I am a Republican. For those who know me that is not a surprise. I live in a red state. I have never voted for a Democratic presidential candidate. I can field strip, clean and reassemble a Remington 12-gauge pump blindfolded. And on top of it, I think we should talk about having a single payer national health care plan. The reason is quite simple. In my view, we already have one; we just don’t take advantage of it. 

Firstly, Medicare and the Center for Medicare and Medicaid Services (CMS) are de facto setting all of the rules now. They are a single payer system.  When we go to lobby the Hill, we lobby Congress and CMS.  Talking to Blue Cross, Aetna, Cigna and United Health care is essentially a waste of time. All the third party payers do is play off the Medicare rules to their advantage and profit. They have higher premiums, pay a somewhat higher benefit and have a significantly higher level of regulation which impedes the care of their customers.  This is no longer consumer choice but effectively extortion, a less than hidden shake down in which the “choice” for a family of four is company A at $900 per month or company B at $1100 per month.  The payers are simply taking advantage of the system, playing both ends against the middle. 

Secondly, in order to move forward with true health care finance we need complete transparency in cost and expense… and we need it now. As was noted in a recent Time magazine piece on the hidden cost of health care, our current system is a vulgar, less than honorable construct more akin to used car sales than medical care, cloaked under the guise of generally accepted accounting principles and hospital cost shifting. 

Thirdly, with a single payer system would potentially come real utilization data, real quality metrics and real accountability. The promise of ICD-10 with all of its difficulties is that of a much more granular claims-made data. We could use some granularity in health care data and we will never achieve it in big data quantities without a single payer system.

Lastly, I think that the physicians should be in charge of health care and not the insurance companies and hospital systems. With a single price structure, it becomes all about medical decision making, efficiency, the provision of care to our patients, and shared decision making, all of which we do well. 

How, you might say, could a Republican come to such a position? The simple answer is I really think it is quite Republican.  Oh, I know there will be many raised eyebrows and many critics. I accept that.  I understand the fact that no single payer system is perfect, that it is “socialist,” that it is “un-American.” 

I would submit to you, however, that it is un-American to allow many of our citizens to be uninsured, that it is un-American to shunt money away from a strong military in order to support a bloated, inefficient and fraud-laden health care system, that it is un-American not to be open and above board with the cost of what we do, the expense of that service and the profit that we make. Mostly, it is un-American to let this outrageous health care injustice continue.

I would be interested in hearing your thoughts in the comment section below.

Addendum: Listen to Dr. May’s interview about a single payer system with Arnie Arnesen, host of “The Attitude WNHN 94.7FM” here.

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.  

I thought it would be important to share a link to the recent House Ways and Means Committee Health Subcommittee meeting on MedPAC's Annual March Report to Congress. Glenn Hackbarth, JD, MA, chair of MedPAC, gave an outstanding testimony, which can be downloaded and viewed here.

Hackbarth calls for the repeal of the sustainable growth rate (SGR), rebalancing payment, particularly by rebasing skilled nursing and home health, but the most important for us in cardiology, is the testimony starting at minute 53 regarding the differential between outpatient hospital and private office payment rates. He states that the most efficient provider is the private office and suggests that the payment rates may be adjusted to that level. MedPAC does not, at this time, make that recommendation but it appears to be coming.

Whether you are private or integrated, I would urge you to download the video and watch it. It is the "real deal" without spin.

Also, you can get the full MedPAC transcript here to read the actual discussion regarding the HOPPS and the PFS, beginning on page 193 of the transcript.

Earlier this week the nation waited in anticipation as the American Taxpayer Relief Act of 2012 was passed through the Senate, and eventually through the House late New Year’s Day, therefore averting the so-called “fiscal cliff” from taking effect. The bipartisan deal included a one-year patch of the flawed Sustainable Growth Rate (SGR) formula, preventing Medicare payment cuts of 26.5 percent that were set to kick-in on Jan. 1. Across-the-board sequester cuts of 2 percent were also delayed, keeping Medicare reimbursement safe for another two months.

Throughout the past year, ACC leadership and staff helped lay the groundwork for several quality-related provisions in the new law through ongoing dialogue with congressional committees about ACC’s quality improvement tools, including registries. Included in the legislation, was an extension of the Geographic Work Adjustment through 2013 and reauthorization of funding for measure endorsement for another year. The ACC worked with the Stand for Quality coalition, including the National Quality Forum and the American Medical Association, to advocate for extension of this funding.

Also thanks to the incredible efforts of ACC’s Advocacy team, a provision to qualify registry programs to meet Physician Quality Reporting System (PQRS) reporting requirements was included. Professional society clinical data registries, such as the ACC’s National Cardiovascular Data Registry, collect robust data that are used to provide feedback to physicians and enhance performance. This focus on quality, evidence-based care by itself is an effective way to reduce overall costs while enhancing quality of care. Registry participation is a more robust performance improvement method than the current PQRS, and now that more physicians can meet PQRS requirements, physicians can avoid future penalties under the program. This provision was the result of discussions between ACC, the American Society of Clinical Oncology, the Society of Thoracic Surgeons, and a few other organizations with bipartisan staff for the Senate Finance Committee and House Ways and Means Committee in the summer and fall.

The College also played a key role in a provision to enhance the quality of data needed for new delivery and payment models. The law now requires the Secretary of HHS to develop a strategy to provide data for performance improvement to physicians in a timely manner. This provision is the direct result of testimony by physicians, including ACC Past President Doug Weaver, MD, MACC, before the Senate Finance Committee this summer as well, as a roundtable discussion between committee staff, ACC and several other specialties this fall.

While the offsets used to pay for the $25 billion SGR patch do result in an increase in the equipment utilization rate for advanced imaging modalities that is limited to CT/MR/PET, which will mean reduced payments, but fortunately ACC staff were able to keep prior authorization and changes to the in-office ancillary services exception kept out of the agreement.

Moving forward, ACC’s Senior Vice President Jim Fasules, MD, FACC, said it best when he told the ACC presidential team earlier this week  that while “the work now shifts to the spending cuts debate with a big spotlight on entitlements … right now we get to stop holding our breath.” It is now more important than ever that the cardiovascular community and the rest of the house of medicine build on the momentum from these efforts and continue to push for a permanent repeal of the SGR. As I mentioned in my blog post last week, 90 percent of ACC PAC-supported candidates (104) won their respective elections in November 2012, strengthening the College’s allies on Capitol Hill. These relationships and grassroots efforts have and will continue to be increasingly important as we work towards a permanent repeal over the next year. The ACC stands ready to work with Congress as it confronts the challenges and opportunities within Medicare.

Stay tuned to the ACC Advocate and CardioSource.org for additional details in the coming months.

This post is authored by Stephen R. Ramee, MD, FACC, chair-elect of the Interventional Scientific Council.

The 2013 Medicare Physician Fee Schedule continues the Centers for Medicare and Medicaid Services' (CMS) campaign to reduce payments for complex procedures and diagnostic tests in order to redirect resources to other services. An agenda that began with crippling cuts to echocardiography and SPECT and continued with implementation of faulty practice expense data that cut cardiology services across the board has now targeted EP procedures and PCI.  Although the cuts result in large measure from decreases in the amount of time needed to perform the typical EP study and ablation or PCI (note that the system for determining RVUs is heavily driven by procedure time), CMS payment policy decisions have made things worse. By unilaterally rejecting recommendations from the physician community that would provide opportunities for cardiologists to accurately report more complex procedures, CMS is preventing physicians who care for the most challenging patients from being fairly compensated. ACC will be vigorously opposing CMS’s decisions and working with the Society for Cardiovascular Angiography and Interventions (SCAI) and the Heart Rhythm Society (HRS) to rectify these decisions. Unfortunately, no changes to the fee schedule can happen before 2014.

Our practices that have already experienced precipitous cuts in payment for core services now face payment reductions on the order of 27 percent for EP studies/ablations and 20 percent for PCI. Many of us, myself included, are astonished that the reward for a relentless focus on quality that has brought about a 27-percent reduction in mortality from heart disease is a payment cut.

While the cardiovascular field is justifiably angry about the latest round of payment cuts, it’s important to recognize that this is the byproduct of a broken system for physician payment. Congress’s inability to fix the Sustainable Growth Rate (SGR) has meant a decline in real terms in the resources our nation devotes to paying for the physician services Medicare patients need and deserve. Rest assured that ACC will be doing everything possible to reverse CMS’s bad decisions and to stop the SGR cut from going into effect. But we will also be redoubling our efforts to make sure policymakers understand the value of the lifesaving work cardiologists do every day and to move toward a payment system that supports and rewards our specialty’s dedication to improving care and outcomes for patients with heart disease.

For full coverage of the 2013 fee schedule and coding changes, visit CardioSource.org/PhysicianPayment. Stay tuned to The ACC Advocate for updates on ACC’s action. Be sure to follow @Cardiology on Twitter for the latest advocacy and health policy news.

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

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

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

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

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

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

Hope to see you all next year!

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

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

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

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

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

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

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

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

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

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

This post is authored by James Tcheng, MD, FACC, co-chair of the ACC’s Informatics Committee

As we kick off the 7th Annual National Health IT Week, I’m reminded of just how far discussions around health IT have evolved in a relatively short time. Only a few years ago, the conversation was focused on how to choose an electronic health record (EHR) system. Today, we have moved beyond basic implementation to discussing how best to leverage systems to provide meaningful and timely clinical decision support, improve patient communications, reduce errors, and improve delivery of high quality care.

A recent ACC survey of cardiovascular practices found that 74 percent of practices are using, or are in the process of implementing, an EHR system. In addition, most practices are either already participating or plan to participate in the federal EHR Incentive Program. This is great news on a number of fronts. Not only does more structured and interoperable data enable increase quantitative decision making and improve clinical decision support, the availability of data will ultimately enable a learning health care environment that continuously returns information useful to improving health care delivery, quality, and outcomes. (Important note: Oct. 3 is the last day for eligible professionals to begin their 90-day reporting period for the 2012 EHR Incentive Program. To get the maximum incentive payment, Medicare eligible professionals must begin participation by 2012).

That’s not to say we don’t still have challenges. In fact, one of the biggest challenges is how to best optimize the potential of health IT now that so many providers are on board.  Health technology solutions are inherently complex, requiring substantial resources to maintain and optimize. But there are severe constraints on available resources, and funding is not distributed equally. Changes in the IT portfolios will need to occur without compromising care during transition periods.  Also given the fast-moving nature of health IT, maintaining the security and privacy of information is a challenge. (This will definitely need to be a focus as we move forward with exciting opportunities around mobile technologies).

We also need to move beyond the current emphasis on financial levers to push Meaningful Use compliance.  The real drivers ultimately will be increases in usability, efficiency, and productivity.  Until a true return on investment can be achieved, health IT will remain on the wrong side of the ledger, and thus will be subject to compromise.  A plan for long term assistance with the costs of Health IT should be considered.

When it comes to health IT, my best advice is to never be afraid to tear down what was previously built. Technology evolves rapidly and what was once a good plan/design/technology may not be optimal in the future. We need to be flexible and forward thinking – as do governments, consumers and health care systems. To borrow the National Health IT Week theme, we need to come together with “one voice, one vision [to] transform health and care.”

Be a part of Health IT Week:

• Take part in the “Health IT is…” Twitter Chat on Friday, Sept. 14. at noon ET moderated by @HIMSS and @HealthStandards. Use the hashtag #HITsm and follow ACC's @Cardiology account.
• Visit the ACC’s Health IT Resource Center for information on e-prescribing, the EHR Incentive Program, and choosing and using an EHR.
• Share your thoughts on Health IT on this blog, or on the ACC’s Facebook page.
• For additional information about National Health IT Week, visit healthitweek.org
  

This post was authored by Kathy Blake, MD, FACC, member of the ACC’s Advocacy Steering Committee.

A recent article in the Wall Street Journal, “Same Doctor Visit, Double the Cost” (subscription required) detailed the shift we have seen across the country of hospital systems acquiring private practices, often leading to higher prices of services.
The article notes that “as physicians are subsumed into hospital systems, they can get paid for services at the systems’ rates, which are typically more generous than what insurers pay independent doctors. What’s more, some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost. The result is that the same service, even sometimes provided in the same location, can cost more once a practice signs on with a hospital.”

The article lays the groundwork for much of what the College has been advocating for over the past few years: the need for payment reform. The payers have noticed. The patients have noticed. The Centers for Medicare & Medicaid Services (CMS), as the article suggests, may have its hands (somewhat) tied by statute. The love affair with independent practice ended a long time ago. The infatuation of business with private payers and HMOs died awhile back. The current love affair, with integrated systems, is looking a bit tattered. The reality suggests that a variety of offerings across the full spectrum probably leads to a healthier delivery ecosystem, especially if there is transparency about cost and quality, and real competition based on accurate determination of value.

The article is timely as the 2012 Legislative Conference is right around the corner and will be touching on issues such as the College’s ongoing payment reform efforts, including advocating for the repeal of the sustainable growth rate (SGR) and instead focusing on quality-based delivery and payment models. Also at Legislative Conference Dr. Zoghbi will give an update on the “State of Cardiology” with results from this year’s Practice Census (we remember the results from two years ago that started documenting this shift in private practice).

The current fee-for-service system in integrated models is not sustainable, and it is up to us to steer the payment reform decisions in the right direction.