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

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

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

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

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

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

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

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!

This post was authored by Pranav Puri, winner of the best CCA poster award.

Early last summer, as the presidential campaigns began to heat up and national dialogue once again shifted to healthcare policy, I decided to leave the rhetoric of the campaigns aside and take a look at the raw figures of healthcare spending for myself.

After sifting through a couple pages of Google search results, I found myself on the website of the Organization for Economic Cooperation and Development (OECD), an organization of developed economies, and the numbers I found there were truly staggering. The U.S. spends $2.6 trillion on healthcare which is approximately 18% of GDP; to put that figure in perspective, the OECD average is 9.5% of GDP.

More importantly, however, the quality of healthcare in the U.S. ranks far closer to the OECD average than to the top of the list. Further research showed that roughly 3,700 percutaneous coronary interventions (PCIs) per million were performed in the U.S. while the OECD average was close to 1,250. Around that time, Trinity Regional Health System in Rock Island, IL, my hometown, had implemented the ACC's appropriate use criteria (AUC) for coronary revascularization.

With the OECD data fresh in my mind, I approached the cardiology department at Trinity to study the effect of implementation of AUC for coronary revascularization on volume of PCIs and cost savings. Data from six months after implementation of AUC was compared to that of corresponding six months in 2010 and 2011. The number of interventional cardiologists did not change over that time period while the number of patients seen by the cardiologists during the time period increased. The number of diagnostics decreased by 9 percent after implementation of the AUC, and the number of interventions decreased by 27 percent.

Due to a decrease in interventions and diagnostics, total hospital reimbursement over the six month time period decreased by 35 percent from the previous year. If the AUC for coronary revascularization were to be further implemented and similar trends were to be observed nationally, we calculated that $2.3 billion would be saved. The maximum decline, I hypothesize, was in interventions that would be labeled as "uncertain." The AUC's greatest impact, therefore, was on influencing physician behavior rather than cutting back on "inappropriate" cases. By adding an element of oversight and better informing staff and patients, the AUC influenced the physician's thought process and reinforced doubts about prospective procedures.

Upon entering Moscone West late Friday evening to complete my registration and pick up my ACC.13 badge, I was taken aback by the frenzy and sheer excitement surrounding the meeting. Coming from a small town of 40,000, it was hard for me to fathom the magnitude of ACC.13. The next day during my poster presentation, I was greeted by attendees that showed great interest in my poster and posed incisive questions. Overall, the attendees were extremely supportive and made ACC.13 a welcoming place for a 16 year old high school student amongst well tenured physicians and researchers. As I get ready to board my last flight home, I can't help but reminisce on the past few days and look forward to ACC.14 in Washington, DC.

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

Despite a rather recalcitrant Congress, last year saw very significant changes for health care and cardiology. After the swirling uncertainty surrounding the Affordable Care Act (ACA), the U.S. Supreme Court ruled the ACA, including its individual mandate, was constitutional. With the federal debate laid to rest, the action shifts to the states where for political and policy reasons a patchwork quilt of variability still leaves physicians, hospitals and patients perplexed on how to adapt to Medicaid expansion, the Exchanges and other insurance changes. Yet hidden in the rancor over the ACA were many challenges and changes effecting cardiology that the ACC tackled with a large degree of success.

For more than a decade, the sustainable growth rate (SGR) and the nearly 30 percent cuts associated with the flawed formula have threatened to impede improvements to the health care system and weaken the sustainability of practices nationwide. While a fight for permanent repeal of the SGR was unsuccessful, the last-minute “fiscal cliff” legislation delayed “the cliff” and its 27 percent cuts until 2014, at least restore a degree of financial security to physicians and ensure patients have continued access to quality care for 2013.

Besides helping achieve the SGR patch in the American Taxpayer Relief Act of 2012 (ATRA), the ACC team succeeded in helping cardiology in two other important ways.  First, last year saw an aggressive campaign waged to close the in-office ancillary services exception (IOASE), also known as the Stark exception that allows us to perform tests and imaging in our offices, mounted by radiology and others. Its inclusion in the ATRA was successfully prevented. In addition, the team’s work with the Senate Finance, Ways and Means and Energy and Commerce Committees, following the stellar testimony of ACC Past President Douglas Weaver, MD, MACC in July, resulted in the law providing that participation in qualified clinical data registries, such as the NCDR®, will count as PQRS participation in 2014. While many details still need to be worked out, this will allow greater ease of avoiding the cuts that now occur for non-participation in PQRS.

Despite our successes, 2013 has many risks. The 2 percent across-the-board sequestration cut to Medicare and the even greater cuts to public health remain a threat when the two month delay in the ATRA expires on March 1. The ACC adamantly opposes the 2 percent Medicare sequester and the approximately 8 percent sequester cut to NIH, CDC, AHRQ and other crucial agencies, and the College will continue to urge Congress to prevent the cuts from going into effect. While successfully prevented in 2012, the forces working to close the IOASE have already marshaled an even stronger campaign this year. In response, we are working with a broad coalition to demonstrate to Congress and the Administration that closure of the exception would cause great disruption to patient care and would effectively end the viability of private practice and actually result in greater expenses for Medicare and insurers. Similarly, the College remains opposed to enactment of prior authorization for imaging services under Medicare.

On the medical liability reform front for this year, the U.S. House of Representatives is expected to take action on the HEALTH Act once again, which includes MICRA-type liability reforms. The College will continue to work with other stakeholders to support this act and advance supplemental medical liability reforms. Often missed in the College’s activities is its work for public health and science.  Again this year, the College will work to support federal funding for NIH; AHRQ; the NHLBI; the Health Resources and Services Administration’s AED program; the Prevention and Public Health Fund; the Million Hearts™ initiative; CDC’s Heart Disease and Stroke Prevention Program; and congenital heart disease research and surveillance.  As Congress struggles to find spending cuts, Graduate Medical Education (GME) finds itself targeted.  Advocacy with the help of the Academic Council is working with the AAMC to prevent any disruption to fellowship training.

As you can see 2013 holds many risks to cardiovascular care.  There are many opportunities for U.S. members to get involved in ACC's advocacy efforts, including learning more about ACCPAC, and participating in legislator practice visits and Legislative Conference.

Stay tuned to CardioSource.org/Advocacy throughout the year for health policy updates. To get involved in ACCPAC, visit accpacweb.org.

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

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

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

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

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

This post was authored by Eric Stecker, MD, FACC, member of the ACC’s Clinical Quality Committee.

Last week I made the argument that value (efficient provision of quality care) is a critical but under-recognized component of successful health care reform. Today we’ll briefly address several potential elements of health care reform that cardiologists should be facile with.

How do you measure quality care?
It is no longer sufficient to say we provide high quality care; we must demonstrate it objectively. Quality metrics remain imperfect but will improve over time and provide important information for patients and policymakers. Patients who see cardiovascular physicians participating in programs like ACC’s Imaging in FOCUS, and using registries such as those that fall under the ACC’s NCDR^® umbrella, can be assured the appropriateness and quality of their inpatient and outpatient care is being monitored and in most cases continuously improved.  The ACC’s clinical publications, including practice guidelines, consensus documents, appropriate use criteria, data standards and health policy statements are also excellent resources when it comes to guiding the most appropriate, evidence-based care.

Financial incentives for providers and patients
Medicare has initiated “value-based purchasing” programs to incentivize health care systems to improve quality. These programs could expand considerably in the future if proven successful. Individual health systems and insurers have experimented for many years with various financial programs to incentivize physicians to improve quality metrics or outcomes. The impact of these pay-for-performance programs has been mixed, but as pointed out by Ryan and Blustein, appropriately targeted and scaled monetary incentives are likely to have an impact.  Programs to incentivize patients by lowering or eliminating copayments (“Value-Based Insurance Design”) have proven very effective and are critical to aligning both the “supply” and “demand” aspects of high value care.

Managing individuals versus managing populations
Physicians are accustomed to caring for individual patients who engage them in the clinic, emergency department or procedural suite. However, by necessity the measure of a population’s health is made at the population level, not the individual level. Federal, state and local governments as well as businesses and employers have become more sophisticated and motivated to track aggregate health measures.  As a result cardiologists will become increasingly responsible for reporting and improving the health of all of the patients in their practice as a whole.  It will be important for cardiologists to gain the familiarity and skill to manage populations, but also retain sensitivity to issues that could harm individual patients so that policies and metrics can be modified accordingly.

If health care reform efforts are appropriately structured, cardiologists can thrive by focusing on efficient provision of high quality care for individuals and populations.  This will be best achieved when cardiologists align with and achieve leadership roles in health systems that focus on and incentivize quality systems of care.

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

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

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

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

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

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

This post was authored by ACC Past President W. Douglas Weaver, MD, MACC.

Wednesday was an exciting day in Washington, DC, where I testified on behalf of the ACC before the Senate Finance Committee hearing regarding Medicare physician payments. The hearing addressed problems plaguing the current Medicare physician payment system and sought to identify new payment models and quality initiatives that incentivize high-quality and high-value care at reduced costs.

Following recent discussions with former Centers for Medicare and Medicaid (CMS) administrators and insurers, the ACC, along with the American Medical Association, American Academy of Family Physicians, American College of Surgeons and American Society of Clinical Oncology, was invited to share lessons learned on effective physician payment approaches. This was a vital opportunity to reiterate our long-term dedication to exploring innovative payment models in Medicare and share how our many quality programs and evidence-based measures are working to improve the delivery of high quality, affordable care.

I cannot stress enough how critical the discussion on Medicare physician payment is to the sustainability of our health care system. Congress must avert scheduled reimbursement cuts just released in the proposed 2013 Medicare Physician Fee Schedule, repeal the SGR, and provide stable payments for several years to allow the development of new delivery and payment models. They know this, but just don’t know how to do it. Although I was prepared to provide suggestions to improving value over the next several years; I was surprised to be asked about what we can do this year which will dramatically reduce Medicare costs beginning in January.

The SGR has been a problem for years and a key issue I faced during my tenure as ACC President in 2008. The current uncertainty in the future stifle both our practices and our hospitals in making real investments aimed at improving integration and reducing the current fragmentation of care and reducing waste. It is discouraging that Congress has yet to come up with a solution, but I am hopeful that we can develop a system that aligns compensation with performance of evidence-based medicine and higher value, appropriate health care.

During my testimony, I had the opportunity to discuss several of the College's exciting innovations currently underway, such as our clinical registries which can be used to increase quality far beyond the PQRS quality measures of CMS. We also have appropriate use criteria embedded into Cath PCI-which has begun to lower the number of patients getting unneeded revascularization.  I asked them to incent doctors to use these tools and incent EMR venders to incorporate them into their products which also need to be made interoperable among all of the suppliers.

I also told them they need to support care management in the out-patient setting, which is paying primary care docs and specialties such has ours in which the vast majority of our patients are billed under primary care diagnoses (eg, heart failure, coronary disease, hypertension). These extra dollars allow us to fund the needed physician infrastructure to keep these patients on a care plan, and to reduce emergency visits and hospitalization.

The bottom line is that ACC knows how to improve quality and efficiency use our registries and other specialty specific tools. If Medicare promotes these activities by incentivizing their use and helping pay for the efforts, I believe the current improvements that we are witnessing will accelerate.

Read more about the ACC's involvement in the Senate Finance Committee roundtable on Medicare Physician Payments on CardioSource.org including the submitted testimony. Also read a statement from ACC President William Zoghbi, MD, FACC on the hearing.

(pictured top: Dr. Weaver testifying before the Senate Finance Committee; pictured bottom: Senator Max Baucus (D-Mont.) and Dr. Weaver)

This post was authored by James Fasules, MD, FACC, Senior Vice President of Advocacy.

E-prescribing has been shown to improve safety and convenience for patients and clinicians, while also saving clinicians and pharmacists time and money. In an effort to encourage e-prescribing use, the Centers for Medicare and Medicaid Services in 2009 launched the E-Prescribing Incentive Program. As part of the program, providers that met the program criteria are able to earn an incentive payment on top of their Medicare Part B earnings.

Three years later, the program is still moving forward. Providers who e-prescribe 25 times between Jan. 1 and Dec. 31, 2012 will receive a one percent bonus – a definite incentive in this time of declining reimbursement. (Other restrictions apply and can be found here.) The newest addition, however, is that all eligible providers not participating in the program are subject to gradually increasing penalties. While it’s too late to avoid the 2012 penalty, there is still time to avoid the 1.5 percent penalty for 2013 … although the June 30 deadline is fast approaching.

According to CMS, individual eligible professionals and group practices can avoid the penalty by meeting the following six-month reporting requirements between now and the end of June:

• Individual eligible professionals: 10 e-prescribing events via claims
• Small e-prescribing group using the group practice reporting option (GPRO): 625 e-prescribing events via claims
• Large e-prescribing group using the GPRO: 2,500 e-prescribing events via claims

More information is also available here.

In addition, individual eligible professionals and group practices can also avoid the penalty by filing for a significant hardship exemption. Hardships exemptions are available to providers who are unable to electronically prescribe due to local, state, or federal law or regulation; have or will prescribe fewer than 100 prescriptions during a six-month reporting period (Jan. 1 – June 30); practice in a rural area without sufficient high-speed Internet access; or practice in an area without sufficient available pharmacies for e-prescribing. Hardship exemptions must be submitted through the Quality Reporting Communication Support Page no later than June 30. These requests are granted on a case-by-case basis and all decisions are final. Given the issues experienced last year by providers trying to request exemptions via the website, CMS has developed two documents outlining how to navigate the support page (Quality Reporting Communication Support Page User Guide and Tips for Using the Quality Reporting Communication Support Page). The College urges members not to wait until the deadline to file for an exemption!

For more information on health IT visit CardioSource.org/HealthIT.

This post was authored by David May, MD, FACC, BOG Chair-Elect.

There was an interesting article published in Sunday’s Washington Post by Jordan Rau titled, “Medicare moves to tie doctors pay to quality and cost of care,” which offered a glimpse into the public view of physician payment and pay for performance.

The article was about resource use reports and outlines the complexity of attempting to characterize how much each of us actually costs the Medicare system, the huge problem of bundled payment system implementation, and all this on top of not having clear outcomes data on most of what we do.

Imagine for a moment the inverse of your first reaction to this concept. Imagine you are a primary care provider and receive a report that says your favorite cardiologist, Dr. X, spent an enormous amount of money working up your patients, and it cost you pay for performance money! How will that change your referrals?

Further, as a private practice cardiologist, I own the costs of my care. What is the cost of an employed cardiologist who uses the outpatient department of the employer hospital on the HOPPS payment scale? Is the cardiologist saddled with the "cost" or is the cardiologist "hidden" from exposure even though they cost the Medicare system twice as much? Quite a conundrum.

The ACC Advocacy team is currently assembling a group of physicians to review the resource use reports and have a meeting with CMS in the coming weeks.  They’re also interested in the feedback on the nature of these reports and suggestions on how they can be improved.  Leave your comments below or email advocate[at]acc.org.