I am a Republican. For those who know me that is not a surprise. I live in a red state. I have never voted for a Democratic presidential candidate. I can field strip, clean and reassemble a Remington 12-gauge pump blindfolded. And on top of it, I think we should talk about having a single payer national health care plan. The reason is quite simple. In my view, we already have one; we just don’t take advantage of it. 

Firstly, Medicare and the Center for Medicare and Medicaid Services (CMS) are de facto setting all of the rules now. They are a single payer system.  When we go to lobby the Hill, we lobby Congress and CMS.  Talking to Blue Cross, Aetna, Cigna and United Health care is essentially a waste of time. All the third party payers do is play off the Medicare rules to their advantage and profit. They have higher premiums, pay a somewhat higher benefit and have a significantly higher level of regulation which impedes the care of their customers.  This is no longer consumer choice but effectively extortion, a less than hidden shake down in which the “choice” for a family of four is company A at $900 per month or company B at $1100 per month.  The payers are simply taking advantage of the system, playing both ends against the middle. 

Secondly, in order to move forward with true health care finance we need complete transparency in cost and expense… and we need it now. As was noted in a recent Time magazine piece on the hidden cost of health care, our current system is a vulgar, less than honorable construct more akin to used car sales than medical care, cloaked under the guise of generally accepted accounting principles and hospital cost shifting. 

Thirdly, with a single payer system would potentially come real utilization data, real quality metrics and real accountability. The promise of ICD-10 with all of its difficulties is that of a much more granular claims-made data. We could use some granularity in health care data and we will never achieve it in big data quantities without a single payer system.

Lastly, I think that the physicians should be in charge of health care and not the insurance companies and hospital systems. With a single price structure, it becomes all about medical decision making, efficiency, the provision of care to our patients, and shared decision making, all of which we do well. 

How, you might say, could a Republican come to such a position? The simple answer is I really think it is quite Republican.  Oh, I know there will be many raised eyebrows and many critics. I accept that.  I understand the fact that no single payer system is perfect, that it is “socialist,” that it is “un-American.” 

I would submit to you, however, that it is un-American to allow many of our citizens to be uninsured, that it is un-American to shunt money away from a strong military in order to support a bloated, inefficient and fraud-laden health care system, that it is un-American not to be open and above board with the cost of what we do, the expense of that service and the profit that we make. Mostly, it is un-American to let this outrageous health care injustice continue.

I would be interested in hearing your thoughts in the comment section below.

Addendum: Listen to Dr. May’s interview about a single payer system with Arnie Arnesen, host of “The Attitude WNHN 94.7FM” here.

In the last 10 to 15 years, technological advances have completely changed the way we deliver patient care on a daily basis. For cardiology in particular, noninvasive imaging is now central to clinical practice and research, irrespective of the disease entity or the area of interest of the cardiologist. Despite its unquestionable benefits, and because of earlier trends of increased utilization, medical imaging has been an area of focus by policymakers at the state and national level, as well as private payers; attempting to control who can perform imaging tests and where, through administrative protocols or state and federal laws as a means of reducing health care costs.

In my newest President’s Page in the Journal of the American College of Cardiology, I take a closer look at the past, present and future of cardiovascular imaging.  In particular I focus on what I consider to be a new imperative for medical imaging in light of the trend towards a more value-driven health care system and the fact that technology will continue to improve, enhancing our ability to diagnose and treat patients earlier. Novel technologies need to show a positive effect in patient care and outcome since ultimately, our driving concern is to achieve the triple aim of quality care, reasonable cost, and the health of the population.

The ACC has developed several tools to address over- and under-use of procedures and technologies and is widely credited by payers, members of Congress, and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care. 

Notably, appropriate use criteria (AUC) define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC can be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging tests, while reducing clinically less appropriate tests. By providing physicians with their imaging utilization, use of AUC also encourages the providers in shared responsibility for judicious use of imaging services and can effect appropriate change in behavior better than that observed with changing reimbursement.

Further, the College’s “Imaging in FOCUS” (FOCUS) tool, a self-directed, quality improvement software and interactive community was developed to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. It has proven successful in reducing overuse of imaging. Unlike Radiology Benefit Managers (RBMs) which have been criticized by health care providers for delaying or denying unnecessary administrative burdens, basing decisions on inconsistent rules and practices and lacking clinical guideline transparency, FOCUS is transparent, grounded in AUC, and provides opportunities, and in some cases, incentives, for improved AUC adherence.

Along the line of appropriate use, this past spring the ACC released a list of “Five things Physicians and Patients Should Question” as part of the Choosing Wisely campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care. Three of the five recommendations were imaging related:

• Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
  

As we continue to work towards implementing quality tools and efforts to address over- and under-use of procedures, I am proud of the College and its members for being at the forefront of this continuously developing field and working to make sure that patients reap the benefits of advances in imaging technology in a transparent, evidence-based manner.

This post is authored by Joe Allen, director of Translating Research into Practice at the ACC.

We have come a long way over the past few years with the implementation of Appropriate Use Criteria (AUC) and recognizing the value it provides for patient and physician decision making. The College is often credited by our members, payers, members of Congress and other stakeholders for taking proactive efforts to identify care with minimal benefit and provide tools to guide more appropriate, cost-effective care.

There is a positive outlook for AUC, as accreditation agencies, MOC Part IV, and Physician Quality Reporting System (PQRS) participation in 2013 all offer incentives in many states for use of AUC that can enhance the value of these efforts in a direct way.

Originally, AUC moved the discussion away from self-referral and allowed us to focus on quality with legislators avoiding several efforts to remove the Stark exemption. Congress has approved a specific demonstration project on AUC now being implemented by Centers for Medicare and Medicaid Services (CMS). This bill allowed us to offer an alternative to various payment cuts and avoid movement toward radiology benefits managers (RBMs) for now by CMS.

Several payers have begun discussions with ACC about implementing an alternative to RBMs through a FOCUS decision support tool and Quality Improvement program. Maryland and several other states were able to use AUC as a part of discussions about how standards should be set for review of percutaneous coronary intervention use.  Several states had their own efforts begun to develop their own state based standard and dropped theirs to adopt the ACC AUC.

Some RBMs, although not 100 percent concordant, have changed their policies for approval to more closely align with ACC over time. Some plans also have aligned coverage policies with the AUC, including expanding coverage in some cases for computed tomographic angiography. AUC are being used by the ACC Wisconsin and Florida Chapters to engage payers and the business community in a dialogue about how to stabilize and reform payment using AUC measures and shared decision making.

While there are instances in which AUC have been linked to review, authorization, and other policies that misuse the AUC for individual case review, these policies often preceded the AUC or would have occurred anyhow using more arbitrary criteria. Proactive adoption of AUC tools, review of AUC registry data, engagement in quality improvement efforts like FOCUS, and patient outreach like the Choosing Wisely Campaign can help obviate the need for such third party review in the future. The Criteria are never a perfect match for every patient and thus they should be used to inform and not dictate care for individual patients. AUC are best used to engage patients and practices in discussions of appropriate use, as a mirror to understand patient case mix over time, and to benchmark patient populations against others.

AUC can and will evolve in the future in response to member concerns about cookbook medicine, barriers to care, and misuse of the AUC.  However, the items above are just a few of the many ways AUC have been used to empower physicians and patients and counter the desire for third party regulation of clinical practice.  By doing so, the profession demonstrates the value of various procedures while helping all stakeholders engage in a dialogue on the value of various procedures for different patient populations.

The ACC’s 2012 Legislative Conference is coming up on Sept. 9-11. Also don’t miss the Annual Scientific Session of the American Society of Nuclear Cardiology (ASNC) held Sept. 6-9 in Baltimore, which will cover the latest advances in nuclear cardiology and multimodality imaging. Click here to register.

Last week I had the pleasure of testifying on behalf of the ACC at the House Ways and Means Subcommittee on Health during a special hearing to explore how private sector payers are rewarding physicians who deliver high quality and efficient care. I was joined by other panelists: Lewis G. Sandy, MD, senior vice president, Clinical Advancement, UnitedHealth Group; David Share, MD, MPH, vice president, Value Partnerships, Blue Cross Blue Shield Michigan; John L. Bender, MD president and CEO, Miramont Family Medicine; and Len Nichols, PhD, director, Center for Health Policy Research and Ethics and editor-in-chief of the ACC’s online Community on Payment Innovations.

During my testimony I discussed several of the quality improvement collaborations underway in cardiology and what lessons can be applied across the health care system to simultaneously reduce unnecessary readmissions, complications, testing, and ineffective spending. My testimony also focused on the power of data as exemplified by our experience with the NCDR and the importance of decision support tools in helping care providers actually use evidence-based guidelines and appropriate use criteria to “get science to the point of care” to ensure not only the right therapy and/or test, but also engage patients in the decision making process. I also focused on the ways the ACC is currently working to “put the data to work” through programs like Hospital to Home, Imaging in FOCUS and PINNACLE. I also expressed the need for payment reforms linked to these tools.

A big part of my testimony was also the “SMARTCare” projects currently underway in Wisconsin and Florida that combine data collection, decision support and quality improvement initiatives into a focused project that documents clinical quality, resource use and cost variation in the treatment of stable ischemic heart disease. The projects are driven by the ACC’s state chapters and the ACC in collaboration with integrated health care systems, payers and multi-stakeholder collaborative groups.

The ACC was absolutely a vital part of this conversation. The development of innovative new programs and payment models that reward physicians who deliver high quality and efficient care has been a College priority over the last several years in light of health care reform and the need to curb out-of-control health care costs. I also told the Subcommittee that one of the key points to keep in mind about new systems is the time it takes to implement -- so the faster they are established the faster we can move forward with implementing these new payment reforms!

I invite you to share your “big ideas" on how to reward providers for quality care and cost savings in the comment section below.

Read the complete testimony and learn more about the hearing here.

The Centers for Medicare & Medicaid Services (CMS) last week issued a report that highlights significant trends in the growth of two “pay-for-reporting" programs: the ePrescribing Incentive Program and Physician Quality Reporting System (PQRS...formerly known as the Physician Quality Reporting Initiative or PQRI). According to the report, 2009 Physician Quality Reporting System and ePrescribing Experience Report, 119,804 physicians/eligible professionals in 12,647 practices received incentive payments under PQRS totaling more than $234 million—well above the $36 million paid in 2007, the first year of the program. Under the ePrescribing Program, CMS paid $148 million to 48,354 physicians/eligible professionals in 2009. Results show that participation in PQRS has grown at about 50 percent every year, on average, since the program began.

On average, 2009 bonus payments for satisfactory reporters in PQRS were $1,956 per eligible professional, but $18,525 per practice that participated. Eligible professionals received even more from the ePrescribing Program in 2009: the average bonus payment was just over $3,000 per eligible professional and $14,501 per practice.

The report also shows health care professionals report complying more often with evidence-based care practices. Based on reported data on the 55 measures that have been a part of the PQRI/PQRS program since it began in 2007, providers have improved the frequency for which they deliver recommended care by about 3.1 percent on average. Similarly, of the 99 measures that were part of the System in 2008 and 2009, performance improved at about 10.6 percent on average. In some cases, gains have been even more dramatic. More about the report is available on the CMS website.

The incentives are still trivially small to really move the system. At least our PINNACLE Registry users got fully reimbursed with no hassles through the PQRS program. For 2009, 172 providers from 14 practices used the PINNACLE Registry to report --100% successfully--with an average payment of $8,352 per provider. But the CMS incentives need to be made much more significant if we want these programs to work and to significantly improve quality systematically.

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 saga of precertification for echo goes on. I see three basic patterns evolving across the country that I will attempt to summarize below:

1. “I'm mad as hell, and I'm not going to take it anymore.” The Delaware Chapter has been successful in illustrating to the public and Congress the harm that can come to patients when a Radiology Benefits Manager (RBM) comes between the patient and their cardiologist. There are not only flat denials, but delays and mandated substitutions, such as stress echo instead of stress nuclear. The scientific data regarding the specificity and sensitivity of these particular tests has been transmogrified into a position that the two tests are always interchangeable and are equivalent. RBMs demand substitution of echo for MPI without detailed knowledge of the clinical situation. These intrusions into patient care are inappropriate and unacceptable.
   
   
2. “Cardiologists, enabled with tools to insure the appropriate use of imaging, can do this better than a RBM.” Several chapters, working with local payers, are looking at testing regional programs that would use an ACC FOCUS tool in place of RBMs. The FOCUS tool would provide cardiovascular imaging strategies based on ACC appropriate use criteria and could ultimately serve as national models -- rational, data driven and less intrusive than a 20 minute call to the RBM for precertification of an outpatient echo.
   
   
3. “We just have to grin and bear it.” Some practices are simply reconciled to the fact that insurance companies will impose regulations that are not value added to the patient or the practice, but must be endured. These practices are adding additional precertification staff, streamlining their processes, and "playing the pre-cert game" to take the process from a 20 minute one to a 5 minute one.

Where does your practice fit? I suspect that there may be a blend of all three approaches in most practices. Personally, I have tried to streamline the pre-cert process, while resisting the most egregious denials by the RBM. I look for the ACC, as my professional society, to provide me with a tool that will allow me to demonstrate my appropriate use of imaging with minimal workflow hassles in the office. This tool is in the works, so stay tuned for more information.