This post was authored by Douglas Weaver, MD, MACC, past president of the ACC.

This year has been a painful one for healthcare providers due to the continued atmosphere of uncertainty.  Many of us began this year working on initiatives that deal with some of the changes attendant with the Affordable Care Act – e.g. reduce unnecessary admissions and change them to observation status, decrease readmissions for patients with a recent MI or for heart failure, and putting together means to provide better continuity of care.  Before the election, it was impossible to fully engage given the polarizing rhetoric between parties.  At the present time our payment policies don’t reward either physicians or hospitals for reducing readmissions, and rather we take a hit. 

However, even after the election, it still isn’t better. We are in an environment with continued partisan bickering about the legislation, lack of agreement on a common approach to sequestration, the tax cuts, unemployment benefit extension, reducing the deficit, how to pay for the SGR (and possibly with further Medicaid cuts, reduced NIH funding, loss of facility based E and M dollars, IME reductions).

After studying the issues and listening to the pundits, I have come to the following conclusions: first, our national debt is a major problem and one that needs to be fixed.  If you include the “promised entitlements” of Medicare and Social Security, it is close to 86 trillion dollars — and this number would require collecting 8 trillion dollars a year in taxes to just keep it from going higher. Congress can’t agree on ways to get a few hundred billion to balance the budget for the coming year. The total earnings of all of us filing tax returns is a little over 5 trillion dollars a year — and that is earnings not the taxes you and I currently pay.  Conclusion: we have to curb entitlements no matter what happens to taxes.

Second, people are spending less on healthcare. Visits are down, admissions are down—the cost curve has been bent already. If you count up the 50 million people in our country with no insurance, add 40 million who do, but who can’t pay their deductibles or co-pays, and the almost 55 million on Medicaid—this says that half the people in our country can’t afford our healthcare.  Conclusion: it is not about healthcare inflationary costs (these are now fixed), it is about the absolute cost.  Cost of healthcare in the U.S. is 1.5 to 2 times more expensive than elsewhere.  With peoples’ individual contributions increasing for care, they are voting with their feet and avoiding, when possible, doctor visits and procedures.

Lastly, there are some basic problems with the way we are approaching enacting “change.”  If all of our patients are going to pay more now for coverage and we are going to move to pay for quality, our patients should be getting something for this right up front—not years down the road.  Second, don’t harness the providers to the plain vanilla PQRS quality reporting measures and 18 month old administrative data to track performance. Instead, let specialty societies like the ACC, who can focus initiatives in areas where its members determine deserve improvement, and support these organizations to provide feedback and tools for improvement to their constituencies, instead of funding a larger, but less relevant reporting now done by the insurers.

We are adaptable—we can move more quickly and deliver more, but not at our own expense. We can however do so with a promised reduction in the overall cost of care and with equal or higher satisfaction from our patients.  

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.

CMS Administrator Donald Berwick, MD, and CMS Chief Actuary Richard Foster testified before the House Ways and Means Committee last week at a hearing titled, “The Impact of the Affordable Care Act on the Medicare Program and Medicare Beneficiaries.” We were there.

In the fall, Dr. Berwick testified before the Senate Finance Committee but this was his first time in front of a House committee. After discussing his background in medicine and what he views to be the many the benefits of the Affordable Care Act (ACA), Dr. Berwick held his own during tough questioning. This was also a ‘sniff him over’ process, given he has been promoted for confirmation again.

In his opening statement, Chairman Dave Camp (R-MI) noted the contrast between Dr. Berwick’s optimism on the ACA and Mr. Foster’s bleak outlook for Medicare due to the ACA. Foster has disagreed with others and the Congressional Budget Office on ACA savings, which Foster thinks are unlikely to be achieved. Democrats used the hearing to try to “shatter the myths about reform,” as stated by Ranking Member Sander Levin (D-MI) during his opening statement. Democrats repeatedly pointed to what they view as the most popular provisions of the law and what would happen if the law was repealed. In other words, this was a genuine partisan circus event.

There were plenty of controversial questions and answers. On tort reform, Dr. Berwick said he supports “exploring a national solution” on medical liability but would not comment on non-economic caps. Rep. Vern Buchanan (R-FL) told Dr. Berwick about a letter he wrote to CMS regarding concerns of Florida cardiologists with Medicare payment cuts for cardiology services (this "2010 Rule" issue preceded Berwick’s coming to CMS, but he’s sure hearing about it). When  Rep. Sam Johnson (R-TX) described physicians no longer participating in Medicare and having to reduce staff, benefits and charity care, Dr. Berwick stated that enrollment in Medicare is the highest ever for physicians. Poor Dr. Berwick -- he wants to talk about improving quality and patient safety and lowering costs in those ways, but there was no chance of that. Too bad he couldn’t just speak his mind, though. He had a lot of constructive non-partisan things he could have shared there, but that wasn’t what this hearing was about.

What did we and the nation learn from this hearing that we don’t already know? Nothing.

I loved President Obama’s challenge to the nation and the Congress in his State of the Union last week that we invest in science, innovation, and education to effectively take on the competition of China, India, Brazil, and EU to remain on the cutting edge of leading the future -- e.g. to rise to address our ‘Sputnik moment.' That was leadership and creative thinking.

But what was weird to me was his failure to apparently embrace any of the advice of his Deficit Commission or to suggest how to reduce the national debt before it chokes us out of global competition. He did promise on his part to hold government (civil service) spending flat for 5 years, other than funding his ‘innovation’ challenge.  

I heard between the lines a general indication from both sides of the aisle that increasing reimbursements and fixing the SGR are not likely to be high on the Senate’s or the President’s real list of priorities. It’s hard to paint fixing the SGR as a way to promote innovation -- but indirectly it is in that the profession and the Congress remain hypnotized and constantly preoccupied on the SGR albatross around our necks, rather than on designing new quality-incentivized payment reforms to innovate health care delivery. 

Obama was strong on keeping the Affordable Care Act (ACA) moving (his potential for re-election looking better now than in 2010 means he might have 6 years left to make it work), but he expressed openness to amending the ACA in partnership with Repubs.  He emphasized expanded access, drug funding, insurance reform, and $250 billion in savings. And, he unexpectedly promoted tort reform! That’s great, even though he won’t support caps on non-economic damages. But, we must jump on the opportunity of proposing significant tort reform.

David Cameron is “streamlining” the UK National Health Service budget, and colleagues there know reimbursement will be flat or down; and the Netherlands, Ireland, Spain, and other EU countries are slashing physician payments by over 30%. FFS payment here will be in jeopardy here -- only payment reforms that go after bundled and global population based payment gainshare options seem to be possible routes to ongoing viability.

So, what does this all mean? Well, in summary, my final advice on the implications of the State of the Union and Congress’ current plans is: Gird your loins.

Sixty House seats and six Senate seats changed parties this week, along with a number of elected state governors. What does it all mean, and why should you care what I think when you have so many other pundits to read? Well, maybe because most of the pundits aren’t thinking about health care, much less cardiovascular medicine.

The ACC guessed pretty accurately on the vast majority of these races. We took a big chance, for example, supporting John Dingell when a fellow physician was running against him. But Dingell prevailed, and he will be in a position to help us in various ways, I guarantee. It is similar with many of the other races we bet on with our PAC and our advocacy efforts.

That said, I don’t think this election contains much good news for physicians and medicine. There’s a lot of rhetoric about how the Affordable Care Act (ACA) was a big negative for Democrats in their races, but it seems more apparent to me that the sluggish economy, the persistent unemployment, and fears in general about the growing national deficit and government spending (in tough times) were the culprit issues. All the recent polls indicate that the public is gradually warming up to some of the provisions in the ACA that they actually like.

For example, Brandeis health care guru Stuart Altman, Ph.D., has recently pointed out that persons over 65 express the most angst about the ACA, based on fears about adverse effects on Medicare, while these concerns had absolutely no basis in fact. Two-thirds of seniors polled leading up to the election had no idea that the ACA relieves them of prescription costs by filling up the donut hole or that physical exams and preventive services are covered with no copay. Eighty percent have no awareness that the law provides an additional decade of stability to Medicare where it was headed to bankruptcy in 2017 with the status quo. Many of these folks and many younger voters voted out incumbents who have committed in their campaigns to cut federal spending. And, guess what? The most available places to cut will be Medicare and Medicaid!

Despite all the banter about repealing the ACA, that will be a heck of a difficult thing to do. It will be impossible as long as Obama is president and the current Senate, even with six more Republicans, will certainly not be able to muster a 60-vote plurality on much of anything. So the repeal of the health care law banter is more hyperbole and political positioning. The incoming Speaker of the House, Mr. Boehner, has very circumspect about the possibility of “repeal.” What’s going to happen is that most voters (who by the way support many of the provisions of the ACA when asked about them) will start to become more informed about things they like in the bill and be much more hesitant about repealing it.

But the bad news for doctors, patients and medicine relate to the fact that the new Congress has promised America it will not increase federal spending. So, the SGR is not going to get fixed at a price tag of $350 billion, and instead fee-for-service Medicare and Medicaid will continue to be devalued and flat, reducing access to physicians and the viability of private practice. Patients who can’t afford a concierge physician will be hard pressed to find Medicare and Medicaid providers increasingly as time passes – unless some of these new members of Congress wake up to the fact that some federal spending is a positive investment in our future. I’m talking health care, including prevention, chronic disease management and expanded access.

The good news for ACC and cardiology practices is that we do know how to bend the cost curve by systematically improving quality and evidence-based care. We know how to reduce disparities and unnecessary expenditures through application of our clinical tools and the use of our registries. Is anybody listening? I hope so, because we can move beyond the “faith based” provision in the ACA to offer real ways to improve quality, improve heart health, and reduce unnecessary cardiovascular spending, which just happens to be 43% of Medicare spending cost. And, we can provide similar value for kids and adults with congenital heart disease as well.

Bottom line for me: While everybody’s grousing or cheering or staring like deer in the headlights, I hope we roll up our sleeves and get busy on doing the things we know we can do to help get us out the dead-end scenario of rising health care costs that outstrip a reasonable return on investment.

In one of the first rounds of challenges to the new Affordable Care Act (ACA) health reform law, a federal judge in Michigan upheld its constitutionality. US District Court Judge George Steeh rejected the request for an injunction to block implementation of the individual mandate for health insurance. The decision found that it is within the power of Congress under the Constitution to collect penalties for individuals not obtaining health coverage and require people to buy insurance, under the Commerce Clause.

The court's decision appears to have been based on a finding that the health care market is unlike any other markets because no one can guarantee their health or ensure they will never get sick or require health care services. The court’s analysis suggests that the individual mandate is justified because the risk exists that health care costs for individuals not obtaining health coverage would be shifted to others. Whether you like the law or not, this is a fact of life -- everybody needs to pay their fair share of health costs and not shift the burden to others when they need care.

There are suits filed in 17 states, so this is not the end of the issue, but it definitely helps keep the momentum moving.  Republicans in many states are running on repealing the ACA, but this is truly political hype unless and until there are 60 Republicans in the Senate, and a Republican President. Even then, once 35 million additional people get coverage by 2014, it will be very hard to reverse the law. Opponents to Medicare and Medicaid couldn’t turn those laws around either.

Jack Lewin’s blog post this week summarizes the current situation better than I could ever hope to do, but I want to reiterate that members of Congress are back in their home districts, and are listening to constituents with the acuity that comes at the time of a critical election. They need to hear from all of us about the challenges we face in providing access to quality care for our patients in the face of declining reimbursement from Medicare.

The results of the ACC’s practice census clearly show that practices are cutting staff, postponing or cancelling investments in equipment and curtailing services to Medicare beneficiaries in response to the cuts. Failure to fix the SGR will only accelerate the process. The creation of the Independent Payment Advisory Board provides additional uncertainty, and the concern that poorly thought-out payment cuts will paralyze our practices’ ability to serve our patients has never been greater.

Make sure your members of Congress hear your concerns. Learn more ways to get involved in advocacy on CardioSource.

Hollywood on the Potomac (our U.S. capitol) has in many ways shut down politically in preparation for the November elections. The unpopularity of the Affordable Care Act (ACA), even if based on sound bite political conjecture, is really complicating things for the Administration and the Democrats. The Tea Party is all about shrinking federal spending and entitlements, which would in a megatrend-sense mean that physicians would have to collect more and more of their compensation from patients as cash on the line. Historically, that didn’t work too well – doctors got a lot of chickens and farm produce in those old days before insurance reimbursement.

On the other hand, a different kind of pressure is building to pay doctors through the mysterious and as yet undefined “accountable care organization” (ACO) model. ACC plans to be at the table and very much involved in helping to define what the ACO is, and how to position physicians to lead in implementing them, presuming this will be a new pathway to higher reimbursement incentives for improving quality.

We won’t hear much about ACOs on the campaign trail in the next 6 weeks, but we will hear a lot about the need for cost containment. The Democrats should rightly brag about the importance of expanding access to uninsured Americans, and about needed insurance reforms and about their at least framing in the law the importance of increased prevention, chronic disease management and some means of incentivizing improved quality of care.

But let’s face it; the dirty little reality is that the pressure is really about cost containment in health care. ACC knows the real secret here is that improving quality is the only sure way of reducing costs in the long run, but I don’t think that has fully sunk in to the Congress or the public.

The current prediction is still that the House is likely to shift to the Republican side of the aisle. But it is amazing how much the predictions change EVERY week! What does that mean for health care? In a word: more gridlock. The Senate will gain a few Republican seats, but likely stay in Democratic control, but even that looks more up in the air this week than last. There is NO WAY the Senate will have a 60 vote majority for the Republicans or veto-proof majority, so the seated president will surely veto any attempt by the House of Representatives to completely overturn the ACA.

A very likely Republican-dominated House could clearly mess up the authorizations for funding in the bill in a big way. For those who might rejoice over the gridlock scenario, I wouldn’t get too excited. The market forces that are making health care completely unaffordable for American families, small businesses and even organizations like ACC will relentlessly push us toward massive change. Rather than just girding our loins or looking in the rearview mirror and wishing the good old days would come back, we better roll up our sleeves and get busy to protect the integrity of health care for patients, the viability of the profession of medicine and the ongoing potential for innovation here.

In the keynote speech at today’s 2009 Legislative Conference, grassroots advocacy expert Mike Dunn spoke to ACC members about the importance of grassroots lobbying and political action committees in influencing policy. He made very clear how much of an effect the two can have in influencing policy. If you want to do what you do (treating patients), you have to get involved in politics, he said. It doesn’t matter whether you like politics, he noted -- politics likes you. According to Mike, he who determines the rules, determines the care patients receive. Cardiovascular professionals have to be part of the equation of who determines the rules.

Mike also discussed a brief history of political donations. With the outlaw of soft donations, organizations like the ACC have a limited ability to influence lawmakers and form relationships. Because PACs and grassroots are the only two ways for us to influence policymakers legally, cardiovascular professionals must see themselves not just as medical professionals, but also as government relations professionals. Our strength is in our relationships with lawmakers, which we must bolster through our visits and through our donations.

He closed his presentation with some pointers for our Hill visits tomorrow:

• Don’t tell the history of cardiology or your own income concerns – your time is too short
  
  
• Emphasize the effects of the CMS cuts on quality of care and the viability of your practice
  
  
• Put in a word for tort reform. Health care reform should have tort reform – we won’t get Republican support without it
  
  
• Don’t ignore the staffer in the room

Mike started his presentation by saying, "Your house is on fire." Sadly, this is true. We got to use our advocacy efforts – even if you don’t like to get involved, even if you hate politics – to make sure we can put the fire out. Visit's ACC PAC's Web site here.

Dr. Peggy Hamberg’s appointment at FDA has been well received in town (we had better ideas); no word yet on the all-important CMS job, given Medicare’s status as the means for much of the reform process; and hearings for Governor Sebelius have yet to be set up.

I still hope our own Past President Tim Garson is in the mix for Surgeon General or Assistant Secretary for Health after Gupta pulled out. Tim may not agree with me on promoting this, given his dedication to his wonderful current position as Health Provost at U of VA, but he’d be great there.

Also, last week HHS (Department of Health and Human Services) established an Office of Recovery Act Coordination, which will coordinate all ARRA (Stimulus) implementation efforts and serve as the primary liaison to the Office of Management and Budget. Dennis Williams, former Deputy Administrator of the Health Resources and Services Administration has been selected to oversee the new office as Deputy Assistant Secretary. Dennis is due to have lots of new friends, us included!