While listening to the President’s third State of the Union (SOTU) address since taking office, it was clear his messaging was very much the start of his campaign for re-election with themes like creating jobs and the economy. But unlike like his previous speeches, which I blogged about here and here, the President only touched on the Affordable Care Act (ACA) a few times, saying “I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage or charge women differently from men.” Although the ACA is now in the hands of the Supreme Court, I predict much of what the ACA has already implemented will NOT be undone for powerful political reasons.

The President mentioned innovation and research funding for medical advancements several times, claiming “don’t gut these investments in our budget. Don’t let other countries win the race for the future.” This innovation is something the ACC fully supports and stands behind, as it is innovation that will help combat the number one killer in the U.S.

Although the President didn’t speak of tort reform as he did in last year’s SOTU speech, he did speak of reforming Medicare, “I'm prepared to make more reforms that rein in the long term costs of Medicare and Medicaid, and strengthen Social Security, so long as those programs remain a guarantee of security for seniors.” This is encouraging as we are slowly approaching the deadline to do something about the sustainable growth rate (or SGRrrr expressed as a growl, Medicare’s broken physician payment formula). The profession has been urging Congress to use money from military savings to permanently repeal the SGR, noting it is politically still a long shot.

The President also spoke of putting politics aside to come together as one team to make some real changes. Let’s hope there can be some bipartisan compromise this year to address means of appropriately addressing the deficit reduction to include eliminating the SGR, but also without destroying health care in the process. We need to promote the paradigm shift of policy thinking from “cutting care” to “improving care” in order to address the deficit.

I have perhaps too often emphasized the negative side of politics and economics of health care this past year. I feel justified in this. Congress is certainly not heroic; and the looming consequences of health care’s overwhelming contribution to the growing national debt are very concerning. But there are some very positive trends and issues to take into consideration as well.

Medicare cost trends have been considerably lower than CBO projections over 2011 -- of course, the overall costs of Medicare are growing as 10,000 baby boomers a day become eligible, and new diagnostics and therapeutics are being introduced -- but the slowing of the cost curve projections is a positive and unexpected phenomenon.

Science is clearly advancing rapidly, despite the economic downturn. New therapeutic frontiers in cardiovascular care alone are impressive. For example, the promise of much-heralded CETP (cholesteryl ester transfer protein) inhibitor drugs; rapidly evolving genomic, cell therapy, and electrophysiological and imaging advances; and new procedures including transcatheter valve therapy (TVT) are all examples of the stunning pace of scientific evolution.

Despite the controversy surrounding the Affordable Care Act, publicly funded programs have enabled 1.2 million children to gain health insurance since 2008, and according to Obama administration officials, this is in part due to the efforts by many states to sign up eligible children. In addition, millions of previously uninsurable people with high risk conditions now have affordable coverage.

Further, despite the growing political and economic strains on the profession and medicine in general, the best and the brightest physicians and nurses and other clinicians-in-training still aspire to cardiovascular careers and participate with the ACC on the ongoing and stunning reduction of morbidity and mortality in cardiovascular disease.  The ACC itself has been able to grow by about 5 percent year-over-year since the recession of 2008 to better serve the CV community and CV patients.

2012 will host the all-important November elections, the Supreme Court ruling on the Affordable Care Act, and the need for deficit limit and reduction action -- it won’t be a boring year. In fact this year will call all of us in medicine to seek ways to help the entire nation deal with all of these critical issues.

There’s still a lot to be optimistic about, folks, but it’s certainly not all rosy.

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!

An interesting study from the New England Journal of Medicine on weight-loss techniqueswas presented this morning at the AHA’s Scientific Sessions in Orlando. The Practice-Based Opportunities for Weight Reduction (POWER) trial examined theeffectiveness of weight-loss programs in obese patients with high bloodpressure, high cholesterol, or diabetes. Outpatient treatment of obese patients at risk of heart disease has been a struggle for physicians everywhere and alternative, convenient solutions that encourage weight-loss and a healthy lifestyle are much needed.

The goal for patients in the 24-month long study was to lose five percent of initial weight within six months. Two methods were explored: one with in-person health coaches and one driven by technology where patients were counseled on weight reduction over the phone. Both methods engaged primary care physicians as an integral part of the support team. The study found that patients who received information over the phone were equally as likely to lose weight and keep it off as patients who met directly with coaches.  Fifty three percent of patients enrolled in the phone driven program, which also had an interactive website component, achieved their goal. This outcome has the exciting potential to change the way weight-loss programs are developed and delivered in the future, increasing patient access to essential counseling and tools.

I will be excited to follow the impact this study will haveon patient access, especially in my home state of Mississippi. Given the high obesity rates of the South and the increasing rates across the country, effective solutions for weight-loss are greatly needed andhave been an ongoing struggle to develop. The results of the POWER trial can open the doors to a whole new way to treat overweight patients at risk for heart disease.  This trial demonstrates that information can be disseminated to a wide-range of patients not only nationally, but also globally, using common communications channels.

Finding innovative and flexible weight-loss education programs is key. Here at the College, we identified the importance of patient education several years ago with the launch of CardioSmart, which has been a successful initiative to get out in the community and promote a healthy lifestyle. NASCAR Track Walks that couple fitness with entertainment have been a huge hit and create the foundation for making smart choices. The Health and Wellness Center on CardioSmart has a section devoted to diet and exercise, providing patients with the tools and information they need to reduce their risk of heart disease. The Walk With a Doc program featured in the latest issue of Cardiology is another successful grassroots program that has seen tremendous success ininspiring and educating patients. Thinking outside the box and finding practical solutions to problems we encounter every day can truly impact the care and outcomes of our patients.  

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.

Just ahead of the Oct. 14 deadline for Congressional recommendations to the Super Committee regarding Medicare cuts, the sustainable growth rate (SGR) battle has really heated up. Last week, after 10 years of Congress “kicking the can down the road” by implementing a series of short-term fixes costing $300 billion, Rep. Allyson Schwartz (D-PA) took initiative, sending a letter to the Joint Select Committee on Deficit Reduction. In just a few short days, Rep. Schwartz’s appeal gained traction and has been signed by 113 Members of Congress. The letter calls on bipartisan Congressional action to permanently repeal the SGR and replace it with “a payment system that promotes efficiency, quality and value and ensures access to medical services for Medicare beneficiaries.”

Unfortunately, today’s Medicare Payment Advisory Commission (MedPAC) recommendation on the flawed SGR issue is not a viable solution. MedPAC’s proposal targets specialists who, after five years of flat payments, would face extreme cuts of 5.9 percent per year for the first three years followed by seven years of reimbursement rates freezes. Instead of addressing the shortage of primary care physicians, the Commission’s solution is to simply freeze their rates for 10 years.  

This decision is unacceptable and fails to carve out a comprehensive payment reform plan, enhance Medicare beneficiary access, or promote quality or resource stewardship. ACC believes that physicians should be paid for quality and care coordination, not their specialty designation. Additionally, the notion that doctors can make more by increasing volume ignores the significant marginal costs associated with seeing each additional patient.   

MedPAC has voted to increase physician payment by 1-2 percent for each of the last five years, despite the SGR issue.  They have abandoned their focus on what are the most appropriate payments to maintain access and to attempt to fix a Congressional mistake. 

While the ACC has long advocated for Congress to permanently repeal the SGR, we strongly oppose the MedPAC recommendation.  Joining forces with 42 other medical societies, ACC sent a letter to the Commission earlier this week stressing the consequences of penalizing specialists across the board regardless of quality of care. This approach is detrimental to the institution of cardiology and threatens the advances that we have made and are determined to make in the future. 

Visit the Budget Countdown page for related information on the issues of SGR, medical liability reform, and imaging cuts. I also urge you to take part in the ACC’s new Payment Innovations Community, in partnership with the American Journal of Managed Care. While there, don’t miss the New England Journal of Medicine article that looks at the question: “How Much Savings Can We Wring From Medicare?”

KevinMD had a great guest post recently by Mary Pat Whaley on the time associated with a patient visit. I think the title sums up the blog well: “Your 10-Minute Office Visit Needs 8 People and 45 Minutes of Work.”

As Whaley notes, even the shortest of office visits have a lot of work behind-the-scenes that needs to be done; seeing the patient is just a small part of the overall visit.  And, I would submit that far more than 8 people and much more than 45 minutes is required.   Health care is a regulation- and administration-heavy field, and this requires time to make sure the regulatory and administrative rules are followed. For example, HIPAA requires privacy forms to be filled out prior to the patient being seen. Verifying someone’s insurance information is time-intensive. Not to mention ensuring that we charge the patient the right co-pay based on their insurer and insurance plan. On top of that, pay-for-performance programs require time- and technology-intensive data collection during and after the visit. All of this, and more, makes up one “10-minute office visit.”

Whaley concludes: “The practice, the patients and the overseers of health care want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.”

I have to agree with her. The complexity of the American health care system is incredible. And, the layers of complexity account for much of the cost. Our system has been built by accretion.  We “reform” the system by adding on layers of regulation, of bureaucracy, of administration.  As you look behind the eight people figured in this visit, the cost if not the time includes coders, compliance workers, claims specialists, re-claim specialists, computer network and now electronic health record experts,  lawyers, front office personnel, and even standard maintenance personnel for the  building.

As the regulation and administrative burdens add on, the cost of practicing gets greater and it is harder to cover these expenses with income.  Add to that more and more cuts to cardiology, and it’s no wonder that a large number of private cardiology practices are integrating with hospitals. Last year, the ACC reported the results of a survey of ACC members that found nearly 40 percent of private group practices were currently integrating with hospitals or merging with other practices. An additional 13 percent of all cardiovascular practices were considering hospital integration or a merger in the next three years to help stem the financial burden.

These are uncertain times for cardiology and for the House of Medicine in general.  To be clear, the ACC supports the triple aim of better health, better health care, and at less cost. But to get there, we will have to deal with the repercussions of massive changes, and may I say probably the accretion of more layers, to our health care system. In my opinion, “dealing” with the repercussions will not be enough – we need to shape the discussions if we want to be pleased with the health care system structure of the future.  And, maybe we can even help peal away some of the layers.

This post is written by President-Elect William Zoghbi, MD, FACC.   

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Yesterday and today, I am in New York City representing the ACC at the landmark United Nations (UN) Summit on Non-Communicable Diseases (NCDs).  ACC CEO Jack Lewin, MD, is accompanying me in advocating for the inclusion of cardiovascular disease (CVD) in the UN’s eight Millennium Development Goals, an imperative step to combating NCDs in the developing world. Driving leaders around the world to address this issue are the astonishing statistics surrounding NCDs: 82% of the 17.1 million deaths caused by CVD occur in the world’s poorest countries -- that’s 14 million deaths per year. Despite this, only 3 percent of global funding is allocated towards NCDs.  

The General Assembly kicked off the meeting by unanimously approving without a vote a political declaration that creates a plan of action for combatting NCDs. Although the declaration does not contain specific targets for reductions in morbidity and mortality, it does contain an agreement to develop a comprehensive global monitoring framework for NCDs in 2012, as well as a set of voluntary global targets and indicators. Other commitments included in the declaration are to:

• Accelerate the implementation of the Framework Convention on Tobacco Control
• Eliminate industrially-produced trans-fats in foods, and implement interventions to reduce consumption of salt, sugars and saturated fats
• Curb harmful use of alcohol
• Restrict the marketing to children of foods high in fats, sugar and salt.

While imperfect, the declaration has galvanized the focus on this pandemic and is critical a first step to improving the health conditions of people worldwide.

• Tobacco control/elimination
• Sodium reduction
• Promoting healthy diet and exercise (low fat, sugar and alcohol intake, increased physical activity)
• Generic multidrug treatment for patients with high risk of NCDs

While significant attention has been paid to the above areas in developed nations, little education exists on these issues in the developing world. Worldwide, over 1.3 billion people smoke, 600 million have hypertension, and 220 million battle diabetes. These risk factors contribute to the estimated $500 billion per year NCDs cost in low-income and middle-income countries. Community programs -- such as Let’s Move, which was mentioned by U.S. Surgeon General Regina Benjamin, MD, during a lunch session as a program that could enable people to adopt healthier lifestyles -- are reported to have a 5-year return on investment of $5.60 for every dollar spent.

The Holmes, et al., paper is very clear on the need for worldwide unity and collaboration among leaders from the UN, World Health Organization (WHO), global and local governments, foundations, non-government organizations, and pharmaceutical companies, among others.

As a member of the Partner’s Group of the NCD Alliance, the ACC is epitomizing this collaboration by working with organizations such as the World Heart Federation and the Global Health Council to maximize international efforts to reduce the impact of NCDs. Given the success of NCDR in the U.S., Middle East and Asia, there is potential for developing nations to engage these tools to track their progress on CV care, ultimately improving their patients' outcomes.

Stay tuned for developments in the coming days as we continue to participate in the UN NCD Summit. Follow @ACCinTouch on Twitter for live updates and visit the American College of Cardiology Facebook page for photos and conversation revolving around the Summit. 

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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 prestigious Institute of Medicine (IOM) earlier this month opined concerned that most medical devices are cleared for sale without sufficient evidence that they are safe and effective -- even though we tend to delay approvals of devices far longer than the EU, Canada and most of the developed world. IOM’s assessment should give everyone pause -- particularly because they declared the current regulatory approach (related to the FDA 510K approval process) to be so messed up that we should scrap it and start over. FDA reacted immediately that they disagreed, stating they would instead work to fix the problems acknowledged in the 510K regulatory system.

The IOM committee found no major new horror stories related to existing devices on the market, but worried that FDA and the public have no good way to determine where risk may exist because there is virtually no good clinical data to rely on. Hello. The NCDR has the clinical data they seek; and if we could get the feds to offer incentives to help us diffuse the PINNACLE Registry across more outpatient practices, we could track post-approval performance and look for even low-signal adverse events incredibly effectively!

The IOM committee commented specifically on what they termed "highest-risk" CV devices, such as implantable defibrillators and replacement heart valves. They noted that clinical trials with relatively few enrolled patients are used to demonstrate safety and effectiveness of such devices, deeming that they afford only a “moderate risk,” based on having the manufacturer show that they are “substantially equivalent” to devices previously cleared. The added concern is that those devices in turn may have been cleared because they were “substantially equivalent” to earlier devices that may no longer be in use -- a ‘house of cards’ process.

IOM deserves credit for spotlighting the issues. But, not only the FDA objected to IOM’s recommendations: the device industry, already frustrated with the cumbersomeness of the 35-year old 510K process, are yet even more worried about and opposed to completely scrapping the process. They want to see it streamlined instead. What we need to do is show FDA, IOM and industry what the broad use of registries could do to carefully track ALL patients who are device recipients. That’s what needs to happen! Upcoming FDA hearings on the IOM recommendations and the future of the 510K process will give us an opportunity to promote this potential of using our registries to provide more rigorous and effective surveillance of CV devices after they are on the market.