This post was authored by Douglas Weaver, MD, MACC, past president of the ACC.

This year has been a painful one for healthcare providers due to the continued atmosphere of uncertainty.  Many of us began this year working on initiatives that deal with some of the changes attendant with the Affordable Care Act – e.g. reduce unnecessary admissions and change them to observation status, decrease readmissions for patients with a recent MI or for heart failure, and putting together means to provide better continuity of care.  Before the election, it was impossible to fully engage given the polarizing rhetoric between parties.  At the present time our payment policies don’t reward either physicians or hospitals for reducing readmissions, and rather we take a hit. 

However, even after the election, it still isn’t better. We are in an environment with continued partisan bickering about the legislation, lack of agreement on a common approach to sequestration, the tax cuts, unemployment benefit extension, reducing the deficit, how to pay for the SGR (and possibly with further Medicaid cuts, reduced NIH funding, loss of facility based E and M dollars, IME reductions).

After studying the issues and listening to the pundits, I have come to the following conclusions: first, our national debt is a major problem and one that needs to be fixed.  If you include the “promised entitlements” of Medicare and Social Security, it is close to 86 trillion dollars — and this number would require collecting 8 trillion dollars a year in taxes to just keep it from going higher. Congress can’t agree on ways to get a few hundred billion to balance the budget for the coming year. The total earnings of all of us filing tax returns is a little over 5 trillion dollars a year — and that is earnings not the taxes you and I currently pay.  Conclusion: we have to curb entitlements no matter what happens to taxes.

Second, people are spending less on healthcare. Visits are down, admissions are down—the cost curve has been bent already. If you count up the 50 million people in our country with no insurance, add 40 million who do, but who can’t pay their deductibles or co-pays, and the almost 55 million on Medicaid—this says that half the people in our country can’t afford our healthcare.  Conclusion: it is not about healthcare inflationary costs (these are now fixed), it is about the absolute cost.  Cost of healthcare in the U.S. is 1.5 to 2 times more expensive than elsewhere.  With peoples’ individual contributions increasing for care, they are voting with their feet and avoiding, when possible, doctor visits and procedures.

Lastly, there are some basic problems with the way we are approaching enacting “change.”  If all of our patients are going to pay more now for coverage and we are going to move to pay for quality, our patients should be getting something for this right up front—not years down the road.  Second, don’t harness the providers to the plain vanilla PQRS quality reporting measures and 18 month old administrative data to track performance. Instead, let specialty societies like the ACC, who can focus initiatives in areas where its members determine deserve improvement, and support these organizations to provide feedback and tools for improvement to their constituencies, instead of funding a larger, but less relevant reporting now done by the insurers.

We are adaptable—we can move more quickly and deliver more, but not at our own expense. We can however do so with a promised reduction in the overall cost of care and with equal or higher satisfaction from our patients.  

The announcement of the resignation of Don Berwick, MD, administrator of the Centers for Medicare and Medicaid Services (CMS), came a month earlier than expected. President Obama had appointed him without Senate confirmation a year ago during a Congressional recess, and such appointments expire within a year.

Berwick has been a visionary CMS Administrator with his “triple aim” of better care for individuals, better health for populations, and slower growth in costs through improvements in care. A pediatrician by training, he has been a good friend of the ACC, and most of the House of Medicine will be sorry to see him go before he had a chance to move needed delivery system and payment reforms ahead.

During his tenure at CMS, Berwick helped implement a number of key provisions of the Affordable Care Act (ACA), but unfortunately, Berwick has been a scapegoat for Republicans who are mad about the ACA, and he steps down from his CMS position after having run through a gauntlet of criticism in Congress as well as the conservative blogosphere.

As I stated in a recent interview with Medscape Medical News: I credit Dr. Berwick with having listened to physicians in the process of reforming the healthcare system. When organized medicine panned the first version of the Accountable Care Organization (ACO) rules, Dr. Berwick went back and changed them significantly. CMS is trying to do its job as a regulatory agency, but facilitate innovation at the same time. They're partnering with us. That's clearly part of Don's legacy. It's been a great era.

Berwick’s CMS Deputy, Marilyn Tavenner, RN, MHA, a highly respected nurse and former Virginia health administrator, has been named to replace him. Although Berwick will surely be missed, we’re well situated to work with Tavenner and look forward to continuing a strong relationship with our friends at CMS as we work together to better the U.S. health care system.

Managing a physician practice, hospital, academic institution, health insurance company, or any other health sector business is going to be tougher in some ways than perhaps ever in history over the next decade. Why? Because health care of necessity will undergo unprecedented change, and much of how it will shake out is uncertain. The ongoing explosive increase in knowledge and science is itself a blessing and unprecedented challenge. But it’s the economics and financing of health care that generates the most uncertainty in terms of how to position for success and excellence.

Who can guess what the Supreme Court will do when they (most certainly) review the constitutionality of the Affordable Care Act? It is uncertain. How will the solution to the debt ceiling affect health care funding? It is uncertain. But, because the “bullish forces” which underlie health care reform -- pressures to reduce costs; improve consistency of quality; move away from volume-based fee-for-service reimbursement; focus on population-based health improvement; greatly promote integration/mergers of physicians, hospitals and insurers; and get more uninsured people into coverage -- are unrelenting, major shifts in financing, payment systems and delivery models are inevitable. To what extent will changes manifest, how fast, and in what directions? Who knows? There is a lot of uncertainty!

For example:

• Shifts in amount and type of reimbursement: What will happen with reimbursement and payment reform? How much average funding will be available per person? McKinsey & Company believe millions more people will be covered with more overall dollars added to the system in five years, but that the per capita funding -- across public and private payers -- will drop, regardless of the ACA.  How does that affect practice? It ain’t positive, gang. New forms of reimbursement are already developing -- to what extent will these developments plus regulatory change affect the viability of private practices?
  
  
• Changes to Medicare (and Medicaid): Federal budget pressures could produce unexpected crises in funding. The debt ceiling discussions could create some really big nightmares if drastic cuts are enacted or created through poor public policy. How do we plan for the future -- will private practice survive if massive cuts occur? Can payment reforms head off draconian changes that may be imminent?
  
  
• The future of integration: Will accountable care organizations work and become a common phenomenon? Will hospitals or physicians or insurers dominate them?
  
  
• The future of CV technology and imaging and innovation: CV technology and imaging has been under financial assault for a decade as its use and contribution of costs has increased dramatically -- largely due to new diagnostic and therapeutic benefits conferred. But will these economic assaults continue, or will new scientific evidence actually promote increased investment in and appropriate use of imaging and new technology? Will these technologies now spread hugely across the developing world, versus primary prevention -- or will both things occur?

Managing in uncertainty will require that we depart from traditional strategic planning to instead develop an array of scenarios of possible developments and have action plans to apply to the various scenarios that we could face. That’s not how most of us are approaching the uncertainties of the next 5-10 years. There will be spectacular winners and big losers in this era. But, we cannot approach this future with a status quo, ‘business as usual’ philosophy, folks.

I was fortunate to get some consultant folks to visit Heart House from McKinsey this week to talk with ACC senior staff about the importance of starting to model scenarios around the many uncertain variables we face in cardiology and CV care -- to be ready for likely discontinuities and/or crises -- and to take advantage of possible opportunities for members and the patients they care for.  It was fascinating. It made me aware of how important it is to get this kind of management and leadership education to our board and other physician leaders as well. In fact, all of medicine needs to begin to think about how to prepare to be nimbly able to respond to the irony of certain change in the face of uncertainty.

In one of the first rounds of challenges to the new Affordable Care Act (ACA) health reform law, a federal judge in Michigan upheld its constitutionality. US District Court Judge George Steeh rejected the request for an injunction to block implementation of the individual mandate for health insurance. The decision found that it is within the power of Congress under the Constitution to collect penalties for individuals not obtaining health coverage and require people to buy insurance, under the Commerce Clause.

The court's decision appears to have been based on a finding that the health care market is unlike any other markets because no one can guarantee their health or ensure they will never get sick or require health care services. The court’s analysis suggests that the individual mandate is justified because the risk exists that health care costs for individuals not obtaining health coverage would be shifted to others. Whether you like the law or not, this is a fact of life -- everybody needs to pay their fair share of health costs and not shift the burden to others when they need care.

There are suits filed in 17 states, so this is not the end of the issue, but it definitely helps keep the momentum moving.  Republicans in many states are running on repealing the ACA, but this is truly political hype unless and until there are 60 Republicans in the Senate, and a Republican President. Even then, once 35 million additional people get coverage by 2014, it will be very hard to reverse the law. Opponents to Medicare and Medicaid couldn’t turn those laws around either.

This post is authored by ACC Health IT Committee Vice-Chair James Tcheng, M.D., F.A.C.C., and Committee member Jeffrey Westcott, M.D., F.A.C.C.

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Earlier this week, CMS completed a crucial step toward the goal of universal use of electronic health records (EHR) by all practitioners for all patients across the nation. The event?  CMS released its final rule that defines how eligible providers and hospitals can successfully participate in its EHR Incentive Program. This program provides payments – up to $44,000 over five years under Medicare and $63,750 under Medicaid – to providers who can meet its requirements of being a “meaningful user” of a certified EHR system.

According to the final rule, to be a “meaningful user,” you will need to use a certified EHR system and satisfy a series of measures, including 15 core requirements and five out of 10 optional requirements (for a list of these requirements, read this perspective piece by David Blumenthal, M.D., M.P.P., director of the Office of the National Coordinator, or ONC). These include a key core requirement – quality reporting – that builds on the remarkable achievements of the past several decades of the cardiovascular community in improving outcomes of our cardiovascular patients.

The Proposed vs. the Final Rule
CMS received nearly 2,000 comments on its initial “notice of proposed rulemaking” for the program, including extensive feedback authored by the ACC on your behalf.  We were deeply concerned about how CMS proposed to define meaningful use, as the first version included difficult and complex requirements that would have made it virtually impossible for you to participate in the program.

CMS and ONC have clearly been listening. They made extensive changes to the proposed rule in the final rule. For example, in the proposed rule, physicians would have had to meet 25 very specific requirements in their entirety to qualify for the program. This was changed to 15 “core set” requirements, plus your choice of five out of 10 “menu set” optional requirements.

And the metrics for achieving compliance with most of the requirements have been scaled back.  A prime example is computerized physician order entry (CPOE). The initial proposal would have required physicians to use CPOE for 80% of all orders.  Although the Final Rule requires a CPOE system that is able to capture orders for medication prescriptions, laboratory, and radiology / imaging studies, the performance measure for Stage 1 is only that physicians will have used CPOE to author 30 percent or more of medication prescriptions – a significantly reduced requirement.

Additional flexibility has also been added with respect to clinical quality measurement. Rather than requiring practitioners to report on three core measures and a rigid, pre-defined set of 3-5 specialty measures, the Final Rule requires reporting on a total of six measures – a combination of three core measures AND any three additional measures of the providers choosing. There are even alternative core measures that can be substituted for the base core measures.

CMS and ONC did remove several requirements (primarily administrative transactions) from the list of requirements. The proposed rule required professionals to submit claims electronically, as well as to perform the HIPAA eligibility transaction. The ACC and other professional associations successfully argued that these requirements were inappropriate at this time, especially with respect to the HIPAA eligibility transaction, which most health plans, including Medicare, have not fully implemented at this time.

The large number of changes reflects that they listened to the feedback they received. Their changes will help make the program goals – improved quality and patient care – attainable to a larger number of physicians. More...

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

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

Colleagues---- The administration finally announced, as we had long expected, that Don Berwick, MD, will become the new Administrator of CMS (Medicare and Medicaid), subject to Senate confirmation. Berwick, a pediatrician by training, is a good friend of the ACC. I have known him for decades, interacting on many projects. This year, ACC and Berwick’s Institute for Health Improvement are partnering on the H2H, or Hospital to Home, a national project designed to systematically reduce heart failure readmissions to hospitals. This is a positive announcement for us and for Medicare and Medicaid at a critical time.

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

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

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

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

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

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

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

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

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

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

Take a look at this nonpartisan, patient-centric ad that ACC is running in all of the news venues in front of Congress, the administration and the whole array of consumer and business lobbying entities in Washington, D.C., the rest of this week. Note that the ad does not take sides with either side of the aisle; it does not mention the Senate bill or reconciliation or any specific legislation; it emphasizes that the only real cost containment will come by getting physicians engaged in meaningful payment reform, including tort reform; and it asks that Medicare, Medicaid and the Secretary receive sufficient funding to hire the expertise to meaningfully engage in such new payment systems (given the truly outdated culture that is currently theirs).  Take a look — this lets all those constituencies know we still care about making sure that every American has access to quality care in a timely fashion!

Click on the ad to view it larger.

The Senate Finance Committee voted earlier today 14-9 to approve the America's Healthy Future Act. All the Dems voted for it, and Sen. Snowe was the only Republican who voted for it. The committee's approval allows the process to proceed to merger with the Senate HELP bill and then to the floor. The Congressional Budget Office (CBO) has estimated that the bill would cost $829 billion over the next decade and reduce the deficit by more than $80 billion. One reason it's less costly than the House bill is that it doesn’t fix the SGRrrr.

The CBO has slowed activity in the House as they analyze costs and debate whether the House SGR fix must be added to the cost of HR 3200. So, floor action there is unlikely in the next two to three weeks; and the Senate will take some time to sort through their issues as well as they try to merge the Finance and the HELP Committees bills. In terms of more details about the activities on the bills:

First, on the House side:

• The caucus considered several options for reducing the gross cost of their bill to $900 billion, none of which had great appeal to House members.  But that does seem to be an agreed-upon goal. And CBO is watching.
  
  
• The conversation regarding the public option revolved around a version that would use Medicare +5% rates, negotiated rates, or “some combination thereof.”  The last reference appears to suggest a trigger-like mechanism for starting with negotiated rates but moving to Medicare-like rates if savings targets are not achieved – an idea discussed in some of this morning’s press reports.  In sum, a “robust” public option appears likely in the House.  Leadership’s strategy is that is the best means of producing the left-most version in conference, although with the Senate heading for 60 or 61 votes at most, how far that issue can shift in conference is dubious at best.
  
  
• One means of lowering the cost of the bill that’s being considered in the House is to raise the Medicaid eligibility threshold from 133% of poverty to 150%, with the federal government absorbing most, if not all, of those incremental costs.
  
  
• The high-end insurance plan tax is unlikely to be included in the first House-passed bill, although many caucus members acknowledged some version of it is likely to come out of conference with the Senate.

Then, on the Senate side:

• “Rule 28”, which prohibits extraneous provisions from being included in House-Senate conference negotiations, will apply to the HELP-Finance merger process.  Staff for both committees have been adamant that provisions not included in either the final HELP or Senate bills will not be considered at this stage.  We predict that “rule” (more of a “guideline,” as Dr. Peter Venkman would say) will get broken at least once, but it is an added barrier to new issues being introduced to the process in the near term.  The “Manager’s Amendment” laid down once the Senate has moved to the reform bill could include new provisions, and there will likely be extensive consideration of amendments on the floor.
  
  
• Due to the fact that the $81B “surplus” in the Finance bill is “off budget” – because it is derived from new payroll/Social Security tax revenues – we think it is unlikely that the provider “fees” and other offsets and revenue raisers in the bill will change meaningfully during the merger process with HELP.
  
  
• Many Senate Democrats do not consider this the final word on, or even as necessarily relevant to, the public plan debate in that chamber.  Sens. Carper and Snowe continue to push their approaches to a fallback public plan, with the key distinction being Carper’s is almost exclusively state-managed, while Snowe’s would entail a single, federally-chartered corporation that would administer the state-based plans where the trigger has been pulled.  Neither appears to have made significant concessions to the other at this point, but inclusion of some compromise version looks probable via an amendment on the Senate floor.

Every day these and other issues are being debated and debated. We’re in there, pushing for the SGR fix, tort reform, and protection of the physician right of ownership, among other issues. And, we’re always reminding everyone about the 2010 Payment Rule debacle -- and asking they do something about so we can turn our attention to reform.