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1
The Healthcare Landscape How the College and Its
Members Can Shape It Michigan Chapter ACC
Conference Ralph Brindis MD MPH FACC President
-Elect American College of Cardiology October
17, 2009
2
American College of Cardiology 60 Years of
Quality and Education1949-2009
Dr. Franz Groedel- ACC Founder
3
Early Scientific Sessions
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BOG- BOT Partnership
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Board of Trustees 2008-2009
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August 2008-BOT Initiatives
39 Efforts to Change the World

• Science Quality
• NCDR Platform Modernization
• The Year of the Patient
• NCDR Infrastructure Enhancements
• Cardiopath (Clinical decision support)
• D2B Transition, Certification Maintenance Project
• Cardiovascular Recognition Program (CVRP)
• NCDR Enhance Analytic Services
• Heart House Fellowship (Outcome Research, Health
  Policy)
• Integrating the Healthcare Enterprise (IHE)
• Congenital Heart Disease Registry
• Define ACC's Role in the Ambulatory Setting -IC3
  Project
• Appropriateness Criteria -SPECT MPI Pilot
  Expansion
• Informatics Strategy
• NCDR PAD Registry Development
• Medication Adherence Program (MAP)
• Hospital to Home Project (H2H)

• Advocacy
• Quality First/ Health System Reform (Yr 2)

• Education
• Cardiosource 3.0/ Web Integration
• Maintenance of Competence -MOC Toolkit
• Annual Scientific Session Enhancements for ACC.09
• Shorten Training Program Pilot Grad.
• Individual Learner Portfolio (Pfizer)
• Innovative Educational Programming (Medtronic)
• Patient Centered Team Based Care Pilot (YR 1)
• Annual Scientific Session i2 Summit Satellite
  Symposia
• International Education Fulfillment
• Strategic Assessment for CME/CE Grant Support
• Innovation in Intervention i2 Summit 2009
• ACC 60th Anniversary
• ACC Consulting Institute

• Membership Engagement
• Expansion and integration of Sections and
  Councils
• International strategy -Yr 3 Implementation
• Cardiovascular leadership institute
• Expansion Integration of Sections/Councils
• Minority Outreach Diversity Training Funding
  Sources Assessment
• ACC Bright Futures (Student Resident Outreach)
• Workforce Taskforce Lewin Study Results
  Dissemination Project
• Internal Medicine Residents Underrepresented
  Minority Survey
• Cardiovascular Leadership Institute YR 2

7
Challenging Financial Times and Health Care
Reform
8
Streamlining the Strategic Ambition
1M Reduction in Strategic Expenditures
9
Rebalancing the Budget
3.6M Reduction in Operational Expenditures
10
Nothing Lost, Just More Easily Managed
All Board Initiatives Encapsulated under 6
Strategic Priorities
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Confusion of CMS Payments Health System Reform

• CMS payment rule NOVEMBER 1st
• Weiner Braley in office imaging
• SGR (Sustained Growth Rate)
• 245 Billion Dollars !!, Risk of 21.5 decrease
  reimbursement
• Health Care Reform
• HR 3200 (House), Baucus (Senate)

13
The Current System

• The reimbursement Circle

Cost increase
Reduced payment - SGR
See more patients Do more procedures
Increased Practice costs
Procedure based reimbursement
14
CMS Proposed CutsAwaiting the Final Nov. 1 Ruling

• Overall 11 decrease in Medicare payments for
  cardiology services.
• Reimbursement for almost all cardiovascular
  services would see cuts ranging from 10 - 40.
• The CMS cuts are separate from Health Reform
  efforts!

15
Troubling Data

• Practice expense survey data (CPPIS) used by CMS
  to determine cuts were not reviewed or validated.
• CMS used responses from only 55 practices
• Other survey data suggests practice expense has
  increased
• ACC survey suggests 95 of members in private
  practice will be affected by cuts, with staff
  layoffs and service limitations the leading
  impacts.

16
ACC Message to Congress

• Stop proposed CMS cuts!
• Replace flawed SGR formula with more sustainable
  system that reflects increases in practice costs
  and accounts for appropriate growth in services
• Test models that seek to reduce variations in
  spending and ensure patients receive
  evidence-based care

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ACC Continues Fight Against Proposed Physician
Pay Cuts

• In the House, 59 members have signed on to the
  Gonzalez/Rogers letter to CMS.
• Twenty-five letters from individual House and
  Senate members also have been sent to CMS.
• Five calls have been placed to the agency from
  federal lawmakers, while members from Florida,
  Ohio and Oklahoma have sent or will send letters
  from their delegation to CMS.
• In Florida, the letter had signatures from a
  majority of the delegation including bipartisan
  support.

20
ACC Continues Fight Against Proposed Physician
Pay Cuts

• ACC met with the HHS leaders to discuss our
  concerns regarding the calculation of practice
  expense relative value units under the proposed
  2010 Medicare Physician Fee Schedule.
• We urged the delay implementing this proposal
  until there is further review and analysis.
• The final rule is due out by Nov. 1
• All-member call scheduled Nov. 12 from 4 p.m. to
  530 pm EDT.
• For more on ACCs efforts regarding the proposed
  rule, visit http//qualityfirst.acc.org.
• Patient materials and sample letters to lawmakers
  are also available at www.acc.org/can.

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CMS Rule- Effective 2010

• Ruling released 10/30 5pm EDT
• CMS will use the CPPIS flawed survey data
• Cuts from 10 to gt 40 for individual services
  phased in over 4 years
• Approx. 5-7 cuts in 2010
• ACC will work to change the Rule in coming year
• Looking immediately at other options
• Legislative approaches possibly available?

23
CMS Rule- Effective 2010

• SPECT Myocardial Imaging 36 cut
  Transthoracic echo--10 cut PCI 4 cut EKG
  5 cut

24
CMS Rule Equipment utilization

• Diagnostic equipment with cost gt 1 million, (CT
  and MR) is used 90 of the time
• Drives down practice expense RVUs for services

25
Two Views of Cardiologys Future

• The pessimist complains about the wind the
  optimist expects it to change the realist
  adjusts the sails.
• - William Arthur Ward

Running with the Wind
Broken by the Tempest
26
Running with the Wind

• ACC 2009 Legislative Conference
• 350 ACC members from 48 states
• Imaging Win Weiner Braley Amendment withdrawn
• Active lobbying on CMS rule 2010 MD Fee
  Schedule
• PAC 575,576 from 1565 donors

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Addressing the Immediate CrisisAction
StepsAppropriate Use and Practice Management

• 1. Developing Life Boat options and guidance
  for small practices to survive and thrive
• 2. Tools not RulesStart building usable,
  point-of-care appropriate use (AUC), clinical
  decision support, and NCDR / IC3 tools NOW!
• 3. Provide feedback to practices on the
  appropriate use opportunitiesidentify and
  communicate significant opportunities to replace
  cuts with AUC projects.

29

• Cardiovascular Practice Symposium

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2010 Goals

• Improve member value through
• competency based education
• self assessment
• performance recognition
• MOC tools
• Create an environment that fosters continuous
  practice transformation through QI and life long
  learning
• Lead practice and care delivery transformation
  across the continuum
• Provide tools and resources that will enhance
  practice viability

33
Cost of Healthcare per-capita vs. GNPWhy is the
US so far off the line?
Medicare and Medicaid spending will double in 10
years
Source OECD Health Data 2007 W D Weaver ACC
Opening Plenary
Total Health Cost 4.4 Trillion by 2018 20 GDP
34
How to Bend the Cost Curve?
35
CVD Mortality is declining
Deaths from cardiovascular disease Source NCHS
and NHLBI
36
CVD highest hospital admissions
Hospital Discharges 2005 Source NHDS/NCHS and
NHLBI.
37
ACC Principles for a Health System

• Provides universal coverage
• Provides coverage through an expansion of public
  and private programs
• Focuses on patient value
• Emphasizes professionalism
• Ensures coordination of care
• Reward quality and ensures value

38
ACC Principles for a Health System

•  Provides access to affordable health care
  for all  Includes delivery and payment system
  reforms that provide incentives for improvement
  of quality/outcomes Repeals the sustainable
  growth rate (SGR) formula used to calculate
  Medicare physician payment Improves care
  coordination across sources and sites through
  interoperable health information
  technology Implements medical liability reforms
  that reduce legal and defensive medicine
  costs Promotes CER to better inform guidelines,
  performance measures and appropriate use
  criteria.

39
Why Emphasize Quality?

• Improve outcomes
• Improve efficiency
• Improve public data
• Improve uniformity of care
• Avoid legislative burdens

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We must all hang together, or we shall surely all
hang separately

• Benjamin Franklin , Philadelphia,1776

44
Past ACC President Doug Weaver was there for Us
45
Senate Finance Committee Approves Health Reform
Bill 10/14/09

• The Senate Finance Committee approved its version
  of HCR legislation in a 14-9 vote with CBO
  favorable assessment cost-wise (900 billion).
• The Senate leadership will now merge the Finance
  Committee legislation with the legislation
  approved by the Senate Health, Education, Labor
  and Pensions Committee for a Senate floor vote.

46
Senate Public Option????

• Three ideas for public option
• Create nonprofit cooperatives (Senate Finance
  Bill)
• Insert a trigger as Sen. Snowe suggests only
  if other steps leave too many Americans uninsured
• Leave it up to the states to create public option
  if they choose
• Opt in or a opt out model being discussed

47
Affordable Health Care for America Act H.R.
3962 

• Released This past Thursday October 29th
• Floor vote either next week or week following
• Requires purchase of health insurance by 2013
• Expands Medicaid by 15 million people
• Creates a government run program similar to
  Medicare but with negotiated fees
• Children up to 26 yo can stay on family policy
• CBO estimates would cover 96 of Americans by
  2019 at 1 trillion/10 yr cost leaving 12 million
  uninsured

48
Affordable Health Care for America Act H.R.
3962 

• Primary Care Incentive Increases Medicare
  payment rate by 5 percent for primary care
• SGR provisions have been stripped from the bill 
• Imaging Equipment use rate was changed from the
  current 50 percent to 75 percent for advanced
  imaging (decrease payments 10-15)
• PQRI  1.4 billion for 2 bonus payment
• Misvalued Codes HHS to review fee schedule
  rates for physician services paid by Medicare

49
Affordable Health Care for America Act H.R.
3962 

• Medical Liability Establishes an incentive
  program for States
• Specialty Hospitals Prohibits new physician
  ownership in hospitals Jan 2009
• CMS Innovation Center
• Research, develop, test, and expand innovative
  payment and delivery arrangements to improve the
  quality and reduce the cost of care provided to
  patients

50
Affordable Health Care for America Act H.R.
3962 

• High Value Health Care Promotion The Secretary
  will develop an implementation plan for changing
  Medicare payment systems
• ACO Pilot Creates an alternative payment model
  within fee-for-service Medicare to reward
  physician-led organizations that take
  responsibility for the costs and quality of care
  received by their patient panel over time.

51
Affordable Health Care for America Act H.R.
3962 

• Comparative Effectiveness Creates a new center
  at AHRQ supported by public and private funding
  to conduct, support and synthesize comparative
  effectiveness research.  The bill contains
  protections to prevent the center from mandating
  payment, coverage, or reimbursement policies.
• Physician Payment Sunshine Requires
  manufacturers to electronically report to HHS any
  payments or other transfers of value above 5 to
  a physician.

52
Pay the Piper??

• House Democrats -surtax on the wealthy
• 5.4 on couples gt1 mil, individuals gt 0.5 mil
• Would raise 460 billion/10 years
• Senate Finance tax on Cadillac health
  insurance premiums gt 8k individual, gt21k family
• Decrease subsidies to middle-class families
  buying insurance policy
• OMB projections related to decreased CMS
  reimbursement, etc.
• Imaging a big target

53
Senate S. 1776 - the Medicare Physicians
Fairness Act
X

• Michigan Senator Debbie Stabenows defeated
  47-53 last week that
• would have permanently repeal the SGR
• wiped away past debt
• set physician payment updates starting in 2010
  and beyond at zero/freeze
• cost of the bill was 245 billion
• Senate was nervous about rapidity of this bill
  coming to vote without time to fully digest

54
House SGR Meeting October 28th

• Pelosi, Hoyer, Rangel, Waxman, Stark
• The House Leadership is committed to SGR
  permanent fix bill  separate from the health
  reform bill. 
• The House bill,  245 billion over 10
  years, will bypass PAYGO rules and unpaid for
• repeal the 21 percent cut and replace it with MEI
  for 2010
• wipe away accumulated debt
• promotes primary care services
• include the promotion of ACOs

55
House SGR Meeting October 28th

• SGR Bill and Affordable Health Care for America
  Act H.R. 3962 voting may be the same day or the
  next day
• The intent is to send these two bills as a
  package to the Senate for them to consider
• The House is "committed" to these two bills
  coming out of conference

56
ACC HCR Activity/Positions

• Actively discussing HCR with administration
  officials and lawmakers, but not fully endorsing
  any legislation.
• The ACC appreciates the SGR reforms and PQRI
  incentives contained in the House legislation, as
  well as the CMS' Innovations Center in the Senate
  legislation.
• The ACC is disappointed that the Senate
  legislation does not contain a longer term SGR
  fix, and does not support the Senate bills PQRI
  penalties or penalties for physicians who are
  outliers based on resource use.

57
ACC HCR Activity/Positions

• The ACC opposes imaging equipment use rate
  change in both the House and Senate legislation,
  which will result in lower payments for imaging
  services.
• ACC staff and leaders continuous lobbying and
  advisory roles in Congress, White House and OMB
• ACC CEO Jack Lewin attended White House Rose
  Garden address on health care reform last week
  private visit with the POTUS in Oval office.
• For more on ACCs health care reform efforts,
  visit http//qualityfirst.acc.org

58
What You Can Do

• Contact your Senators/Representatives
• and ask them to  Repeal the
  SGR formula
•  Test delivery system and payment models that
  reward quality improvement and outcomes
•  Reform the current medical liability system

59
What You Can Do

• Tell your senators how the new CMS cuts will
  affect your practice, your patients and your
  ability to successfully participate in reform
  efforts.
• Give concrete examples and stories
• Sample letter you can send to your senator on
  CardioAdvocacy Network.

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Member Resources

• Patient Materials www.acc.org/Chapters
• Health IT Resources www.acc.org/healthit
• Lewin Report Online Forum lewinreport.acc.org

63
National Data Repository for Comparative
Effectiveness Research
Pharm
STS Registry
NDI
UPI
NCDR CATHPCI
CLAIMS
64
Timeline of building a true
PAD Registry
ICD Long
National CardioVascularDataRegistry
IC3
SPECT MPI
EP Registry
IMPACT Registry
ACTION Registry
CARE Registry
ICD Registry
CathPCI Registry
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Influence of NCDR Research

• Public Policy
• Quality Improvement Guideline Adherence
• Reducing D2B Times
• Clinical Indications Outcomes
• Quality Improvement Translational Research
• Post Market Surveillance
• Adverse Events in Closure Devices
• New Technologies and Effectiveness
• Diffusion of New Technology

66
ACC/Duke Partnership Develop a National
Cardiovascular Research Infrastructure (NCRI)
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NHLBI GO Grant ProposalACC/STS - CardioLINK

• Purpose
• Compare CABG and PCI using linked databases from
  the CathPCI and STS Registries for in-hospital
  outcomes
• Clinical data linked to MEDPAR data for
  long-term survival and economic outcomes
• Develop prediction models of death after initial
  revascularization in setting of chronic CAD

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Unprotected Left Main PCI
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ACC/STS CardioLINK

• Create propensity score for patients undergoing
  isolated CABG or PCI in stable CAD
• Create a model to predict the SYNTAX score based
  on co-variables available in STS and NCDR
  databases
• Compare long-term survival, hospitalization for
  MI, renal failure, stroke, and repeat
  revascularization using propensity scores
• from matched pairs and also by disease
• severity from derived SYNTAX scores

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ACC/STS CardioLINK

• Cost and incremental cost-effectiveness of CABG
  vs PCI for matched subgroups
• Outcomes in cost per life year gained and cost
  per quality-adjusted life year gained

71
CER and Registries

• Perfect Opportunity for Coverage with Evidence
  Development (CED)
• Offers the Carrots and Sticks for Registry
  participation
• Realizes opportunities to assess new technology
  in real world applications non-RCT and off
  label uses
• An ultimate national tool for assessing safety
  and efficacy of new devices/drugs with low
  adverse event rates
• Percutaneous Aortic Valves
• Atrial Fibrillation Ablation
• New CV Imaging Technologies

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Happy Halloween !!!!!