FOCUS participants then use the reports to complete action plans and share best practices.

This model for managing medical costs by focusing on patient-centered decision making and quality care will hopefully be implemented by other insurers and within other states when it comes to ensuring appropriate use of medical imaging. I’m happy to see our efforts to implement this program in Delaware have not gone unnoticed as several other ACC chapters are currently in talks with health plans to implement this program at the state level.

For more information about Imaging in FOCUS, visit CardioSource.org/FOCUS. This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

This post is written by Bill Oetgen, MD, MBA, FACC, and John Harold, MD, MACC, co-chairs of ACC’s Medical Professional Liability Working Group. 

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A recent article, “Malpractice Risk According to Specialty,” in NEJM provides interesting insights for cardiologists and CV surgeons. The study looks at all of the claims of a large physician-owned professional liability insurer from 1991 to 2005. Of 233,738 physician-years of coverage, cardiologists represented 1.8%, and cardiovascular-thoracic surgeons (CVTS) represented 1.6% of the experience. 

For all (40,916) physicians, the average annual medical professional liability (MPL) claims rate was 7.4%, with only 1.6% resulting in a payment to the plaintiff. Seventy-eight percent of claims resulted in no payment. For cardiologists on average, 8.6% were named each year in an MPL claim, and 1.0% had paid claims. Thus, cardiologists were at slightly higher risk to be named than were physicians in general, but they had a lower likelihood of actually paying any claim that was filed. For cardiologists, 88% of claims resulted in no payment. 

For CVTS, the numbers are less comforting. Annually, 18.9% of CVTS were named in a medical professional liability suit, and 3.8% had paid claims. Of the CVTS claims, however, 80% resulted in no payment, a proportion only minimally higher than all physicians. 

With respect to the amounts of payments made in 2008 dollars, the mean payment for all physicians was $274,887 and the median was $111,749. For cardiologists, the mean payment was $306,430, and the median was $145,886. For CVTS, the mean was $291,790, and the median was $161,452. 

CVT surgeons appear to be at higher risk for claims and have higher mean and median payments when compare to all physicians while sharing a ~20% risk of having to pay a claim that is brought.   

For cardiologists compared to all physicians, there is good news and bad news. The bad news is that cardiologists were slightly more likely to have a claim filed in a given year and that, if a payment was made, the amount was moderately higher that those paid for all physicians. The good news is that if a claim has been filed, cardiologists are less likely to make a payment than are all physicians. These results are in general concordance with the results of a study we led that was published last year in the American Journal of Cardiology.

The ACC partnered with hospitals (AHA), insurers (AHIP), AARP, AMA and others on a study on the impacts of the various proposals out there to cap Medicare premiums and/or propose across-the-board Medicare and Medicaid spending cuts. These proposals do not fairly estimate the downstream impacts that will occur to everyday citizens and to health care. We selected the Lewin Group (I can obviously get a family discount there). The study was released to members of Congress and the public. It’s a necessary part of this necessary discussion on how to reduce the national deficit. But let’s do it with eyes wide open and with an objective understanding of the impacts of various proposals -- and new ones pop up every day.

A call for across-the-board spending cuts is imminent. We asked the The Lewin Group to specifically examine the Commitment to American Prosperity (CAP) Act -- since it passed the House -- even though we recognize that deficit reduction is a process, and that the CAP Act is unlikely to be the final piece of legislation brought to a vote. We think similar consequences would result from any across-the-board measure that limits spending. Recognizing and supporting the need for deficit reduction for the nation’s well being, the report calls for payment reform and other approaches. We think this is the right approach.

President Obama and VP Joe Biden and Senate Minority Leader Mitch McConnell (R-Ky.) are now trying to wrestle out a plan before the debt ceiling default hits in another month. If there are no additional revenues proposed, the Lewin Group projected that the CAP act or similar across the board cuts would produce:

• Cuts by nearly 20 percent over ten years to Social Security benefits;
• Cuts to Social Security and other income support programs that would force 3.8 million people into poverty -- 2.1 million of them seniors, a 45% increase;
• Lost health insurance for 5.1 million individuals;
• Cuts to hospitals that could force most to operate in the red, jeopardizing access to care;
• Dramatic reductions in fees for physicians that would lead to fewer physicians participating in Medicare;
• Lost jobs for up to 1.3 million health care workers; and
• A nearly 5% increase in health insurance premiums due to cost-shifting of federal payment shortfalls to private employers.

The message to Congress should not be to avoid making cuts to balance the budget and eliminate the deficit over the next decade or so. That needs to happen. But, without additional revenues, the consequences to medicine, patients, and health care will much more grim than anyone’s talking about.

More coverage: "Doc Groups Get Figures on Feds' Spending Cut Plans," MedPage Today

Last week, the Medicare Payment Advisory Commission (MedPAC) released its June report. Not good, folks.

The report includes four recommendations related to the provision of imaging services in Medicare.  Most troubling is the last recommendation, which encourages the creation of a prior authorization program for practitioners who order substantially more advanced diagnostic imaging services than their peers. The ACC strongly opposes prior authorization because requiring prior authorization would increase the administrative burden on Medicare, increase physician practice costs and could interfere with the physician-patient relationship, potentially delaying timely access to life-saving procedures. The ACC continues to believe that the adoption of decision-support tools based on appropriate use criteria is a better option than prior authorization.

MedPAC recommendations are non-binding but, in a Congress that is very concerned with spending cuts, these recommendations could easily be picked up for potential enactment.  In addition, these recommendations could also be picked up by CMS without further Congressional action. CardioSource has more  on the report’s other recommendations.

The U.S. Senate Commerce Committee and the Delaware Insurance Commission last Friday released separate reports on the results of their investigations into consumer access to imaging tests in Delaware. Both reports were commissioned in 2010 after the Wilmington, Del., newspaper ran a story on a Delaware man that was denied a cardiac stress test by MedSolutions, BCBS of Delaware's “radiology benefit manager (RBM).”  The man ultimately was admitted to the ER, and then received CABG. NBC Nightly News ran a story on it yesterday, as did TheHeart.org and Cardiovascular Business.

The report highlights ACC's concerns with RBMs, such as the administrative burdens for doctors and patients, the non-transparent decision-making tools, and the chronic lack of best science and appropriate use criteria in their methodologies. Let's face it, RBMs are designed to save money, not improve care. 

The investigation's significant findings were: 

• After an outside consultant reviewed the denied cases, MedSolutions denied a significant number of both inappropriate and appropriate test requests
• The RBM's pre-authorization process is burdensome and confusing for consumers and health care providers, and this confusion is compounded by conflicting “evidence-based” cardiac testing guidelines
• According to their own professional guidelines, Delaware doctors routinely order unnecessary nuclear stress tests

But, there may be a happy ending here:  The ACC is working to implement the FOCUS imaging appropriate use criteria (AUC) tool in many states that are beginning to express interest in saving money AND improving careas as an alternative to RBMs, and we're making great progress! Yesterday's ACC Advocate has more about the findings and "next steps" of the report. The Senate report is available here: Consumers' Access to Diagnostic Heart Tests in Delaware.

Does this report surprise you? Have you had any similar experiences with RBMs?

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.

Increasingly, insurance companies are selling health policies that are pure vaporware in terms of their claims of “out of network” coverage, when preferred or needed by beneficiaries. So, when patients choose an out-of network doctor or hospital, the actual coverage is paid at a small fraction of the actual cost. Patients are stuck with the difference, and physicians are often stuck with non-payment. The reality is that these policies are misrepresentations of actual coverage, and recently physician and patient advocates in New York (and other states) and the AMA have successfully filed suit against blatant abuses. Catherine Hanson, JD, a fantastic AMA health attorney, has been all over these issues on behalf of doctors and patients.

FairHealth is a two-year old organization formed out of a settlement in New York that AMA and MSSNY (Medical Society of the State of New York) and others against these kinds of abuses. Former ASMA President Nancy Nielson, MD, former Aetna CEO Jack Rowe, MD, consumer advocate attorney Sarah Rosenbaum and others are working to educate the public and patients about these problems, and try to encourage fair practices by the industry. AMA is also proposing a “truth in benefits” act in Congress to remedy these injustices and rip offs.

Has your practice seen non-payment as a result of scan insurance coverage?

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.