Last week I had the pleasure of testifying on behalf of the ACC at the House Ways and Means Subcommittee on Health during a special hearing to explore how private sector payers are rewarding physicians who deliver high quality and efficient care. I was joined by other panelists: Lewis G. Sandy, MD, senior vice president, Clinical Advancement, UnitedHealth Group; David Share, MD, MPH, vice president, Value Partnerships, Blue Cross Blue Shield Michigan; John L. Bender, MD president and CEO, Miramont Family Medicine; and Len Nichols, PhD, director, Center for Health Policy Research and Ethics and editor-in-chief of the ACC’s online Community on Payment Innovations.

During my testimony I discussed several of the quality improvement collaborations underway in cardiology and what lessons can be applied across the health care system to simultaneously reduce unnecessary readmissions, complications, testing, and ineffective spending. My testimony also focused on the power of data as exemplified by our experience with the NCDR and the importance of decision support tools in helping care providers actually use evidence-based guidelines and appropriate use criteria to “get science to the point of care” to ensure not only the right therapy and/or test, but also engage patients in the decision making process. I also focused on the ways the ACC is currently working to “put the data to work” through programs like Hospital to Home, Imaging in FOCUS and PINNACLE. I also expressed the need for payment reforms linked to these tools.

A big part of my testimony was also the “SMARTCare” projects currently underway in Wisconsin and Florida that combine data collection, decision support and quality improvement initiatives into a focused project that documents clinical quality, resource use and cost variation in the treatment of stable ischemic heart disease. The projects are driven by the ACC’s state chapters and the ACC in collaboration with integrated health care systems, payers and multi-stakeholder collaborative groups.

The ACC was absolutely a vital part of this conversation. The development of innovative new programs and payment models that reward physicians who deliver high quality and efficient care has been a College priority over the last several years in light of health care reform and the need to curb out-of-control health care costs. I also told the Subcommittee that one of the key points to keep in mind about new systems is the time it takes to implement -- so the faster they are established the faster we can move forward with implementing these new payment reforms!

I invite you to share your “big ideas" on how to reward providers for quality care and cost savings in the comment section below.

Read the complete testimony and learn more about the hearing here.

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.

What an exciting weekend! I can safely say that the Cardiovascular Care Summit is not something that happened in Las Vegas that should stay in Las Vegas. Whether it was hearing from national health plan representatives on the role of the cardiologist and the cardiovascular program in a reformed reimbursement environment, or discussing best practices for building and managing a cardiovascular service line, this unique conference offered solutions for the entire cardiovascular care team to thrive in a time of change.

David Lansky, PhD, president and CEO of the Pacific Business Group on Health; Deborah Ness, president of the National Partnership of Women and Families; Lonny Reisman, MD, chief medical officer at Aetna; and Reed Tuckson, MD, executive vice president and chief of medical affairs at UnitedHealth Group kicked off the Summit by providing a unique perspective on the cardiovascular community’s role in payment reform. Whether examining the components of value-based purchasing, helping to reduce patient readmissions, there are a number of opportunities to share our expertise and work with health plans.

The Summit also featured discussions on the future of health care reform and how the physician community as a whole can affect this process and lead change. Obviously, one of the key areas requiring substantial change is physician payment. Following on the heels of the health reform session, Summit attendees were able to take part in a panel discussion that looked at a variety of compensation models and their potential roles in the changing reimbursement environment. Breakout groups also offered opportunities to discuss major financial changes, ranging from contract negotiations, winning academic business models and how to financially survive in private practice.

Outside of payment and health care reform, the Summit also focused substantially on data collection and management, providing a focused look at the myriad of data available today and why accurately reporting data will be so critical in the future. The writing is on the wall, whether we like it or not, and future compensation models will be based at least in some part on quality of care and outcomes. We have the experience with NCDR to make sure this is done in a way that is transparent and accurately reflects the quality and appropriateness of care being provided.

Finally, the final day of the Summit really provided a comprehensive look at issues related to the cardiovascular service line. Physician management of the cardiovascular service line is today’s contemporary approach to a physician-driven, professionally managed cardiovascular program.

The integration of physicians into the management of the service line provides an opportunity to strategically and operationally align hospitals and physician groups. ACC leaders and other stakeholders involved in service line management provided first-hand reports and best practices for designing and leading a successful cardiovascular service line model.

I’d like to thank and recognize ACC leaders and staff involved in making this Summit a great success. It was a true testament to the many ways the ACC and its leaders are working to meet the needs of the entire cardiovascular care team in this time of rapid change. Viva Las Vegas!

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.

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

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

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

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

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

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

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

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. 

 ********************************

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).

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?”

Recommendations on how to further reduce the federal deficit are due to the budget “Super Committee” on Oct. 14. With a budget package this big, Congress is going to have to make some difficult choices. For this reason, it’s critical that House and Senate leaders hear from us over the next two weeks about our priorities.

The College’s goals are three-fold:

1. Permanently repeal the sustainable growth rate (SGR) formula as part of any deficit reduction plan
2. Include medical liability reforms in any deficit reduction plan
3. Protect medical imaging from any further cuts

When it comes to the SGR, time constraints and the diminishing pool of spending offsets makes the Super Committee the only viable vehicle for addressing the flawed formulas this year. For every year that Congress postpones fixing the SGR, the cost grows. The American Medical Association (AMA) estimates that by 2016 the cost of permanent repeal would be $600 billion – a significant increase from the roughly $50 billion it would have cost in 2005. If we’re talking about reducing costs, then the SGR should be on the table.

On a similar note, the Congressional Budget Office estimates that medical liability reform would result in cost savings to the federal budget of more than $50 billion over the next 10 years. Including provisions in any deficit reduction plan could help curb these costs. If you attended the Legislative Conference a few weeks ago, you heard from ACC staff and leaders about the need for a system that increases patient safety, compensates injured patients quickly and fairly,  improves provider-patient communications, and ensures affordable and accessible medical liability insurance. It’s also important that federal reform efforts do not impact reforms already enacted and working at the state level.

Protecting medical imaging from additional cuts is also crucial. Imaging has been the focus of numerous drastic cuts over the past five years and continues to remain a target by Congress and regulators for potential payment reductions. Additional payment cuts and restrictions on imaging services cannot be absorbed by physician practices without impacting quality and access to high quality care. We cannot stress this enough to our members of Congress.

While at the end of the day we might not like all of the recommendations made by the Super Committee, now is our chance to stand together and at the very least educate members of Congress about the long-term ramifications if our requests are ignored. For those who think this is futile, I’ll leave you with an email that a fellow ACC governor just forwarded; he had received it from his congressman's legislative director. The governor had met with the congressional staff during the Legislative Conference. He received the email as he was about to respond to an ACC alert asking for help in generating support for a sign-on letter to repeal the SGR in the House. The email he received said: “Since we were just talking about the SGR, I wanted to let you know that my boss agreed to sign on to the letter below to the Super committee asking that they include a permanent solution to the SGR.” In the letter, the congressman stated the following important facts: "We are presented with an important choice: continue to distort the picture of our nation’s fiscal status with another short-term solution or restore fiscal transparency to the Medicare program by eliminating the $300 billion debt that has accumulated as a result of the SGR". 

Now that’s what I call Advocacy in action. OK, y'all, let’s hit the phones!

 

ACC’s 2011 Legislative Conference had some great afternoon speakers on Monday, including health economist Len Nichols, PhD, and Nancy Nielson, MD, senior advisor to the Centers for Medicare and Medicaid Innovation (CMMI). Both Nichols and Nielson spoke about the need for cardiovascular professionals to get involved in payment innovation. We have the knowledge on how to make it work, they said. If we don’t get involved, someone else less knowledgeable will do it for us.

Nichols talked about the winding road that is payment reform, noting that the current unaccountable fee-for-service and third-party payment system has brought us to a place where the value of care per dollar is less than it could be, prices are above minimal costs and quality is not optimal for every patient. Failure to address these issues in a way that works for patients and providers will very likely result in across-the-board cost controls and/or utilization reviews or benefit cuts, he said.

According to Nichols, new payment models will require the alignment of care coordination outside of typical boundaries, and will involve a greater level of risk to providers than the current fee-for-service system. In addition any new model, outside of pure cost or benefit reductions, will require that patients be engaged in their own care through cost-sharing, wellness education and incentives to stay healthy. Decision support also will be critical in order to ensure that clinicians and patients have right the right incentives and information to make the most appropriate care decisions and facilitate risk sharing.

Nichols is the editor-in-chief of a newly launched website, the Community on Payment Innovation, which aims to bring great ideas together and highlight innovative payment models. By using the site, which is a joint venture of the ACC and the American Journal of Managed Care, we hope to generate ideas that we can bring to federal agencies, such as CMMI, to implement.

 

Nielson discussed the different payment pilots that CMMI has underway. The health care reform law authorized $10 billion in funding to study new ways to deliver health care, and that funding is what created CMMI, Neilson said. CMMI has a unique advantage over other agencies: waiver authority. This means it has the power to do things, like offer gain-sharing, that its parent agency, the Centers for Medicare and Medicaid Services (CMS), cannot. Some of CMMI’s pilots that you may have heard of: Partnership for Patients, Pioneer Accountable Care Organizations (ACO) and the CMMI bundling initiative.

The bundling initiative is interesting for a couple of reasons. It’s based on a CMS pilot, the ACE demonstration, which looked at bundling payments for acute care for certain cardiovascular and orthopedic procedures. CMMI took this base model and looked for a way to make it more flexible for a variety of different practice environments. What it ends up being, she said, is a way to get your feet wet with a new payment method if you’re not ready to be part of an ACO. You’ll still get a fee-for-service payment, but you may also get a gain-sharing payment on top of the fee-for-service payment. In addition, participants don’t need to go all-or-nothing; you’re able to try the payment method for one or two DRGs and see how it goes.

 

Both Nichols and Nielson stressed repeatedly that payment innovation WILL happen because we simply can’t afford not to. As Nielson said: “We are in a crisis. The cost of medical care is a major issue.” I couldn’t agree more. The pilots of CMMI, if implemented nationwide, may begin to address some of the issues. We’ll need to be leaders in this though. As Jack Lewin, MD, used to say frequently while the health reform law was being drafted: If you’re not at the table, you’re on the menu. Let’s get our thinking caps on a figure out what’s the best way to innovate our payment system.