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.

This post was authored by Joseph G. Cacchione, MD, FACC, chair of the CQC Partners in Quality (PIQ) Subcommittee and chairman of Operations and Strategy for the Cleveland Clinic Heart and Vascular Institute.

The promise of payment reform to rescue the growth in health care expenditures is central to fundamentals of the Affordable Care Act (ACA). A 2010 study by RAND showed that only two things will bend the cost curve:  more financial risk for consumers and provider risk. Provider risk is not a new concept as the 1990’s version of “managed care” transiently muted health care spending increases but there was little attention to quality. The managed care/capitation era of the 1990’s gave way to an era of significant growth in health care spending with predominantly a fee-for-service (FFS) reimbursement system. The proposed novel payment changes ushered in by the reform movement are an expansion of provider risk and now include pay-for-performance, bundle/episode payments and total global payment. 

As stated in a Health Affairs article by Robert E. Mechanic and Stuart H. Altman: to be successful, payment reform options must include the following criteria: 1) Potential for reducing unnecessary utilization, 2) Encouraging high quality, 3) Supporting provider integration and 4) Operational feasibility.

The U.S. government has chosen to pilot bundled payment programs. Bundles are one claim for an event of care whereas episodes are time sensitive bundles and include both a hospitalization and some post-acute period.  Several health care organizations entered into pilot agreements around bundling services for a specific diagnosis and in many circumstances episode payment. As part of these bundle pilots, there are required commitments in cost savings to CMS. These pilots are just underway and the results will fuel further CMS programs.  In addition, pilots with bundling using the Prometheus grouper tool are underway. These programs have had limited penetration due to the inability to implement the new payment methodology in what has traditionally been a system that is dominated by FFS claims systems.

The constituents of any payment system include the insurers, patients and providers; and each will have challenges with the conversion away from FFS. The vast majority of health insurers’ systems are designed exclusively for FFS payments and adding in a bundled/episode claim program will be administratively challenging. As an example, related claims that should be inside a bundle may be paid as an individual FFS claim, thus causing rework and duplication. The operations of bundling will require modification of the insurer’s existing work flows and systems. In most cases the providers have little information about utilization patterns once patients leave the acute care setting. Many providers are entering into the pilots described above with CMS and other private insurers based on small amounts of claims data. It is hopeful that the experience they gain will allow them to take on the intended financial risk successfully. 

In addition to cost data, there will be the need for longitudinal clinical data registries with outcome measures at timed intervals that are coterminous with the episode period.  This is one of the major differences with the latest iteration of the risk programs compared to the 1990’s version, the addition of quality outcomes. 

Last but not least, patients don’t live in episodes nor do they understand how their financial responsibility may be impacted by these new payment methodologies.  Clearly the constituents of the health care system are on a very steep part of the learning curve for the new payment system.  Providers will need to garner far more information about longitudinal cost and quality measures before going at significant risk for bundled payments.  

Last week I had the chance to attend the Cardiovascular Summit: Solutions for Thriving in a Time of Change, held in Las Vegas. The CV Summit started last year with much success and continued this year with more than 400 attendees!  It was a superb meeting that left participants with more knowledge, solutions, and next steps to thrive as physicians in a time of uncertainty and continuous change.

The meeting kicked-off with sessions on the status of health care reform in the U.S. and the potential impact on cardiovascular medicine over the next few years. The keynote address, given by Harold Miller, executive director of the Center for Healthcare Quality and Payment Reform, taught us ways that physicians can lead the way to a new reimbursement system that rewards quality, rather than quantity, while saving money for the health care system.

The following day covered data management and the cardiovascular service line, essentially how to work better with each other and using data to connect the dots, as well as how to implement a solid infrastructure from the get-go.

In a special workshop for congenital heart disease professionals, ACC Senior VP of Advocacy Jim Fasules, MD, FACC, shared Medicaid changes expected as a result of the Affordable Care Act, as well as widely anticipated value-based purchasing programs and their potential effects on pediatric cardiology.

In addition, due to the massive coding changes this year stemming from the Medicare Physician Fee Schedule, a pre-conference session discussed appropriate documentation for those codes and concerns about audits.

Finally, the Summit appropriately concluded with sessions on leadership and governance. Workshops on finance and evolving payment models discussed contracts, horizontal integration, incentivizing physician and MLP compensation, and more, and left attendees with ways to deal with the new, evolving environment – things that they don’t necessarily teach you in medical school.

In the session on strategic change and how to keep your organization from becoming irrelevant, W. Martin, MD, eloquently stated that change never stops. There may be a reprieve between changes, but a broader vision requires a next evolution, another change. I couldn’t agree more, and it is our duty to educate ourselves and lead the change.

Special thanks to everyone involved for making this meeting a huge success, especially Howard Walpole, Jr., MBA, MD, FACC, course director of the ACC Cardiovascular Summit, and Pamela S. Douglas, MD, MACC and C. Michael Valentine, MD, FACC, course co-directors.

Be sure to check out ACC’s Facebook page for photos from the CV Summit.

Stay on top of 2013 changes and efficiently and accurately report cardiovascular services and procedures with the updated 2013 CPT® Reference Guide for Cardiovascular Coding. Visit CardioSource.org/CPT to order your copy.

This post was authored by Mike Tempelhof, MD, cardiovascular disease fellow, Northwestern University Medical Center.

Beginning January 2013, the Affordable Care Act (ACA), the Budget Control Act of 2011, the Sustainable Growth Rate (SGR) formula and additional health care reform programs as proposed by the Center for Medicare and Medicaid Services (CMS) will be implemented. Unless modified, several provisions within these policies will have a detrimental effect on the quality of patient care, physician autonomy, reimbursement and the future of medicine in America. It is imperative that health care practitioners have an appreciation of the critical health care policy issues and how their implementation will limit our ability to continue to provide high-quality, high-value health care in the future.

If implemented, the SGR formula will cut Medicare physician payments by 28 percent starting Jan. 1, 2013, and budget sequestration targets as defined in the 2011 Budget Control Act will cut Medicare reimbursement annually by an additional 2 percent. The combined 30 percent reduction in physician reimbursement will limit critical investments in diagnostic and therapeutic equipment, ultimately threatening Medicare beneficiaries’ access to quality care. These reductions in Medicare funding will have a dramatic impact on Graduate Medical Education (GME) and research funding, which will likely reduce the number of trainee positions and de-incentivize trainees from pursing specialized medical training. At a time of growing physician shortages in conjunction with an aging population, these cuts would have a significant impact on the quality and availability of US health care in the future. Finally, sequestration is estimated to reduce federal funding of all scientific research by 8.4 percent. Any reduction to the already resource deficient medical research sector will further limit the innovation and development of new medical therapies that our medical system depends on. Such setbacks would stifle the recent gains made in the morbidity and mortality associated with cardiovascular disease.

The ACC is advocating to repeal the SGR, and stabilize sequestration payments until a new reimbursement system is in place. Juxtaposed to the current volume-based payment system, the ACC is strongly advocating for payment models that align payment incentives with evidence-based improvements in health care quality and outcomes. With a proactive approach to health care reform, the ACC has implemented quality improvement tools including clinical data base registries (NCDR, PINNACLE) and appropriate use criteria into clinical practice. This practice model affords the ACC the ability to hold cardiologists accountable for reaching benchmarks in standard of care. Evidence suggests that an evidence-based, incentive payment program modeled on similar quality improvement tools will improve the quality and cost-utility of health care in America. Therefore, the ACC strongly advocates for a quality and not volume-based payment system that aligns payment incentives with evidence-based medicine.

As our health care system evolves at this time of momentous reform, cardiologists and all practitioners must remain the patient’s strongest advocate by continuing to practice medicine with beneficence; delivering effective and efficient health care to all Americans. Collectively, we must act now to repeal the SGR and the sequestration cuts scheduled for January 2013. We must advocate for a meaningful medical liability reform and a sustainable payment system that incentivizes high-quality health care. Choosing not to act, would be the greatest risk to the future our patient’s lives and quality of their care.

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.

By Eric Stecker, MD, FACC, member of the ACC’s Clinical Quality Committee 

The Supreme Court’s decision upholding most elements of the Affordable Care Act introduced certainty that major structural changes in health care will continue to rapidly evolve.  Most discussions of reform have centered on access to coverage, access to care and potential mechanisms of cost savings.  But this is only half of the story.

A critical factor differentiating the current round of health care reforms from the managed-care reforms of the 1990s is an emphasis on “value” across the spectrum of reform approaches.  High value medical services maximize quality while minimizing cost.  The ACC has led efforts among medical societies to structure the debate in Congress to emphasize quality considerations. 

As health care reforms are implemented at the national, state and local levels, responsibility for managing quality will fall on cardiologists working in concert with hospital and clinic administrators. In the past, cardiologists added significant monetary value for health systems by generating large patient encounter volumes with only crude measures of quality in a fee-for-service environment.  In the future, individual cardiologist’s importance for an organization will be defined using sophisticated measures of quality balanced with revenues and costs in a global payment (capitated) environment. To achieve this, cardiologists must identify which organizations can succeed in such an environment and work in leadership roles to help those organizations adapt as health care reform evolves. 

Anyone reading this blog who has experience with Medicare Meaningful Use could be skeptical regarding the accuracy and impact of quality improvement efforts.  Quality efforts in medicine remain in their infancy and are being rolled out across a fragmented industry that often has 1990s-era information technology infrastructure and entrenched organizational siloes. But many other complex industries have successfully approached quality improvement and some health care institutions such as Intermountain Health Care in Utah have already gained considerable traction and efficiency.

Stay tuned next Thursday for the sequel to this blog, which will address several specific aspects of health care reform that are important for cardiologists to gain familiarity with. 

The long-awaited U.S. Supreme Court ruling regarding provisions in the Affordable Care Act (ACA) was released yesterday. In a majority decision, the Court ruled that the ACA, including its individual mandate that virtually all Americans buy health insurance, is constitutional.

The ACA is the largest expansion of health care coverage since Medicare and Medicaid were initiated in the sixties. Having this decision behind us means that we can continue to move forward with supporting policies and provisions within the law that are in line with our overarching health care reform principles – particularly those that expand health care coverage, encourage preventive care, and foster innovative payment and delivery system models that reward quality and ensure value.

At the same time, the College will also continue to work with Congress and the Centers for Medicare and Medicaid Services (CMS) on provisions that affect cardiovascular care. Among those:

• Implementation of the controversial Independent Payment Advisory Board, a 15-member Board tasked with developing and presenting proposals to the president and Congress, starting in 2014, to extend the solvency of Medicare, slow cost growth, improve quality of care, and reduce national health expenditures. The College remains concerned by the authority granted to an independent body to determine payment cuts for only physicians, particularly in light of ongoing payment reductions as a result of the Medicare physician payment formula.
• Implementation of the Physician Payments Sunshine Act requiring that industry disclose payments to physicians and teaching hospitals, both direct and indirect. While the ACC supports the overarching objectives of the Act, the College has raised concerns regarding CMS’s interpretation and proposed implementation of the Act. Final regulations are expected in the coming months so stay tuned!

Outside of the ACA, there remains a lot of hard work before we can arrive at a sustainable health care system that emphasizes value and a strong patient-doctor relationship. In the coming months the College will actively be advocating for overarching payment and medical liability reforms that are critical for comprehensive health reform to be truly effective. In addition, our Advocacy team is focused on several regulatory proposals and legislative efforts that will have major impacts on cardiology. Among them:

• The 2013 Medicare Physician Fee Schedule (the proposed rule is expected any day);
• Additional cardiovascular coding changes as a result of continued bundling efforts;
• The annual battle to repeal/stop the flawed sustainable growth rate (SGR) formula used to calculate Medicare physician payment.

These topics, as well as life after the Supreme Court decision and the 2012 elections, will be the focus of the College’s annual Legislative Conference in Washington, DC, this September. (Registration is now open to all ACC members.)  Additionally, the ACC continues to be engaged with CMS, industry and other stakeholders as appropriate on all of these issues. It’s definitely a time of change for health care in the U.S. However, it’s this change that provides the most prospects for action. I’m excited by the opportunities not only for the College, but for the cardiovascular profession as a whole. Now is the time to leverage our successes over the last six decades in improving cardiovascular care and ensure that future policies and programs further these results. Let us work all together for this ultimate goal.

As we wrap up ACC.12 after soaking in all the new and best cardiovascular science and education, I’m continuously amazed at how much progress is made from these meetings. Over the past few days I’ve both presented with and had the honor to learn from some of the most astounding cardiovascular health care innovators in the field. Now the challenge lies in taking what we’ve learned and implementing it – and, as Immediate Past President David Holmes, MD, noted in his ACC.12 Opening Session address, using it to transform how we provide care to patients and work in partnership with others.

With the recent two year anniversary of the Affordable Care Act (ACA) and the start of the Supreme Court hearings of the constitutionality of it all, I’d be remiss not to also mention the timely discussions that took place throughout ACC.12 on health care reform and its impacts on everything from health IT, to imaging, to academia, to the future.

Yesterday I gave the presentation, “ACA for Dummies,” giving a play-by-play of the ACA’s nine separate independent titles, as part of a session that looked at where cardiology will be as a profession in 2015. The bottom line is even if the decision is to rid of the ACA we will still be faced with immense access, cost and quality problems. Our goal at the College is to ensure that we’re poised to help ensure these changes put patients first and reward physicians and other medical professionals for their commitment to quality and evidence-based care.  Congress’ traditional cost reduction strategies of price controls and caps on spending -- as in the broken SGR (or sgrrrr, expressed as a growl) Medicare payment formula -- just won’t work. Instead we need to systematically improve care.

Also yesterday, I was on a progressive panel discussion about the Future of Cardiovascular Diseases: Where Are We Going (and Where Do We Want to Go?) with ACC’s new President Bill Zoghbi, MD, President-Elect John Harold, MD, Million Hearts Director Janet Wright, MD, and others, which discussed the recent UN Summit on NCDs, and others initiatives to combat the growing epidemic of cardiovascular disease. I think Huon Gray, MD, said it best: “Since CV disease knows no boundaries with regards to the patients it affects, nor should the organization and cardiologists whose job it is to help them.”

Professionalism has to be a part of our changing future and the patient must be the center. We have to change the physician/patient relationship and move toward patient centered care, something that Zoghbi is focusing on during his presidential year. We’re not just embracing change, we need to lead change!

Overall it was a great meeting, folks and thanks to everyone who made the journey to the Windy City. Save the Date for ACC.13, March 9-12 in San Francisco!

PS the fun never stops here on Hollywood on the Potomac, check out my testimony before a House Appropriations subcommittee here where I was able to discuss the need for more funding for cardiovascular disease research (just like what was presented at ACC.12), prevention and treatment.

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.

What an exciting weekend! I can safely say that the Cardiovascular Care Summit is not something that happened in Las Vegas that should stay in Las Vegas. Whether it was hearing from national health plan representatives on the role of the cardiologist and the cardiovascular program in a reformed reimbursement environment, or discussing best practices for building and managing a cardiovascular service line, this unique conference offered solutions for the entire cardiovascular care team to thrive in a time of change.

David Lansky, PhD, president and CEO of the Pacific Business Group on Health; Deborah Ness, president of the National Partnership of Women and Families; Lonny Reisman, MD, chief medical officer at Aetna; and Reed Tuckson, MD, executive vice president and chief of medical affairs at UnitedHealth Group kicked off the Summit by providing a unique perspective on the cardiovascular community’s role in payment reform. Whether examining the components of value-based purchasing, helping to reduce patient readmissions, there are a number of opportunities to share our expertise and work with health plans.

The Summit also featured discussions on the future of health care reform and how the physician community as a whole can affect this process and lead change. Obviously, one of the key areas requiring substantial change is physician payment. Following on the heels of the health reform session, Summit attendees were able to take part in a panel discussion that looked at a variety of compensation models and their potential roles in the changing reimbursement environment. Breakout groups also offered opportunities to discuss major financial changes, ranging from contract negotiations, winning academic business models and how to financially survive in private practice.

Outside of payment and health care reform, the Summit also focused substantially on data collection and management, providing a focused look at the myriad of data available today and why accurately reporting data will be so critical in the future. The writing is on the wall, whether we like it or not, and future compensation models will be based at least in some part on quality of care and outcomes. We have the experience with NCDR to make sure this is done in a way that is transparent and accurately reflects the quality and appropriateness of care being provided.

Finally, the final day of the Summit really provided a comprehensive look at issues related to the cardiovascular service line. Physician management of the cardiovascular service line is today’s contemporary approach to a physician-driven, professionally managed cardiovascular program.

The integration of physicians into the management of the service line provides an opportunity to strategically and operationally align hospitals and physician groups. ACC leaders and other stakeholders involved in service line management provided first-hand reports and best practices for designing and leading a successful cardiovascular service line model.

I’d like to thank and recognize ACC leaders and staff involved in making this Summit a great success. It was a true testament to the many ways the ACC and its leaders are working to meet the needs of the entire cardiovascular care team in this time of rapid change. Viva Las Vegas!