“It’s About Time!”, noted Ruben Navarrette, Jr., a CNN contributor and a columnist for the Washington Post, in an article announcing the election of Argentinian Cardinal Jorge Bergoglio as the “first Latino Pope.”  His article explained that it was “about time” that the Roman Catholic Church had recognized the “importance of Latinos” in the church and elected a Pope to represent them; further expounding in great detail that he is a “cafeteria Catholic,” a normally derogatory term meant to imply someone of the Roman Catholic tradition who picks and chooses which parts of Catholicism they wished to embrace a sort of moral relativism.  In practice, however, there is a core set of inviolate tenets which are not “pick and choose” just as most assuredly Bergoglio was not selected to cater to a subset of the Catholic demographic.

Here at the American College of Cardiology, we face a somewhat analogous situation. 

The inviolate tenet of the College is the unwavering commitment to continuously, unabashedly, and with zeal focus on providing the highest quality patient care.  Quite simply, our every effort to append, fix, modify or change our health care system must have as its central theme improving the care of our patients as well as the comfort of their families. 

In some instances, this is easy.  We have many tools and resources to help us accomplish this core mission, such as CardioSmart, which works to engage our patients via education and through endeavors that focus on shared decision making and patient-centered care. We have guidelines and appropriate use criteria that help define the appropriate use of therapies for the betterment of our patients.  
 
In other areas, we make changes to the system in order to improve our working situations, and in most instances these are business decisions which have a neutral effect on patient care.  Changes in affiliation within different medical centers, merging of practices, changes in services provided to patients, and changes in staff levels all come to mind. Sometimes, however, these system changes can inadvertently cause a negative impact on patient care.  An obvious example is a situation in which a practice integrates with a medical center and provider-based billing is initiated, which in return causes the patient’s expense to dramatically increase. Although this is certainly an acceptable business practice, it may reduce the access of those who are unable to afford treatment, and the patient might avoid receiving needed care or diagnostic evaluation due to such changes.  We must work to mitigate these detrimental effects.

In its most egregious manifestation, it takes the form of a decision by physician to ignore proven therapies and treatments, applying their own self-serving rules to an otherwise straightforward medical decision.  All of us have seen the patient who undergoes nuclear exercise testing every six months following an angioplasty, symptoms having been absent for five years, told by the physician that they are going to “prevent a heart attack” by testing them.  There are many other examples.
 
It is our professional responsibility to sight our way forward using a strict moral and ethical sextant focused on the prize of outstanding patient care and service to humanity rather than the “medical moral relativism” that allows us to pick and choose what we would like to do. 

Let us not be “cafeteria cardiologists” drifting in ethical relativism for our own gain, but let us embrace the highest standards of our profession, never losing our way amidst the difficulties of health care reform.

A recent article in Health Affairs examined the supply and distribution of the cardiology workforce across the country given “a sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease.”  The paper was co-authored by Harlan Krumholz, MD, FACC, a member of the ACC Board of Trustees and professor of medicine and epidemiology and public health at Yale University School of Medicine.

The results showed that there has been a modest increase in the cardiology workforce over the past 12 years, whereas the primary care physician and entire physician workforce shortages are more pronounced. But there’s also a big disparity in the geographic distribution of cardiologists across the country, specifically in rural and socioeconomically disadvantaged areas.

As the U.S. “baby boomer” population becomes older, it is clear we will need to rely on team-based practice models to deal with the cardiovascular demands on the U.S. health care system that are certain to increase. A team-based model will enable delivery system and quality of care improvements as it offers solutions to the workforce shortage, and will expanded physician productivity, and improve job satisfaction by reducing workloads and preventing burnout.

According to the CDC, since 1950, age-adjusted death rates from cardiovascular disease have declined 60 percent, representing one of the most important public health achievements of the 20th century. Despite this huge reduction in morbidity and mortality, just imagine what we can accomplish when we work together in a team-based setting using NCDR^® and PINNACLE Registry^® data to systematically improve patient outcomes, and simultaneously improve efficiency and value.

We still have a long way to go in fighting the leading cause of death in the U.S., so let’s get to it!

I am in San Francisco today and speaking about the state of cardiovascular medicine at the CRF's TCT 2011 conference. Here is a snapshot of what I will be discussing:

The trend in U.S. health care is simple: spending is drastically rising. U.S. health care expenditures total more than $2.5 trillion. In the past few decades, hospital, physician and prescription drug expenditures have also been steady to rise. Medicare spending for cancer and heart disease varies greatly – with heart disease still almost double cancer spending even though new hope to someday become take second place in morbidity, mortality and spending. Heart disease spending Medicare alone is projected at about $220 billion in 2011 and will rise to well over $300 billion or more by 2020. Health care spending in the U.S. is more than double that of other developed nations – and health care is the primary driver of future federal spending and the accumulating deficit. With more than 35 million U.S. citizens and 15 million non-citizens uninsured, 50 million on Medicare and 40 million on Medicaid, it is clear that the spending incurred by the American health system is a heavy burden to the nation unless the profession moves in to reduce unnecessary spending.

Baseline demand of physicians is sharply outpacing the baseline supply as medical school enrollment and choice to practice a medical specialty decline. Practices are changing as more than 38 percent surveyed by the ACC in 2010 are either already integrated or considering hospital integration and 14 percent are merged or considering a merger with another practice. Well over 50 percent of CV private practices have sold to hospitals or other employment venue and the trend continues.  It is clear that this is a time of change for CV medicine and health care at large. Practice transformation will be affected by the bullish forces promoting integration, payment reforms, delivery system reform that requires team practice and advanced health information technologies, more informed patients who will engage in shared decision making, public reporting on quality and efficiency, and pressures to use clinical data and feedback to systematically improve quality and value, and to reduce variation and disparities.

Socioeconomic Trends and Imperatives

Stunning technology and infrastructure, a superbly trained workforce, excellent academic institutions, leading innovation – these are hallmarks of the U.S. health care system which currently covers more than 84 percent of Americans with private or public health insurance. Unfortunately, that also means that 16 percent of Americans are uninsured, and the nation is saddled with skyrocketing costs, great variation in quality of care and lack of needed care coordination. Clearly our non-system is in great need of mending. While the embattled Affordable Care Act offers new opportunities to promote access, insurance reform, and prevention, while also adding new funding to stimulate innovation, research,  public health and work force development, it’s fate is uncertain. In this chaotic environment, CV medicine  faces major uncertainties in terms of the impacts of system reform and deficit reduction on the future attractiveness and viability of CV physician practice,  the availability of primary care, and the affects of delivery system reforms and funding changes on patient care.  

While uncertainties abound, the future of health care and CV medicine can be positive influenced by the use of registry data and quality improvement programs which more consistently deliver best evidence at the point of care. ACC’s NCDR® and PINNACLE registries; Hospital to Home, Door-to-Balloon,  and Imaging in FOCUS initiatives, and other quality improvement programs will greatly improve outcomes and  reduce unnecessary spending if they can diffused more widely and include primary care. The ACC is poised to help the nation solve the problems of uneven quality, poor care coordination, and skyrocketing costs in health care through these and other efforts and partnerships.

To emulate management guru Peter Drucker, “The best way to predict the future is to create it.” Let’s get on with it. 

For more information on ACC’s quality initiatives, visit http://www.cardiosource.org/qualityprograms.

Things are changing incredibly fast in health care -- even before the future implementation of the Affordable Care Act (ACA).  A colleague this week introduced me to a new phrase to describe a lot of what’s happening -- it’s the irresistible urge to ‘agglutinate’, he said. By this is meant that market, economic, and demographic forces are together pushing hospitals, doctors, payers, and suppliers to integrate, merge, consolidate and organize differently to survive. The huge increases in physician employment reflect this, and particularly in cardiology and CV medicine, where more than half of private practices have now shifted to employment, mostly in hospital settings. Will non-agglutinators be losers? 

There are many examples of ‘winner and loser’ dichotomies to consider in these tumultuous times. Academic hospitals, insurers and health-related venture capitalists are having banner years of profit and success, while many physicians, public hospitals and the pharma and device industries are relatively hurting. Virtually all major academic centers are full with waiting lines, and are flush with cash. When these hospital systems are hiring doctors they probably mostly are doing so to better manage care across their geographies in preparation for population-based quality and value insurance incentives -- they don’t need more patient referrals. Smaller community hospitals, however, may be more often hiring docs to capture referrals and protect their current bottom line (a strategy that will NOT work in the long run). Meanwhile, public hospitals are rightfully very worried -- they have increasing numbers of uninsured persons and bad debt, and the current political environment is very scary for their future --and for disadvantaged populations.

 Physicians employed in expanding medical groups and physician networks are increasingly in demand, are in a good position. Systems that are not preparing for more emphasis on population-based global budgets are going to be very disadvantaged at some point, I believe. 

Insurers are also doing very well right now as well (check Wall Street performances). Why? In tough economic times, people are avoiding care, probably to save on higher co-payments. Per capita visits to doctors and to pharmacies to pick up medicines are way down in the past three years (pharmacies are worried about these trends, which also will increase unnecessary admissions for chronic diseases). Big labs like Quest Diagnostics also note a decline in business related to people not willing to spend money on their co-pays or doctor visits. These trends raise profits for payers. And, as in Kaiser Permanente’s recent experience, significant reductions in office visits result from new Internet patient-physician connections that allow people to be treated virtually -- at major cost savings and increased convenience.  

Meanwhile, the pharma and device industries are shifting their workforces and focusing offshore to expanding markets and away from what they experience as a semi-hostile regulatory environment and focus on price controls here.  

The thing about all of the above is -- it’s all subject to change. Today’s winner could be tomorrow’s losers, and vice versa.  We’re managing through uncertainty. It’s stressful, and largely based on what happens to spending and access to care in the political environment. And a lot will be determined based on the circus-like debt ceiling negotiations. Ouch.

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

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

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

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

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

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

What challenges will cardiology face in this politically tumultuous year? Read on. Last week the Coalition of Cardiovascular Organizations (CCO) met at Heart House to forecast, discuss, and seek consensus on what is on the horizon in 2011 on the congressional and state advocacy agenda. President Ralph Brindis, MD, FACC, President David Holmes, MD, FACC, and President-Elect Bill Zoghbi, MD, FACC, with ACC SVP of Advocacy Jim Fasules, MD, FACC, and I represented the ACC, along with the officers and staff leaders of Heart Rhythm Society, Society of CV Angiography and Interventions, American Society of Echocardiography, American Society of Nuclear Cardiology, Society of CV Computed Tomography, Society of CV Magnetic Resonance, Heart Failure Society of America, Society for Thoracic Surgery, the Association of Black Cardiologists, and Society of Atherosclerosis Imaging and Prevention. The Society for Vascular Surgery couldn’t attend.

It was a great exchange! Here’s my view of what we came up with as consensus priorities:

• Payment reform issues, including the getting rid of the SGR, are critically important to all. There was a general sense that we have to look beyond fee for service, and explore other bundling, episodes of care, and global budget opportunities, where an upside is conceivably possible, but certainly not easy to achieve. Some members will want to stay with fee for service, and we need to protect them as well. But re-aligning incentives and going where opportunities are is a big challenge for all of us. Business as usual is not going to work.
  
  
• Championing quality improvement is a major part of how we take on the above issues. We need our registries and accelerated abilities to continue to translate science into better clinical guidelines, performance measures, appropriate use criteria, and other tools to do that. This is how we will lead in cost containment and improving value.
  
  
• Addressing and monitoring workforce issues, including what the heck is really going to happen to primary care? What will the future role of specialists be?
  
  
• We need tort reform -- we have ideas here.
  
  
• Accountable care organizations and pressure for integration -- needs to be implemented such that physicians are not at a disadvantage to hospitals or insurers in the design and governance of such structures if they proceed. In some form, I believe, they will.
  
  
• Myriad specific issues: The RUC and CMS assaults on cardiology; precertification issues with insurers; RBMs; meaningful use, PQRS (formerly PQRI), fair e-Rx incentives and requirements; protecting private practice viability; adding value to hospitals where members are employed, consulting cuts, etc. We need to develop leadership skills too!

Doing all of this is tough in a zero-sum Medicare game; with ongoing disparities in evidence; with no respect for long-term value (VADs, transplants, TAVI); and docs not paddling together.

The ACC recently established a new council to inform the College on academic and research concerns with the mission of “advocate[ing] for high-quality cardiovascular care, education, and research by serving as a voice of the academic cardiovascular community.”  The Council on Academic Cardiology held its first meeting during the American Heart Association’s Scientific Sessions in November. While in Chicago, the council’s chair, Joseph Hill, F.A.C.C., Ph.D., and the College’s president-elect, David Holmes, F.A.C.C., recorded an interview for CardioSourceVideoNews. In the interview, Drs. Hill and Holmes discuss the new council’s mission and how it will provide the College with the academic perspective on significant issues such as education, training, and research support as well as the importance of science and education to the entire cardiovascular community and some of the activities the council has planned. View the video.

Academic health centers (AHCs) are a critically important part of the U.S. health care system. Not only do they provide a significant amount of important tertiary and quaternary health care, but they also educate our physicians and other health care professionals, and do an enormous share of our medical research. The AAMC has been generating a lot of advocacy background to protect AHCs in an era of certain cost reductions, noting that AHCs estimate that they’re paid $0.75 on the dollar for Medicare services (big losses) and less than $0.60 on the dollar for Medicaid (bigger losses). NIH relies on AHCs for major research activities, and it would be a very ugly mess if we’re unable to train the next generation of health professionals to meet the expanded access to care that is occurring in health care reform. AAMC President Darrell Kirch MD has been doing his best to educate Congress about the threats to AHCs and about the growing shortage of health care professionals to meet the nation’s future needs.

I heard a brilliant presentation by Duke Health System’s President and CEO Victor Dzau FACC, who articulated parallel concerns for his prestigious institution very clearly. But Victor intends to act to re-invent the institution before it falls victim to radically changing circumstances.  In anticipation of the mega-changes all AHCs will face in the next decade, Duke has already been an innovator in these regards, restructuring their delivery system to vertically integrate ambulatory and inpatient care across the entire region they serve, and bring many hundreds of new physicians and community providers into their expanding networks. They have built many new ambulatory facilities spanning out into the community, as well as a number of “focus factory,” non-teaching surgery- and procedure-oriented centers. They are working on novel community care, quality network, and self care systems, including the Community Care of North Carolina system (CCNC), which offers a per-member, per-month payment subsidy for medical practices to coordinate care similar to the patient-centered medical home concept.

Dzau and Duke leaders, along with counterparts at Johns Hopkins, believe it will be necessary to streamline and re-organize the way research is conducted, along with achieving greater efficiencies in the entire health care delivery process. Duke is one of a number of AHCs across the country that is also reaching out globally to provide needed education and research services to the developing world, which not only provides needed services in such areas but also brings some margin back to the mothership in these difficult economic times. The ACC hopes that other AHCs are embarking upon similar innovative means to protect their viability in the tougher times just ahead.

The intern-resident-fellow work hour issue keeps on being at the forefront of controversy. A recent survey of residents appearing in NEJM found that 51% of residents agreed that new rules from Accreditation Council for Graduate Medical Education (ACGME) would improve their quality of life and well-being, but nearly half also said they would hinder their education. Beginning in July, residents’ duty hours are limited to an average of 80 hours /week, with first-year residents limited to 16-hour days and second-year residents to 24-hour days.

At the Association of American Medical Colleges (AAMC) meeting in November, there was a panel discussion entitled “The New ACGME Standards: A Call for Fundamental Change in Graduate Medical Education” which included Tom Nasca MACP, CEO of ACGME and UCSF CEO Mark Laret as panelists. Colleagues I highly respect and trust noted at the meeting that the medical students, residents, and fellows in attendance at the AAMC are thinking the new restrictions go too far.  During the question and answer period, a hematology oncology fellow from Memorial Sloan Kettering shared a concern -- with other trainees agreeing -- that there is a lack of pedagogical evidence to support the further work-hour restrictions being proposed, raising the question as to whether trainees in the current environment will be competently trained as practicing physicians. What are your thoughts on the restrictions?

The ACC Interventional Committee and SCAI recommend (which for many medical staff means “require”) that interventional cardiologists who perform angioplasty and stenting (PCI) perform at least 75 interventional procedures annually to qualify to perform PCI interventions on acute myocardial infarctions. Many hospitals do not enforce this, but those that do might be creating a perverse incentive to perform PCIs that are not necessary to reach this "magic" number!

A vigorous on-line conversation among many members is going on about whether this is now an obsolete number to require -- one that many highly qualified interventionalists may not reach. Consumer groups are also likely becoming curious that such “practice targets” could be promoting unnecessary procedures. In view of recent public scrutiny, the question is, should this number be revisited -- because better medication and sustained clinical benefits of PCI already provided to persons with coronary artery disease have created a reduced average number of per capita procedures in many areas? It seems obvious that the Interventional Committee and SCAI should revisit the issue. In terms of workforce consideration, maybe we need to think carefully about whether we are training too many interventionalists at this point?