Today the Bipartisan Policy Center’s Task Force on Delivery System Reform and Health Information Technology (IT) released an important report, Transforming Health Care: The Role of Health IT, which outlines recommendations for the most effective use of health IT to achieve the triple aim through new models of care delivery and payment reform. I am a member of the task force – we’ve been working on this plan for over a year.

Following the authorization of up to $30 billion to support health IT under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the report was created to identify real-world examples and best practices that facilitate coordinated, accountable and patient-centered care; and to make recommendations for ensuring that current health IT efforts support delivery system and payment models shown to improve quality and reduce costs in health care, in ways that best utilize scarce public and private resources.

I joined the Bipartisan Policy Center’s co-chairs, former Senators Tom Daschle (D-S.D.) and Bill Frist, MD (R-Tenn.), and former Governors Ted Strickland and John Engler, at a policy briefing featuring prominent leaders in the field to release the report and discuss how to make it happen.

The report identifies key gaps and barriers to achieving widespread adoption of health IT, including: misaligned incentives; a lack of health information exchange; limited level of consumer engagement using electronic tools; limited levels of Electronic Health Record (EHR) adoption; privacy and security concerns; and multiple federal priorities that all require focus and attention.

The task force also identified several goals and recommendations to overcome these barriers including: aligning incentives and payment with higher quality, more cost-effective health care, accelerating health information exchange efforts, accelerating and supporting engagement of consumers using electronic tools, expanding education and implementation assistance, addressing concerns about privacy and security, and further aligning federal health care and health IT programs. Incidentally, the task force has had a kind of brilliant idea on how to get beyond the unique patient identifier controversy – which is politically stalled. We suggest developing “patient tracking” systems to manage patients securely over the continuum.

After the press event was over I had lunch with Daschle, Frist, Strickland, and Engler to talk further about implementation ideas and how the ACC can help move this. The good news is most of the field of cardiology and the ACC with its quality tools and programs are already working to implement most of these recommendations, but as the health care landscape changes and the cost of health care increases, it is important now more than ever to adopt new models of care delivery.

For more information, visit www.CardioSource.org/HealthIT.

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.

The topic of inappropriate use of stenting has been a hot topic this past year in several states including Maryland. As Immediate Past President Ralph Brindis, MD, MPH, MACC wrote in a previous blog entry, “To be perfectly clear, the ACC does not condone inappropriate use of coronary stenting, overuse or misuse of any cardiovascular technology or therapy. That said, what’s happening in Maryland is a prime example of how a negative situation can be turned into a positive opportunity to improve quality and appropriateness of care.”

Over the past year, the Maryland Chapter, along with the Society of Cardiovascular Angiography and Interventions (SCAI), have been advocating for oversight guidelines for cath labs performing percutaneous coronary intervention (PCI).

The Maryland Chapter has been diligently working to implement internal and external peer review, but as MedPage Today recently reported: “a Maryland plan to regulate stent procedures has elicited a push-back from local chapters of the American College of Cardiology and the Society of Cardiovascular Angiography and Interventions (SCAI).” The “public outcry over” allegations of over-stenting have “spurred a technical advisory group to the Maryland Health Commission to recommend giving the commission the authority to regulate stent procedures as well as continuing evaluation of hospitals with stent programs.” However, “both the Maryland Chapter of ACC and the Maryland SCAI chapter said a better plan would be a two-tiered system of checks that includes an internal review that meets specific standards and an external peer review as an auditing mechanism.”

Although the battle in Maryland continues, their gallant efforts have not gone unnoticed, and this past week at Leadership Forum BOG Chair-Elect Dipti Itchhaporia and I presented Sam Goldberg, MD, FACC, governor of the Maryland Chapter with the ACC Chapter award for Advocacy.

As the famous Robert Frost saying goes, “Two roads diverged in a wood, and I - I took the one less traveled by, and that has made all the difference.” I applaud the amazing efforts of the Maryland Chapter who is working to do something more effective to prevent inappropriate uses.

One of the very few and somewhat mysterious successes in health care this year was recently chronicled by Lori Montgomery in an article in The Washington Post describing the substantial drop in the growth of Part B Medicare costs in 2011. Although these costs usually grow by 4% a year or more, they are now growing at a mere 2%. Everyone she interviewed about this was baffled. She writes:

“At first, chief Medicare actuary Rick Foster thought it was a mistake, perhaps a glitch in data collection. No other explanation made sense. Congress had just passed far-reaching health-care legislation that mandated cuts in Medicare spending. But the law was so new that rules for implementation had not been written.”

Montgomery goes on to interview a host of people who couldn't explain it. Some speculated that it is the recession. Others (Democrat politicians) thought it is the salutary effect of Obama's health care law. Still others argued that this shows how efficient the Medicare program is.

I think this is mainly related to the rising co-pay costs for Medicare beneficiaries. Folks are worried about paying their 20% of most services, and are delaying care and not picking up their meds as often as before. We know that’s true. Quest Diagnostics, for example, notes that more patients than ever are not pursuing their ordered lab tests (with co-pays attached) their physicians order, just to save money. This is not a good sign in terms of preventing preventable admissions and complications. But, it’s the result of the Great Recession’s impact on middle class beneficiaries.

For more information about Medicare physician payment, visit the physician payment issues section on CardioSource.org. Also check out the Payment Innovations Community.

The ACC has joined the ABIM Foundation’s Choosing Wisely^TM campaign along with eight other leading medical specialty societies and Consumer Reports to help physicians, patients and other health care stakeholders think and talk about overuse or misuse of health care resources in the U.S.

According to the Organization for Economic Co-operation and Development, decade after decade the U.S. spends more money per capita on health care than any other developed country with little progress in quality or value to show for it. The Congressional Budget Office estimates that up to 30 percent of care delivered in the U.S. goes toward unnecessary tests, procedures, medical appointments, hospital stays and other services that may not improve health. Coupled with the fact that the Centers for Medicare & Medicaid Services estimates U.S. health care spending will reach $4.3 trillion by 2019, it is clear that our current health care system is unsustainable and in need of an intervention.

As part of our longstanding effort to play an active role in addressing the quality of care, the College is joining the campaign to encourage open communication about the risks, costs and benefits of tests and treatments so that our patients can be informed partners when making important decisions about their care. We believe that partnerships between patients and health care providers are crucial to achieving better outcomes and lowering health care costs. From our CardioSmart^TM National Care Initiative, aimed at helping patients better understand and/or prevent heart disease, to our state-of-art educational programing and decision-support tools that place evidence-based guidelines at a clinician’s fingertips, we have been and will continue to be committed to ensuring the most appropriate, cost-effective care.

Over the course of the multi-year campaign, we will be working with the ABIM Foundation to identify and reduce waste in the health care system. With the medications, devices and imaging technology available to cardiologists today, we can save and improve the lives of patients who would not have had a chance just 15 years ago, but we also have a responsibility to use these powerful tools effectively and make sure we are choosing wisely.

To learn more about the Choosing Wisely campaign visit, www.ChoosingWisely.org.

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:

Dynamic Changes in Health Care Resource Allocation

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.

Impact of Changing Demographics of Physician Practice

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.

This post was authored by Michael Chernew, PhD, who sits on the Editorial Panel for the ACC/AJMC Community on Payment Innovations and is a MedPAC Commissioner.  Dr. Chernew's views, however, are his own and do not represent those of ACC, AJMC or MedPAC. 

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A lot has been written of late about the Sustainable Growth Rate (SGR) system.  One point of consensus appears to be that the system is not sustainable. It needs to be repealed.  The controversy surrounds what to do after the repeal.  Ideally, the physician payment system of the future would promote beneficiary access to high quality care and be fiscally sustainable. 

The estimated 10 year cost of replacing the SGR with a freeze in physician fees is over 300 billion dollars.  Replacement with a fee schedule that is adjusted for inflation would be even more costly and options to finance the costs are limited.  Debt financing seems impossible given out current fiscal situation.  An increase in taxes is possible, but seems politically infeasible.  Without taxes or deficit spending, funding an SGR fix requires cuts from elsewhere in the budget, including elsewhere in Medicare. 

The recent MedPAC recommendation assumed financing entirely from Medicare, though MedPAC did not necessarily endorse financing exclusively from Medicare.  This exercise illustrates how difficult financing is.  MedPAC was only able to offset a fraction of the 300 billion dollars by accumulating a series of cost saving measures that affect a wide range of providers and beneficiaries.  Because the offsets were incomplete, cuts in physician fees were still needed to avoid increased Medicare spending.  With constraints against raising taxes or debt financing, alternatives are limited.  Tweaks to payment around the fee-for-service framework are unlikely to achieve significant score able savings and unlikely to pave the way to the health care system we deserve. 

Shifting costs to beneficiaries is possible.  In fact, reform of the benefit design to encourage judicious use of care and improve cost consciousness among patients can improve efficiency and help fund an SGR fix.  This benefit redesign should be a part of the solution; however, it is not clear how much could be saved through such redesign and it is unlikely to be the sole foundation of a solution.  Changes to benefit design will certainly raise serious concerns about equity, access and quality depending on how such a shift is implemented.  In the meantime, payment reform must be addressed.

A way out of the world characterized by the grim fee trajectory remains, but it requires a change in business model.  In addition to the payment proposals, MedPAC offered recommendations that support new delivery models.  Even with the recommended fee cuts, the projected payment per beneficiary rises.  If providers can capture the overall revenue, control rising volumes and eliminate waste (which most agree is significant), high quality care can be coupled with financial success.  Clearly, such a transition will not be easy and evidence that providers can be successful is emerging, at best.  The regulations necessary to guide such a system are still being developed and far from perfect.  Yet the alternative, as the MedPAC recommendations illustrate, is not appealing.  Getting on with the task of reforming the whole system seems the only way forward.

Additional Resources:

• Community on Payment Innovations
• How much savings can we wring from Medicare?
• SGR Issue Brief

 

This week ACC leaders and I are hitting Capitol Hill to meet with key members of Congress and their staff on our three main priorities between now and the end of the year:

1. Fix the SGRrrrrrrrrrrrr
2. Implement medical liability reforms
3. Stop additional cuts to medical imaging

There is currently no guarantee or plan that Congress will fix the SGR before the 29 percent cut kicks in on Jan. 1 and with the Super (Duper) Committee seemingly at a stand-still we could see an additional 2 percent cut across the board.  The impact of such a scenario, coupled with any additional cuts in imaging, would go well beyond what happened two years ago with the practice-expense cuts for cardiovascular services.

It would be irresponsible of all of us to let cuts of this magnitude go through without a fight – thus the meetings on Capitol Hill this week. It would also be irresponsible of us not to take advantage of the Super (Duper) Committee discussions to find a middle ground proposal on medical liability reform that makes progress in terms of lowering premiums, reducing frequency of unnecessary filings, and limits the hemorrhaging of precious health care resources into the legal system.

While all of us vary greatly in our views on political policy and strategy, there is no question that we wield political power when we can come together around common causes. Health care is the biggest sector of the American economy and as providers on the ground level our voices matter. Now more than ever before, we need to let Congress know that fixing the SGR needs to be a priority. At the same time we need to be honest with them about the consequences (both to our practices and our patients) if they don’t act.  We also need to weigh in on new opportunities, such as basic liability reforms or ensuring appropriate use of imaging, that can rise above the partisan gridlock and start moving us toward a better, more economically stable, health care future.  

Now is the time to act! To quote Dr. Seuss: “Unless someone like you cares a whole awful lot, nothing is going to get better. It's not.” Come Jan. 1, 2012 I hope that our combined actions successfully averted devastating cuts to cardiovascular care. At the very least, if we’re not successful, it won’t be for lack of trying! Now hit those phones! 

For more information on the federal budget and the Super Committee timeline go to CardioSource.org/Budget. ACC members in the U.S. can also learn more about the ACC Political Action Committee at www.accpacweb.org (log-in required).

This post is authored by Immediate Past-President Ralph Brindis, MD, MACC. 

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Health Affairs, along with co-sponsors the ABIM Foundation, the California HealthCare Foundation and the Foundation for Informed Medical Decision Making, hosted an event on Oct. 19 focused on discussions around Medicare savings ideas for the federal budget “Super Committee.”  Implantation of ICDs was one of the hot-topic areas in a session on Medicare coverage policy, with speakers highlighting overuse of the procedure among physicians as a major contributor to Medicare costs. Suggestions were made to require prior authorization as a means of reducing Medicare costs.  

It is important to note that the science surrounding ICD implantation is constantly evolving but guidelines and Medicare coverage policy take more time. That being said, it is true that recent studies have indicated a wide variation in ICD implantation. A study published earlier this year in the Journal of the American Medical Association (JAMA) found that ICD implantations were not in accordance with practice guidelines in 22.5% of patients, most commonly because of newly diagnosed heart failure (62%) or an MI within 40 days (37%). The risks of in-hospital death and complications were significantly lower when the ICD implant was consistent with practice guidelines (0.18% and 2.4%, respectively) than when it was not (0.57% and 3.2%, respectively). 

While these statistics are sobering, the ACC and the Heart Rhythm Society (HRS) already have programs and processes in place to turn the tide, so to speak, and ensure providers are appropriately using this procedure on the right patients. For one, the Centers for Medicare and Medicaid Services, has mandated that every U.S. hospital that implants ICDs for the purpose of primary prevention of sudden cardiac death participate in the ACC and HRS ICD Registry. Over the last year we have made great strides in enhancing this registry to allow for the connection of longitudinal Medicare administrative data of ICD patient outcomes -- such as mortality and repeat hospitalizations -- with our in-patient hospital registry data. This longitudinal follow-up assessment will extend our knowledge base substantially. In addition, the electrophysiology community is not only closely examining practice patterns but working more closely with staff responsible for entering ICD Registry data to ensure that the data quality is at the highest level. The ACC and HRS are also encouraging the practice of shared decision making, particularly in the elderly, for the use of ICD implants for prevention of sudden cardiac death. Recent studies actually show substantial underuse of ICD therapy for prevention of sudden cardiac death (SCD).  

Unlike prior authorization, which may reduce costs but not necessarily ensure appropriate patient care and/or change provider behavior, registry use can do all three by ensuring greater adherence to practice guidelines, providing insight into practice patterns and also extending overall physician knowledge and evidence base. At the end of the day, ICDs are effective in stopping life-threatening arrhythmias and enhancing survival and overall quality of care. We believe that we are moving in the right direction to ensure cost-savings in the Medicare system and welcome the discussion on how to do this even better.

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?”