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- Ralph Brindis, MD, MPH, FACC, ACC President⁎ ()
- ↵⁎Address correspondence to:
Ralph Brindis, MD, MPH, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
I am deeply honored and humbled to lead the College at a time when both the ACC and cardiovascular care in the U.S. are at crucial crossroads.
The cardiovascular profession has made significant improvements in the management of cardiovascular disease, including a 50% decrease in mortality for coronary artery disease over the past 25 years (1). Today, we find our ability to further such advances threatened.
Congress has just passed monumental health care reform legislation that makes significant headway in expanding access to care for over 30 million presently uninsured Americans—including those with heart disease. However, it includes several onerous initiatives, such as the creation of an “independent payment advisory board” and prohibitions on physician-owned hospitals. It also fails to address several of the principles that the ACC deems essential for real reform. It does not include delivery and payment system reforms that provide incentives for improvement of quality and outcomes, nor does it repeal the flawed sustainable growth rate (SGR) formula used to calculate Medicare physician payment. It also fails to implement medical liability reforms that reduce legal and defensive medicine costs.
The patient-cardiovascular specialist relationship now is under unprecedented stress. Despite their appropriate desire to control the increase in health care costs, Congress and Medicare have implemented many policies that have had unintended negative consequences. Congress has yet to implement a long-term, fair approach to health care cost containment through its SGR policy. Medicare's efforts to decrease payment for imaging have led to broad and disproportionate cuts in reimbursements for physician offices. Procedural bundling of payments will decrease nuclear imaging reimbursement by 40% this year alone. Finally, Medicare's use of the incredibly flawed Physician Practice Information Survey to determine its 2010 Physician Fee Schedule has resulted in additional severe decreases in reimbursement. We are also seeing, not unexpectedly, private payers following the lead of the Centers for Medicare & Medicaid Services (CMS) in decreasing reimbursements without an evidence-based strategy for cost containment. The ACC estimates that the average private practice is experiencing between a 10% to 30% decrease in reimbursement this year.
How do all these attacks on health care reimbursements impact the patient-cardiovascular specialist relationship? Is this just about whining over lost income? Or is the practicing fellow of the ACC truly concerned about challenges in ensuring patient access to the highest-quality care? Let me share the impacts of these policies at the patient-clinician level. A recently completed FACC member survey (2) to assess the potential impact of the aforementioned policies noted the following:
• Nearly two-thirds of private practices indicate that they have considered, have already begun, or have completed integration of their practice into a hospital system, which could actually increase health care costs for our nation.
• Nearly two-thirds of private practices have cut costs and eliminated staff as a direct result of the CMS fee schedule change.
• Under financial pressures, some practices closed satellite offices that serve inner-city, disadvantaged patients, further exacerbating the racial and socioeconomic disparities of care that unfortunately exist in our country.
• Despite ACC's recent Cardiovascular Workforce Task Force document describing increasing needs for cardiovascular specialists, many academic centers and private practices are now deferring the hiring of cardiovascular physicians due to this challenging environment.
These are sobering statistics and reports from our membership. The situation is both unprecedented and untenable. It threatens the core of our profession and our nation's health.
A significant part of the challenge before us has been the devaluation of the superb services provided by cardiovascular specialists. The reductions in cardiovascular mortality and morbidity, and the unmatched impact we have on quality of life now seem to be reduced to a commodity traded back and forth by Congress, commercial payers, and the public. What is the value of what we have accomplished? What is our value as professionals and healers?
No patient doubts the value of a cardiovascular specialist at 3:30 in the morning when we are caring for an acute myocardial infarction. No patient questions our value when plagued by a recurrent rapid heart rhythm that is then successfully ablated. No patient undermines our value when they are treated for class 4 heart failure and can then enjoy an improved exercise capacity.
So it would seem that what we value the most, and where our greatest value lies, is that direct relationship with our patients. As ACC leaders travel around the country, we hear a very clear message that our FACCs want us to challenge these increasing incursions on the patient-cardiovascular specialist relationship.
The ACC and its membership need to adjust the sails. The ACC must adapt to the changing environment, but not in a way that would be destructive to our mission in providing high quality cardiovascular care and destructive in our patient-cardiovascular specialist relationship.
Some of our membership has asked that the ACC function as a guild rather than a profession. They ask us to focus on members' bottom lines, advocating for higher reimbursement, rather than focusing on improving the quality of patient care with guidelines, appropriate use criteria, and other quality initiatives. This is a bad strategy. To function as a guild is not only wrong, but would quickly marginalize us in ongoing discussions about health care reform. When we forsake our values, we lose our value.
As fellows of the ACC, we must focus on our ACC core values—professionalism, the advancement of cardiovascular knowledge and its widespread implementation, demonstration of the value of our specialty in health care improvements, active engagement of professionals throughout our College activities, and inclusiveness.
Our strategic priorities for 2010 are grounded in these core values.
Given the challenges facing private, community-based practices, we need to focus on providing tools for practice survival and transformation. We must continue to fight Medicare incursions and defend access to quality care. We can do this by promoting value-based payment reform, while influencing national health care reform efforts.
Although this issue is personal for the practicing cardiologist, the rallying issue for our patients and our community is our impassioned concern about diminishing patient access leading to increased socioeconomic disparities.
We have the opportunity to advance our quality tools and resources for translating knowledge into practice. We will do so by expanding the capabilities of the National Cardiovascular Data Registry, PINNACLE (Practice Innovation And Clinical Excellence) Network, life-long learning portfolios, CardioSource, CardioSmart, and our health information technology/decision support tools.
We will focus on patient value—including partnering with patients and promoting patient empowerment. We will create and encourage the implementation of ACC's appropriate use criteria for cardiovascular procedures.
We must reach out to fellows in training and young practitioners through our emerging faculty and young investigator programs to enable all members of the College to participate in teaching, research, and service throughout their careers.
In addition to ensuring practice viability, ensuring the ACC's vitality is crucial. We will focus even more this year on increasing the value of membership, and promoting the value of cardiovascular specialists. We will develop new products for revenue diversification to increase transparency and to minimize potential risks related to our relationships with industry.
We will continue to lead the profession toward systematic and measured reductions in cardiovascular morbidity and mortality and in ongoing improvements in personal and population-based prevention and health care outcomes. Through the promotion of professionalism and improved systems of care, our goal at the ACC is to empower both cardiovascular care teams and their patients to participate in continuous system reform and innovation.
For the past 60 years, the ACC has been a leader in education and science. We need to use this position as a leader to influence health care in ways that benefit the people who matter most—our patients. We must act on our vision and we must communicate and persuade others to follow us. The ACC's ongoing responsibility and accountability is as the premier source of cardiovascular education, quality, and science and as the most respected voice for cardiovascular professionals.
These opportunities are not just possibilities, they are our destiny.
I encourage each of you to call or email me with your concerns or counsel. I am eager and honored to serve the College and all of our FACCs in the coming year by aggressively promoting the value of the cardiovascular professional.
- American College of Cardiology Foundation