Everybody has a budget. Your family does, my practice does, your state has a budget, the ACC has a budget... and so does the country (at least some of the time). This week the president released his 2014 budget and I thought you might like to see some of the proposed provisions that impact cardiology and the practice of medicine as a whole.

Interestingly, there is an assumption that Medicare payments to physicians will not be reduced by the mandated Sustainable Growth Rate (SGR) formula.  This formula is scheduled to cut payments to physicians by 25 percent in 2014, but previous scheduled cuts have been overridden by short-term Congressional action. Perhaps it’s time to just fix it already!

There is also a proposal to reduce payments for the so-called “indirect” costs of graduate medical education (GME) by 10 percent starting in 2014, at a savings of more than $10 billion over 10 years. This is an increasingly important topic that the ACC’s legislative team is following closely.

While it’s important to note that this budget proposal is likely to be dead on arrival given the divided Congress and president, imaging is another area that “we” (the collective ACC) will also be keeping close tabs on this year. The budget proposal includes a provision to mandate prior authorization of advanced imaging (CT, MR, nuclear), as well as a proposal to limit the availability of the in-office ancillary services exception so that advanced imaging services (CT, MR, nuclear) could not be provided if ordered by a physician in that office. (The budget proposal does indicate that the exception could still be available if certain undefined accountability standards are met. But….)

On the brighter side, the budget proposal does contain provisions to increase funding for the FDA, partially by taking advantage of user fee programs authorized last year, previously existing programs for prescription drugs and medical devices, along with the new programs for biosimilars and generic drugs. Also $534 million in user fees are aimed at decreasing use of tobacco products. The National Institutes of Health also gets a small 1.5 percent bump from 2012 levels, for a total of $31 billion. The administration also includes funding for continued investment in health IT implementation and electronic information exchanges, given that current funds from the American Recovery and Reinvestment Act are beginning to expire.

Other proposals include a provision to lower the target growth rate for the Independent Payment Advisory Board so that the board could take binding action even with lower cost growth in health care.  Target growth rate would reduce to GDP plus 0.5 percent.  The IPAB, a major feature of the ACA, has yet to be formed. The budget would also extend funding for a consensus-based entity (likely the National Quality Forum) to focus on performance measures and quality improvement.  Current government funding for NQF expires at the end of 2014.

As I mentioned before, many of the items contained in the budget are unlikely to come to fruition due to the divided Congress and president. However the proposal provides a glimpse at administration priorities for next year. Perhaps we should all make sure to save the date for ACC’s Legislative Conference this September!

“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.

This post was authored by William J Oetgen, MD, MBA, FACC, ACC's senior vice president of Science and Quality.

A recent study using data from the NCDR’s® ICD Registry™ found that the likelihood of receiving cardiac-resynchronization therapy with defibrillation (CRT-D) is mediated by community wealth and hospital resources. The study looked at 22,205 patient stays and found in the full hierarchical model, average median household income (P<0.001) and implantable cardioverter-defibrillator implantable volume (P<0.001) remained significant predictors of CRT-D receipt. Further, patients treated at hospitals in affluent communities were more likely to receive CRT-D than patients treated in poor communities, despite accounting for other patient and hospital characteristics, including insurance status.

Since health care disparities are complex issues, and it has been shown that “variations by race and ethnicity exist in the use of medical devices for the treatment of advanced heart failure,” the study attempted to address the “relative impact of patient-, hospital-, and community-level factors on the likelihood of CRT-D receipt.”

The lead author noted that the analysis demonstrates that the wealth of the community in which patients live impacts the care they receive, and the relationship between median household income and receipt of CRT-D persisted regardless of the patient’s insurance status. The authors also note that their findings have important implications for efforts to address healthcare disparities and that health policy targeting insurance coverage alone will be ineffective in resolving inequities in care.

The ACC has been working on several initiatives to address gaps in care like the example above. ACC’s credo initiative seeks to help clinicians better serve all of their patients, regardless of race, ethnicity, gender, primary language, or other factors that may impact care. The ACC has also been working with groups like the National Minority Quality Forum on the CardioMetabolic Health Alliance, to improve cardiometabolic risk factor control in diverse populations.

In addition, this past year the ACC and its CardioSmart initiative has partnered with the Association of Black Cardiologists on a series of community events aimed at increasing awareness of heart disease and promoting better heart health, particularly in high-risk communities. The next event, called Spirit of the Heart, will take place this weekend in Harlem, NY (read more about Spirit of the Heart and view photos from the event in a previous blog post here).

We know the complex problems related to health care disparities cannot be solved overnight, but it is our hope that these initiatives will slowly but surely help close the gaps in care.

Last weekend I had the privilege of kicking off the first of a series of community events targeted at the nation’s minority and underserved communities in my hometown of Houston, TX.  The program, called Spirit of the Heart is a partnership between the Association of Black Cardiologist (ABC) and ACC’s CardioSmart initiative and aims to increase awareness of heart disease and promote better heart health, particularly in high-risk communities.

The program began with a community leader’s forum on Friday evening, where ABC President, Ola Akinboboye, MD, MPH, MBA, FACC, and I presented opening remarks. After the dinner and entertainment, I sat on a panel discussion alongside Keith Ferdinand, MD, FACC, and other ABC leaders and community partners including Darrell Green, former Washington Redskins cornerback and founder and CEO of WalkFitHealth.  The discussion, moderated by Ryan Neal, MD, was both informative and educational and we heard from advocates of health, exercise and nutrition on how to better manage care.

Dr. Ferdinand gave a presentation on reducing cardiovascular disease risk in diverse populations, and mentioned his work on the executive committee of ACC’s Coalition to Reduce Disparities in Cardiovascular Outcomes (credo) initiative, which provides healthcare providers who treat or prevent cardiovascular disease with the tools to assure optimal care for their diverse patients. He also touched on how CardioSmart and its resources, including our text message platforms, mobile Apps, and more, can help educate patients and their families about healthy lifestyle choices as well as care options.

The audience was full of ACC and ABC’s partners in the community, and during the Q & A portion of the evening, they asked a lot of important questions, especially about personalized care and how we as leaders encourage our patients to live healthier lifestyles.  

In response, along with emphasizing patient-centered care, a style of care that is based on strong physician-patient relationships, I also explained how in the end, medicine is about a healing connection between human beings. We need to re-establish the idea of medicine as an art as well as a science, and restore the physician-patient relationship; patient-centered care is the right thing to do, both in principle and in practice.

The next day ACC and ABC conducted free day-long health screenings for area residents. ACC also gave out practical health information to the community. I heard from ACC staff that there was a great turnout for the screenings and the CardioSmart presence was strong and effective. This type of grassroots outreach in underserved communities is exactly what we are trying to do with CardioSmart: to get together with patients and the public to make a difference in their heart health.

The program concluded on Sunday with ACC and ABC representatives visiting local churches and presenting ABC's 7 Steps to a Healthy Heart:

1. Be Spiritually Active
2. Take Charge of Your Blood Pressure
3. Control Your Cholesterol
4. Track Your Blood Sugar and Maintain Ideal Weight
5. Enjoy Regular Exercise, Follow a Sensible Diet and Get a Good Night's Sleep
6. Don't Smoke
7. Access Better Healthcare, Get a Check Up and Faithfully Take Your Medication

This program will be replicated in Dallas, TX from Oct 5 – 7; Austin, TX from Oct. 12 – 14; Harlem, NY from Dec. 7 – 9; and Oakland, CA on March 7, 2013 (to coincide with ACC.13). If you live in any of these cities I encourage you to come out and help us spread the spirit of the heart!

Follow @CardioSmart on Twitter and search #SpiritHeart to join the conversations. Also be sure to visit CardioSmart’s Facebook page for additional tools and resources for patients.

Check out ACC video coverage of the Houston event.

This post was authored by Scott Lilly, MD, PhD, chair of the FIT Committee and an Interventional Cardiology fellow at the University of Pennsylvania.

This year over 70 fellows-in training (FITs) from across the nation attended the 2012 Legislative Conference in Washington, DC where they met with ACC and congressional leaders to discuss current issues affecting practice of cardiology in both academic and private practice settings. Although it may be difficult to remain apprised of proposed and impending legislation during fellowship years – the conference format addresses this.  On Monday, there was an array of speakers that discussed specific issues for collaborative lobbying. These short (and often entertaining) presentations were interactive and reliably followed by practical questions from the nearly 500 physicians, cardiac care associates or FITs in attendance. In between the discussions, there were a number of breaks that allowed FITs to interact and introduce each other, have smaller group conversations regarding a particular issue, or meet with ACC leadership. Fully debriefed, we received our congressional visit schedules and prepared to “storm the hill” with our fellow state ACC members.

Among the issues we addressed this year was a proposed cut to ACGME spending – something that could directly affect on our training.  Whether these cuts would have a direct affect on the number of fellowship positions, or result in variations in educational infrastructure or national meeting subsidies is unclear. Regardless, these changes are clearly occurring at a time when there is a greater need for cardiovascular physicians – driven both by the aging population and the availability of new and effective therapies that mandate specialized training. The ACC has responded to this and other proposed cuts proactively by requesting a partnership with respect to health care reform. Through addressing overutilization via appropriate use criteria, and improving quality of care by advocating national registries, the hope is that we will be able to more effectively deliver care in a less costly manner.

While we as FITs may spend most of our professional time at the bedside or in the latest scientific journal, I was reminded this weekend of the world outside of the clinic. We have cardiologist advocacy leaders – individuals that, despite busy practices devote a significant amount of time to preserving our ability to learn, care for our patients and help to secure our future. When FITs participate now, it strengthens the delivery of these messages to congress, broadens our perspective, and will hopefully cultivate the next generation of these cardiologist advocacy leaders.

For the many FITs that visited the Capitol last week, I hope you arrived home safely; to the rest, I hope to see you next year.

Today a very important health policy statement was released from the Global Cardiovascular Disease Taskforce, a group of experts representing the ACCF, World Heart Federation, American Heart Association, European Heart Network and European Society of Cardiology, and include ACC Past President David Holmes, MD, MACC, and myself. The jointly released health policy statement urges timely global action to save preventable death from cardiovascular disease (CVD).

The statement is timely and was released on the one year anniversary of the United Nations High-level meeting on non-communicable diseases (read my blog post from last year’s meeting here).  We are calling on government and the cardiovascular community to accelerate the progress on the commitments made last year and support the ten evidence-based targets, including the top four exposure targets on physical activity, tobacco, dietary salt intake and hypertension/blood pressure. By focusing on these top four targets, the goal is to achieve the following by 2025:

• A 10 percent relative reduction in prevalence of insufficient physical activity in adults aged 18+ years;
• A 30 percent relative reduction in prevalence of current tobacco smoking;
• A 30 percent relative reduction in mean adult (aged 18+) population intake of salt, with aim of achieving recommended level of less than 5 grams per day; and
• A 25 percent relative reduction in prevalence of raised blood pressure.

We all agree that this first step is imperative if we are to achieve the overarching goal of a 25 percent reduction in mortality from non-communicable diseases by 2015, a goal that was determined this past May at the 65th World Health Assembly in Geneva.

The ACC is calling upon its members to take this statement to heart. With CVD costing governments nearly $863 billion globally, and the number of deaths related to CVD expected to grow to more than 23.6 million by 2030, the consequences will be astronomical if we are not successful at curbing these preventable deaths. Read more about the statement on CardioSource.org.

A spotlight will be on cardiovascular disease during World Heart Day on Sept. 29, and the College and other stakeholders worldwide are participating in activities focused on prevention for women and children. More information on ACC World Heart Day activities is posted on both the ACC and CardioSmart Facebook pages.

This post is authored by Cathie Biga, RN, MSN, president and chief executive officer of Cardiovascular Management of Illinois.

I just finished a remarkable two days at ACC’s Legislative Conference in our nation’s capital.  While I have been privileged to attend in the past, this was the first time I had the honor of being on the Hill with the ENTIRE cardiac team representing Illinois! Led by our current Governor Marc Shelton, MD, FACC, Past Governor Jerome Hines, MD, PhD, FACC, integrated and independent physicians, FITs, CCAs, and practice administrators, we were 11 strong and hit nine offices.

Sharing our message from the “trenches” was important to all of us, and explaining the vast landscape of cardiology care in Illinois was a challenge we tried to hit head on.  From patient access (explaining why imaging cannot be reduced any more or reductions for same day of service is problematic) to the administrative burdens and cost of running a practice, we relayed our message and asked for their help. 

While speaking with our Legislative aides, chiefs of staff, and a few members of Congress, we relayed that while payment reform will inevitably happen (and it really must), we MUST ensure accurate quality data is used to drive this process – which the College has. In addition, physicians and their team MUST be at the table when these decisions are made.

Change is inevitable and hopefully our trek to the Hill will remind us all how important this health care message is for cardiology and why EVERY member of the team needs to be involved. 

P.S., You don't have to fly all the way to Washington to get involved -- our Senate and Congressional representatives live in your neighborhood! Get to know them, call them, invite them to your practice and support them!

Hope to see you all next year!

For additional coverage of the 2012 Legislative Conference, visit CardioSource.org and check out the photos on ACC’s Facebook page.

This post was authored by Jim Fasules, MD, FACC, senior vice president of Advocacy for the ACC.

This week more than 350 ACC members were in our nation’s capital for the College’s 21st Annual Legislative Conference. ACC’s leaders, FACCs, FITs, CCAs, Practice Administrators and even international members were all on hand to participate in briefings on the critical health policy issues facing medicine today.

The conference kicked-off on Sunday with a special reception and dinner celebrating the 10th Anniversary of ACC’s Political Action Committee. During the keynote speech, Pulitzer Prize winner and syndicated Washington Post columnist George Will shared his insider’s perspective of the current political climate and the impending presidential election. Filled with facts and baseball references, Will was able to engage a packed room full of attendees from both sides of the aisle.

On Monday members heard from ACC President William Zoghbi, MD, FACC, who presented results from the 2012 Practice Census, (read more about the results on CardioSource.org), as well as from a range of politicos including an election outlook from Ronald Brownstein.

Earlier today Rep. Michael Burgess, MD (R-TX) was presented with the President’s Award for his distinguished public service and support of the College’s health policies that promote high-quality patient-centered care.  Soon after, conference participants headed to Capitol Hill for a day full of pre-arranged meetings with their members of Congress. Given the current health care landscape, members stressed the importance of Congress avoiding further harmful spending cuts and reforming the Medicare payment system. With 295 separate legislator meetings scheduled, the ACC’s commitment to quality and patient-centered care was heard loud and clear on the Hill.

Our actions and advocacy efforts this week are important for many reasons. We are dependent on Congressional action to prevent upcoming cuts from the sustainable growth rate (SGR). In addition, the Centers for Medicare and Medicaid Services (CMS) has already proposed an array of new policies for the 2013 Medicare Physician Fee Schedule (read ACC’s comments on the proposed rule here) that include both threats and opportunities for cardiology. These proposed policies include:

• The final year of transition to new PE RVUs causes small reductions to most cardiology services.
• A proposed multiple procedure payment reduction for a wide range of diagnostic cardiology services (e.g., echocardiography, stress tests, vascular ultrasound) would reduce the technical component payment for the second and any subsequent service by 25 percent if performed on the same day.  ACC has vigorously opposed this proposal.
• Medicare has proposed for the first time to pay for transitional care services for patients discharged from hospitals or skilled nursing facilities. Physicians providing care coordination services within the first 30 days of discharge would have the opportunity to bill Medicare for these services. The ACC sees this as an important step forward for Medicare, but expressed some concerns about the specifics of the proposal. We’re hopeful that CMS will make some changes to ensure that patients with cardiovascular disease benefit from the new policy.
• If CMS goes forward with its proposed rules, physicians in groups with 25 or more practitioners will be the first to be subject to the value-based payment modifier established in the Affordable Care Act. Also, beginning in 2015, groups of 25 or more will be subject to a 1 percent penalty or may be eligible for bonus payments based on PQRS participation and performance on quality and cost measures in 2013, and practices with 25 or more physicians and other practitioners will need to take action in the first quarter of 2013 to avoid the penalty and ensure potential eligibility for bonus payments.

Not included in the proposed rule, but of great significance to cardiology, we also expect 2013 coding and valuation changes to result in cuts of 20 percent or more for EP/ablation services and some PCI services, but exact impacts will not be available until Medicare releases payment information on Nov. 1.

Although CMS will review comments and release final decisions on these proposals soon, our efforts on the Hill this week will inevitably help raise awareness of the issues facing cardiology today. Stay tuned to the ACC Advocate and CardioSource.org for updates this fall. Also stay tuned for individual perspectives from Legislative Conference here on the blog in the coming days.

An important expert consensus document on the third universal definition of myocardial infarction (MI) was released today as part of the ESC Congress 2012, and simultaneously released online in JACC. Developed jointly by the ACC, the European Society of Cardiology, the American Heart Association and the World Heart Federation, the updated definition has important and immediate implications for physicians and our patients.

The task force had previously defined MI in a consensus document in 2000 and again in 2007. This new 2012 definition includes new insights and data over the past few years, and will be universally used to diagnose patients and to define endpoints in clinical trials.
 
At the center of the third definition of myocardial infarction, is the detection of a rise and/or fall of cardiac biomarker values, with at least one of the values being elevated (i.e., > 99th percentile upper reference limit). The preferred cardiac biomarker of necrosis is cTn. In addition, at least one of the five following supportive criteria should be met:

1. Symptoms of ischemia
2. New (or presumably new) significant ST/T wave changes or left bundle-branch block (LBBB)
3. Development of pathological Q waves on ECG
4. Imaging evidence of new loss of viable myocardium or regional wall motion abnormality
5. Identification of intracoronary thrombus by angiography or autopsy

The new document notably adds to the previous definition the identification of intracoronary thrombus as one of the supportive criteria for the diagnosis of acute myocardial infarction and sets out the levels of troponin required for the diagnosis of procedural related MI after PCI, CABG and other cardiac and non-cardiac procedures.

Here in the US, the authors of the document communicated with the US Food and Drug Administration (FDA) during the development of the definition, and we anticipate the definition to be used in future clinical trials to ensure consistency moving forward.

Each year, about 1.2 million people in the U.S. alone have heart attacks, often resulting in death. With such drastic statistics, awareness and education of preventative steps for our patients are crucial. On the physician side, in order to analyze trends over time, as the authors note, “it is important to have consistent definitions to quantify adjustments when biomarkers or other diagnostic criteria change.”

There is still a lot of work to be done on a global scale, and as the document notes, for countries with limited economic resources where advancements in technology may be lacking, in addition to cultural, financial, structural and organizational problems, further analysis will be needed to determine their ability to adhere to the new definition. The College is committed to working with other organizations globally towards this effort.

I have said before that ACC’s Board of Governors (BOG) are the foot soldiers of the College, and with a teamwork-focused BOG, previously insurmountable changes can be more easily attainable. The power of the BOG recently came into play when Kentucky Chapter Governor-Elect Jesse Adams III, MD, FACC, reached out to his BOG colleagues to get their feedback and recommendations about a situation he was encountering at his hospital.

Dr. Adams noted that at one of the large local hospitals, administration decided to implement a policy that only intensivists would be able to write orders in the ICU. Dr. Adams approached the BOG to get their thoughts to see if type of model could be found anywhere else, and if specialist were prohibited to write orders in the ICU, how it would impact the hospital’s adherence with guidelines.

He received feedback and guidance from BOG leaders ranging from concerns about order writing, intensivists as the only primary team in this situation, and concerns about the patient. As Dr. Zoghbi noted, “to deny a cardiologist (and all other specialists in this situation) management of their patients, particularly in most acute medical conditions where they provide the expertise needed is completely unacceptable.”  With this powerful feedback from ACC’s leaders, Dr. Adams then took the conversations to the administration and they rapidly clarified and modified the policy which now allows for optimal collaborative involvement of intensivists and cardiovascular specialists consistent with ACC/AHA guidelines.

As we have seen the landscape of cardiology change drastically over the past few years, situations like these are sure to occur in different forms. It is up to the leaders of the College to stand up and bring our expertise and guidance when something is wrong. By banning together to support one another, this advocacy becomes possible. Kudos to Dr. Adams, Dr. Juan Villafane, and the entire Kentucky Chapter, who not only had a successful chapter meeting last weekend, but also had a minor “win” for cardiology with this example. Job well done!