Report from the Chair of the Board of Governors

“Report from the Front”

The following letter was recently received by Mississippi Governor Dr. Thad Waites from one of his Chapter Councilors practicing in the Mississippi Delta. This letter clearly outlines the case for concomitant healthcare and tort reform.

“….As cardiologists in Mississippi we practice at ground zero for cardiovascular illness and death in the US. We are outmanned in our efforts to reach all those in need of our services and it is a constant battle to improve access to quality care. As you know the Delta is a particularly underserved area with many challenges to healthcare delivery. In a good economy a large percentage of our community lives below the poverty line and unemployment runs 14%. More than 15% of patients pay nothing for their care because they have nothing. Despite this we treat all comers because for us improving access to healthcare is not a political football but a daily reality we all take seriously and a responsibility many feel called to share. We serve a minority population of about 70%. We were one of fourteen sites in the US to study causes, limitations, and solutions to healthcare access issues for minorities through a Robert Wood Johnson Foundation grant. Our patients like those in many rural areas have difficulty accessing care due to limited finances and limited transportation.  They receive whatever care is available locally and in general are very grateful for whatever they receive.

We are committed to improving quality not just access.  In this regard we have the first accredited nuclear stress lab in Mississippi and the first accredited echo lab in northwest Mississippi in our office. There are no accredited hospital labs for these services in northwest MS. Because we control quality in our office we can accomplish this and continually work to affect this same quality in our local hospital. We now face substantial cuts to these services that will then jeopardize our ability to advance quality healthcare delivery in our area. Arbitrary cuts serve no one and advance nothing for the individual patient. Promoting quality in healthcare will allow better outcomes at more efficient cost.  

We have had an electronic record in our office for 2 years. I don’t see much in the way of cost savings but will continue to make this effort because I believe we have to explore all options in an effort to improve quality and contain cost. 

Let’s look at more competition among insurers. My personal premiums go up every year but as a physician my reimbursements go down. The insurers can increase profits on both ends without concern for people shopping around for better policies or physicians jumping ship. Better service from the insurers might allow me to decrease the 20-25% overhead cost I have trying to collect from these insurers.

Despite this, private insurers are more effective at cost containment than some government programs. For example, my private insurance policy requires me to use generic drugs when possible and this is appropriate. But my Medicaid patients have a much more extensive formulary than my private insurance provides wasting a lot of money in drug cost. Since we border Arkansas we treat Arkansas Medicaid patients but can’t get paid. When we try to call to find out why, we get a recorded message without the ability to leave a message. Letters go unanswered.  We stopped accepting AR Medicaid, but referring physicians need to send patients who are unable to travel long distances so we see the patients and keep filing for payment with no real expectation of getting paid.

We are now under the mandatory Medicare RAC audit and my biggest concern is that our electronic health record notes through a scribe don’t as completely reflect my decision thought process as my notes once did with handwriting and transcription. I am told that electronic notes are more likely to be scrutinized by Medicare auditors because of the ease of using templates to repeat documentation and making notes more complete.  We will see, but it seems that with the government you will be penalized for compliance with their mandate or penalized for failing to comply with their mandate.

Healthcare cost containment is just a front for socialized medicine if tort reform is not on the table. We continually battle to maintain tort reform in MS with each Supreme Court election. We lost many physicians a few years ago before MS tort reform was enacted.  Our insurance cost went through the roof and in an area that has a difficult time recruiting physicians we still have not regained all the services lost during that time. My wife, who is also a cardiologist, has only been sued once in her career. One of my patients sued her for injuries related to a particular cholesterol drug. His attorneys were filling so many suits that they never requested records to realize that he was never treated by my wife, and he was never prescribed the drug. So in essence you had a patient suing a doctor he never saw, claiming injuries he didn’t have from a drug he was never prescribed. A year and $30,000 later in legal fees, according to our malpractice carrier, the suit was dropped. These types of abuse were common before tort reform and we are always one election away from returning to that environment unless we enact a national policy of tort reform.

In summary:

1.      Encourage and pay for appropriate prevention programs and education

2.      Work to make current government programs more efficient and user friendly to patients and physicians

3.      Allow competition among private payers to effect better plans for patients and more efficiency for providers

4.      Encourage and pay for improved quality

5.      Tort reform will help physicians control over utilization without being second guessed

My wife and I met in training at Harvard and trained at some of the best institutions in the country.  We have many options for employment.  But we, like many of our colleagues, feel we are making a difference for our patients and our communities and hope we can continue to do so. We will do so if we get some common sense into the healthcare reform process.

As a physician you can cut my reimbursement, you can ask me to see more patients with a continually rising overhead, or you can raise my taxes to help pay for the government’s proposals but you can’t do all three and expect patients and the healthcare system to benefit. In the meantime we will continue to provide universal care to all those in need because in hospitals all across this country that is what many physicians do every day regardless of ability to pay… Dr. Mike Mansour”

ACC Update: The ACC has submitted detailed comments on the proposed 2010 CMS Payment Policies. In its comments, the ACC criticized the use of the American Medical Association’s (AMA) Physician Practice Information Survey to calculate practice expense relative value units (RVU). The AMA data has not been reviewed for precision or accuracy, and the ACC is strongly urging CMS and Congress not to finalize the proposal without further examination. The comments also articulate ACC’s opposition to a proposal to adopt a 90 percent utilization rate for equipment with an acquisition cost greater than $1 million, and raises ACC’s concerns about implementation of a new malpractice RVU methodology. However, the rule includes the creation of ACC-recommended cardiology measures and measures groups for the Physician Quality Reporting Initiative, which the ACC in its comments supports. Thanks to all of the Governors, Councilors, and Chapter Constituents who responded in writing during the comment period. The voice of Cardiology was clearly heard on Capitol Hill, the Executive Branch and CMS. Hopefully CMS will reconsider based on the extraordinary input from the House of Cardiology and patients across the Nation.

Over the next several weeks, ACC Advocacy staff had numerous activities planned to reach the Senate and the House. The Senate has been a more difficult arena than the House, but ACC staff has worked with Senators on individual letters to HHS Secretary Sebelius. ACC staff continues to meet with members on Capitol Hill for follow-up and are working the email and phones too. The more than 360 participants in ACC’s Legislative Conference will also go a long way in making sure we’re heard directly by members of Congress.

Survey Update: The ACC paid for a supplemental survey in 2005. There is not time to perform such a large scale reevaluation nor is CMS likely to use individual surveys again. The individual data gathered by members to date is very powerful talking with members of Congress. With this in mind, we're asking each participant in the Legislative Conference to meet with their practice administrator and evaluate the effect of the rule (specifically the practice expense and not including SGR). The templates will be sent by email to all Legislative Conference participants and will be posted on the Chapter Affairs Extranet on Tuesday. The template can also be used to evaluate the indirect effect of other payers following CMS and reducing their reimbursements. Advocacy staff will discuss how best to use this data during the Legislative Conference. Meanwhile, data from MedAxiom and MGMA were used in the comments to CMS. We have also had several surveys about what practices would do if the rules goes through asking FACCs for example, "Will you stop seeing Medicare patients; will you close your practice; will you reduce services…etc?" Academic cardiologists for the most part recognize their clinical patterns won't change much, but are very supportive of fighting the rule and this was highlighted at the recent Board of Trustees meeting. The September issue of Cardiology includes these survey results and an overview of the final ACC comments to CMS.

Get Involved With ACCPAC: Given the issues at hand, the biggest problem for the ACC is the ambivalence of many members and the limited support of the ACC political action committee (ACC PAC). Only 7% of ACC members support the ACCPAC. The percentage of trial lawyers supporting their PACs is much higher. For more information on ACC’s PAC, go to: www.accpacweb.org.

Where Do We Stand? The comments on the proposed CMS fee schedule have been submitted. After extensive dialogues with the ACP and AMA, they'd changed their comments to better reflect possible problems with the survey data for specialty groups, and that the process and data were insufficiently open for review. The Legislative Conference is scheduled for the week after Congress returns from recess. This is perfect timing as the House won't be discussing the full reform bill until the end of September. The House Energy and Commerce Committee will be looking at the 60 or so amendments not discussed in the markup and looking for a consensus packet. While the Gonzales-Rogers letter will have been sent out, the timing is also right for us to ask members of Congress to call the White House and CMS about the rule. We need pressure on CMS, and that is where a national association will have more input and sway than a single individual.

Finally, let's not forget health care reform. The House bill has a long term fix for the sustainable growth rate (SGR), the Senate only a year. In either regard we face a SGR mandated 21% reduction (on top of the physician expense cuts) if action isn't taken. The ACC continues to express its concerns about the SGR formula to Congress and strongly supports a new payment system. However, the problems with the formula have been made even more acute by the inclusion of costs over which physicians have no control. The ACC has requested that CMS remove these physician-administered drugs from the formula for many years and strongly supports the proposal to do so as part of this year’s rule.

See You Next Week: The ACC’s 2009 Legislative Conference will take place Sept. 13-15 at the Fairmont Hotel in Washington, D.C. We look forward to your participation in the both the Legislative Conference and the Board of Governors meeting. Below are three presentations for the BOG meeting, including an update on ABIM and AMA.

BOG SEPTEMBER 2009.pdf

AMA Update.ppt

SEPTEMBER ABIM BOG UPDATE-INFORMATION ONLY.ppt 

We in America do not have government by the majority.

We have government by the majority who participate.
–Thomas Jefferson (1743 - 1826) 

 JOHN GORDON HAROLD, MD, FACC