This post is authored by John S. Rumsfeld, MD, PhD, FACC, chief science officer of the NCDR.

The NCDR’s annual conference (NCDR.13) started today and is already off to a great start. Over 950 registry professionals, cardiovascular physicians and administrators are in attendance, and the meeting opened with a great keynote presentation about excellence in cardiovascular care and the role of the NCDR given by Martha Radford, MD, FACC, director of clinical quality and safety at NYU Hospital Center.

In response to physician and health care administrator’s growing interest in the NCDR, we've added a MD/Administrator track to NCDR.13, which includes a series of workshops specifically designed for their needs. Health care in the U.S. is changing dramatically and cardiovascular professionals face a future that will include more public reporting of quality measures, increased needs to demonstrate performance improvement, and an increased focus on outcomes. The NCDR can directly help physicians and administrators with these, so this is a major focus for the NCDR programs going forward, starting with the NCDR.13 meeting.

Meanwhile, NCDR research will be featured throughout ACC.13. Twenty-two abstracts, including oral and poster presentations will feature NCDR research. Several of the topics discussed at the NCDR.13 will be further fleshed out in educational sessions as well, including sessions focused on the use of registry data for MOC purposes, international registry lessons learned, TAVR research and more.

Congratulation to Jonathan Hsu, MD author of the poster “Inappropriate Oral Anticoagulant Use in Atrial Fibrillation Patients with a Low Risk of Thromboembolism: Insights from the NCDR® PINNACLE Program,” which is being recognized as a Best of Poster and Best FIT Poster at ACC.13. The poster will be on display Monday, March 11th from 9:45-10:30 a.m. in Poster Sessions, Expo North.

For the complete guide to NCDR abstracts at ACC.13, visit NCDR.com/ACC13 or stop by ACC Central during Expo hours.

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.

A Washington D.C. Circuit Court recently ruled in favor of physicians and our privacy. The court found there is no public interest in disclosing to the public global Medicare payments to individual doctors. Consumers’ Checkbook had sought these disclosures through a Freedom of Information Act (FOIA) request. We owe major gratitude to the American Medical Association for intervening with the court on behalf of physicians and their private payment data.

Nonetheless, this issue will re-surface I predict. Congress will be asked to write a law that allows such releases.

How do we get it through to colleagues in cardiology and other specialties that "public reporting" on quality is not an option -- it’s already ineptly happening in multiple venues using claims and administrative data. Our polling indicates that most ACC members do not suffer from 'mural dyslexia' (the inability to see the handwriting on the wall), and see that public reporting on quality is a reality that we need to address head on.

If we are a profession, then society will rightfully expect us to be altruistic (patient centered), focused on assuring that our special expertise is based on valid data, and self regulation in terms of quality, ethics and accountability. Thus, we need to be the purveyors of the information that is publicly reported -- or we will dread what we see. What’s currently happening through CMS (PQRI), employer-insurer coalitions (Bridges to Excellence, PBGH, IHA, etc) and consumer groups needs major work to be valid. For large networks, we should work on using clinical data (like the National Cardiovascular Data Registry) to measure outcomes. At the individual doctor level, we may never be able to have a patient denominator and/or risk adjustment system sufficient to reasonably assess outcomes. But, we could assess the process measure of "adherence to guidelines and performance measures". Adherence to guidelines should not mean adherence to a cookbook approach to care, but rather to a 'learning system' of assuring that the best scientific evidence is applied to all clinical care -- and that when the guidelines typically do not apply 100% to the patient before us, that we take the time to report back as to why not. 

Health system reform will absolutely need to address physician and hospital payment reforms as a central part of delivery system reform and of essential quality and efficiency improvement. These are not issues that we can afford to delegate to non-clinicians to determine and oversee. These are our core responsibilities and accountabilities. I hope -- I pray -- we figure this out and step up to the challenge and opportunity here as a profession.

I guess the biggest challenge is: how do we reach out to our many colleagues who have their heads down taking care of patients, and don’t see the tsunami approaching?

Washington is really buzzed now!

HHS Secretary-designee Daschle had what was mainly a “love-fest” first confirmation hearing this week. He will surely be confirmed. It is interesting that the Transition is alleged to prefer Sanjay Gupta for Surgeon General (SG) over UV Provost Tim Garson. Garson wants to help—and has a lot to offer. But, even if the selection relates more to a “known voice” over “known expertise,” in my view Garson would make a great Asst. Secretary for Health (the SG's boss). The FDA post seems wide open still. But, the HHS team is hoped to be formed shortly after the Inauguration, somewhat dependent on getting Mr. Daschle’s confirmation completed.

I was privileged to have a chat with Sen. Daschle last week (Mr. Obama made an excellent cabinet choice here). Mr. Daschle is interested in establishing support for a national health board to wrestle with the really tough policy and reform issues -- a good idea. Daschle is optimistic about using the stimulus dollars to advance health IT in the short term, and he appropriately promoted health IT, rural health, community clinics, payment reforms, the sunset of the SGR, and promotion of other quality improvement incentives in the first hearing. He is interested in the College's views on health IT adoption strategies, on quality reporting, and on how to engage physicians and the ACC in the reform process. We hope to set up a leaders meeting with him soon. Daschle has become a health care visionary, and he has the trust and support of Congress -- what a dynamite combination!

sCHIP: It appears the House could move a stand-alone sCHIP (state-Children's Health Insurance Program) bill this week. The intention is to move identical CHIP bills through the House and Senate; therefore, no conference committee would be necessary. Timing on the Senate CHIP bill is less certain. The program has to be reauthorized by March 1 for sure. But, getting it done sooner would make major system reform discussions less complicated in the next two months.  The current new funding for sCHIP is rumored to be coming from a tobacco tax increase and an offset of some sort involving specialty hospitals (uh-oh?).

Stimulus: I suspect the stimulus package timeline could be delayed until almost the spring. President-Elect Obama has signaled to Congress that he wants to sign a stimulus bill by mid-February, but the Senate wants more time to consider what the specifics would be for ideas being floated about increased funding for comparative effectiveness, FMAP relief (the Medicaid state funding formula), and for COBRA insurance extensions for unemployed workers. Health IT is still a big stimulus priority too, but the interoperability and privacy issues are very controversial. We might see pilot projects rather than sweeping changes.

When Thomson Reuters published its list of Top 100 CV Hospitals last month, it got me thinking about how richly our National Cardiovascular Data Registry (NCDR) contributes to quality care. Consider the following statistics:

• 100% of hospitals on the U.S. News & World Report Best Hospitals Honor Roll 2008 participate in the NCDR
• 100% of hospitals on the 100 Top Hospitals(R) Performance Improvement Leaders 2007 - Large Community Hospitals participate in the NCDR
• 98% of hospitals on the U.S. News & World Report 50 Best Hospitals Heart & Heart Surgery 2008 participate in the NCDR
• 97.5% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Teaching Hospitals without Cardiovascular Residencies participate in the NCDR
• 96.7% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Teaching Hospitals with Cardiovascular Residencies participate in the NCDR
• 96% of hospitals on HealthGrades® America's 50 Best Hospitals – 2008 participate in the NCDR
• 95% of hospitals on the 100 Top Hospitals® 2007 National Benchmarks for Success - Large Community Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals® 2007 National Benchmarks for Success - Major Teaching Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals® Performance Improvement Leaders 2007 - Major Teaching Hospitals participate in the NCDR
• 93.3% of hospitals on the 100 Top Hospitals 2007 Cardiovascular Benchmarks for Success - Community Hospitals participate in the NCDR

Wow. Now we just have to get the word out to the hospitals not on the lists about how to get there: Participate in the NCDR.

A couple of weeks ago, I talked about offsetting the decrease in payment from the Medicare 2009 Physician Payment Schedule by participating in the PQRI (in the future through the IC3 quality improvement program affiliated with NCDR). Ganpat Thakker, M.D., F.A.C.C., governor of the ACC West Virginia chapter, commented on the post: “Most of us who reported PQRI measures for 2007 did not get [an] incentive payment. CMS did not have necessary setup, and there is no appeal option. I am almost positive that we will not receive any reward for 2008 either.” The reality is that CMS lacks the capacities to run PQRI effectively -- it is a crude beginning of a quality monitoring and incentive program. A few of our larger practices got some actual reward from PQRI, but not many.

My message to all of you exasperated physicians on this topic is: Think of PQRI as an awkward baby step in the potentially good direction of substantially increasing payment for improved quality and risk-adjusted outcomes. I emphasize potentially. We are advocating to Congress and the payers for real "value" and quality-improvement reward programs with significant incentives (at least 7 – 10 percent payment increase). We are further working on Congress and insurers to appreciate the value in using our NCDR systems and the new IC3 quality improvement program to members and primary care practices to collect and populate CV performance data. If we, as the profession, are not engaged in designing and helping to implement quality improvement and reporting programs, they won’t work.

The ACC applauds all of you who made the effort to participate in the PQRI, realizing full well that it was as frustrating for most of you as the Blagojavich Senate seat selection process has been for the people of Illinois. But, since quality reporting is coming for certain, at least those of you who tried to participate are getting ready for the inevitable, and a future program that will hopefully offer real value to patients and doctors.

Please join the conversation on the topic of quality reporting and tell us what you think. Don’t use any four letter words though -- please -- if you’re a PQRI participant. We’re going to make it better.

ACC had an exciting meeting this week with Wellmark, the leading Blue Cross-Blue Shield insurer in Iowa and South Dakota to discuss ways of collaborating on continuous quality improvement and “value” based reporting initiatives. ACC Science and Quality SVP Janet Wright, M.D., F.A.C.C., and her team led the discussions, which I discovered could be fruitful in meetings earlier this year with BCBS.  This company is one of the most progressive of the BCBS plans nationally.  And there appears to be a general interest in working with NCDR, IC3 and ACC in developing some interesting projects.

Thomson Reuters has released its annual list of the 100 Top cardiovascular hospitals. The firm analyzed outcomes for CABG and PCIs at hundreds of hospitals nationwide using Medicare data. The analysis produced 100 hospitals that outperformed their peers on risk-adjusted measures of mortality and complications.

Our National Cardiovascular Data Registry (NCDR) has better data than CMS. I believe it’s time for the ACC to make a name for itself in quality rankings. In an online discussion of this topic this week, ACC leaders suggested reaching out to U.S. News and World Report to work with us on a similar “top hospitals” ranking (of course with permission of the hospitals in question), as well as creating an annual report on trends and disparities similar to the Dartmouth Atlas.

The College is also developing an NCDR recognition program to launch in 2009. For the first time, we offered a "silver award" for ACTION (our acute coronary syndrome registry) sites this year and received tremendous enthusiasm from our eligible participants. The criteria for the award were based on target achievements related to clinical composite measures. 

*** Image from Flickr (alasam) ***

Billy Beane, general manager for the Oakland Athletics, teamed with former Speaker of the House Newt Gingrich and Sen. John Kerry (D-Mass.) to pen an op-ed in the New York Times earlier this month advocating for evidence-based medicine. “Remarkably,” the authors said, “a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures.”

We certainly agree. But Billy, Newt, and Kerry appear not to realize that ACC already has the inpatient data for CV care they are seeking in 2400 U.S. hospitals. Maybe we should start a fantasy medical care team competition to attract more attention.