"A house divided against itself cannot stand." ...We did this under the single impulse of resistance to a common danger, with every external circumstance against us. Of strange, discordant, and even hostile elements, we gathered from the four winds, and formed and fought the battle through, under the constant hot fire of a disciplined, proud, and pampered enemy. Did we brave all them to falter now?-now, when that same enemy is wavering, dissevered, and belligerent? The result is not doubtful. We shall not fail-if we stand firm, we shall not fail. Wise counsels may accelerate, or mistakes delay it, but, sooner or later, the victory is sure to come.  Abraham Lincoln

Fellow Governors,

The Centers for Medicare & Medicaid Services (CMS) announced on July 1, 2009 their proposed changes to policies and payment rates for services to be furnished during 2010 through the Medicare Physician Fee Schedule (MPFS). The proposed fee schedule sets payment rates for more than 7,000 types of services provided by physicians in various venues and was published in the July Federal Register. The Medicare law requires CMS to adjust the MPFS payment rates annually based on an update formula which includes application of the Sustainable Growth Rate or SGR that was adopted in the Balanced Budget Act of 1997. This formula has yielded negative updates every year beginning in 2002, although CMS was able to take administrative steps to avert a reduction in 2003, and Congress has taken a series of legislative actions to prevent reductions in 2004-2009. Based on current data, CMS is projecting a rate reduction of -21.5 percent for 2010. 

The Physician Practice Information Survey (PPIS), designed and conducted by the American Medical Association provided data about physicians’ practice costs. ACC financially supported this survey effort, but has grave doubts about the validity of the survey process that suggested overhead in cardiology practices actually fell over the past five years. CMS will accept comments on the proposed rule until August 31, 2009 and will respond to all comments in a final rule to be issued by November 1, 2009. Unless otherwise specified, the new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after January 1, 2010. CMS proposed several technical changes in how payments are calculated that add up to a projected overall 11 percent decrease in Medicare payments for cardiology services. Taken together, refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums reimbursement for almost all services cardiology practices provide to Medicare patients would see cuts ranging from 10 percent to more than 40 percent.

We acknowledge the extraordinary efforts of the entire Board of Governors in response to this threat to practice viability. The ACC Board of Trustees acknowledged these gargantuan efforts at their recent meeting in Colorado Springs. ACC Chapter constituents across the country have responded to this challenge in writing to CMS and contacted their respective members of Congress and urged them to stop the drastic cuts from being implemented. Our legislators have been repeatedly reminded on Capitol Hill and in their respective District offices about the impacts of these proposed cuts as they relate to practice viability and patient care. The grassroots network has generated over 2300 emails or calls to Congress over the issues and Molly Nichelson has set up 30+ district visits. We continue to highlight the flawed methodology issues that led to the proposed CMS fee schedule cuts including:  

• CMS did not apply the rigorous standards that were developed for evaluating earlier surveys to the new AMA data. CMS said that it did not believe that the data needed to be precise.

• CMS only released the data that would allow a review of the precision data on July 13, 2009. Reviews of the precision of that data showed that responses for many specialties did not meet the tests required for previous data.

• For previous submissions of data, a detailed report was made publicly available on the validity of the presented data. This was not done in this case.

• For previous years, data had been required to be submitted by March 1 in order to allow a review of the data to be incorporated into the proposed rule. This was not done for this data.

• The cardiology practice expense per hour data are based on responses from only 55 respondents. Only a handful of specialties met the survey’s stated goal of 100 respondents per specialty.

While CMS has the authority to make such significant redistribution in payments, to do so requires both confidence in the data and the method used to recommend those changes and a fully public explanation of that process. In this case, there has not been a vigorous opportunity for public understanding and the data, once released, shows that CMS should not be confident in this data. The cardiology community is calling on the Administration to withdraw the proposal to use the AMA survey data for next year’s fee schedule and urges lawmakers to help. College members have repeatedly pointed out that these cuts threaten the fabric of cardiovascular practices and patient access to quality cardiac care across the nation.

The College has partnered with the American Society of Clinical Oncology (ASCO) with support from Representatives Charles Gonzales (D-TX) and Mike Rogers (R-MI) to sponsor a Dear Colleague letter calling for a letter to Secretary Sebelius. The letter urges the Secretary to place a moratorium on implementing the proposed CMS rule and asks CMS to abstain from using the flawed data that justify the cuts. There are now 18 co-sponsors on the letter. Two Senators have sent their own personal letters as well. Reps. Gonzalez and Rogers have expressed their concerns regarding the proposed CMS rule and the data used to justify the practice expense cuts. Unfortunately the House of Medicine is divided on this issue with the Gonzalez/Rogers letter being opposed by twenty one specialty societies including the American College of Physicians. ACC leadership continues to advocate with our other society colleagues by pointing out that "A House divided against itself cannot stand” and that we do support increased reimbursement for primary care. We need to recognize primary care is under paid but the proposed CMS rule does really little more than a token to address that problem. Instead it should be addressed in Healthcare Reform and not at the expense of other specialties. A divided House of Medicine only serves to dilute our advocacy efforts and encourage further cuts for all physicians.

The debate regarding the proposed CMS fee cuts has sidelined discussions on Healthcare Reform. As AMA President and ACC member Dr. James Rohack has pointed out we need to revisit collective high-priority goals in Healthcare Reform:

• Extending coverage to the uninsured

• Making investments in the physician workforce
• Providing long-term relief from Medicare's flawed physician payment formula
• Increasing the nation's focus on preventive care and wellness initiatives
• Simplifying administrative burdens for patients and physicians

Healthcare Reform, practice viability and the CMS fee schedule cuts will be the major focus of the Legislative Conference this September. The BOG Meeting and Legislative conference registration numbers will likely break all prior ACC records. I’m pleased to note that this is the largest and most diverse group of members ever to attend the ACC Legislative conference. We look forward to hosting our Fellows in Training and Cardiac Care Associates travel awardees in these discussions. The structure of the BOG meeting has been changed this year to allow more discussion and feedback to the leadership. We look forward to getting your input and “report from the frontlines” of cardiovascular medicine.

Thank you for your continued leadership to the College and advocacy for your patients. I look forward to seeing those of you who are attending the BOG Meeting and Legislative Conference this September.

History teaches us that men and nations behave wisely once they have exhausted all other alternatives. - Abba Eban

JOHN GORDON HAROLD, M.D., F.A.C.C.

CHAIR, BOARD OF GOVERNORS

2009-2010 Board of Governors Steering Committee Membership:

John Gordon Harold, MD, FACC (Chair), California: john.harold@cshs.org
Jane E. Schauer, MD, PhD, FACC (Past Chair), New Mexico: janeschauer1@msn.com
Richard J. Kovacs, MD, FACC (Chair-Elect), Indiana: rikovacs@iupui.edu
José Rivera Del Río, MD, FACC, Puerto Rico: joseriveradelrio@gmail.com
J. Chris Higgins, MD, FACC, Vermont: jch6@mac.com 
Oscar R. Jenkins, Jr, MD, FACC, North Carolina: oscarj@avlcard.com
Margo Minissian, ACNP-BC, MSN, CNS, California: Margo.Minissian@cshs.org  
Thad F. Waites, MD, FACC, Mississippi: twaites@netdoor.com 
Michael Widmer, MD, FACC, Oregon:  michael@heartdoctorsnw.com 

Comment Deadline Approaching for Proposed Fee Schedule
The deadline for public comments on the Centers for Medicare and Medicaid Services’ (CMS) proposed 2010 Medicare Physician Fee Schedule is August 31. With that in mind, it is critical that ACC members across the country contact their respective members of Congress and urge them to stop the drastic cuts from being implemented. Congress needs to hear about the impacts of these proposed cuts as they relate to practice viability and patient care. ACT NOW! In the House, Reps. Charles Gonzalez (D-TX) and Mike Rogers (R-MI) are circulating a letter to HHS Secretary Kathleen Sebelius, expressing concerns regarding the proposed rule and the data used to justify the practice expense cuts. Patient materials are available for download at www.acc.org/can.

Legislative Conference

Registration for 2009 Legislative Conference closes today after a week's extension. Go to www.acc.org for registration website. Housing at the Westin Grand, 2350 M St, NW, Wash DC, 20037, closes on August 28 or when rooms are no longer available,whichever comes first.  Contact them at (202) 429-0100.  There is no more room at the Fairmont Hotel.

CCA Leader Encourages Action on Proposed Fee Schedule
ACC’s blog, The Lewin Report, today features commentary from Margo Minissian, ACNP-BC, MSN, CNS, Chair of the CCA Chapter Liaison Working Group and Co-Chair of the Cardiovascular Team Council. Minissian discusses the importance of the entire care team meeting with their lawmakers on issues important to the cardiovascular community. She writes, “WE are the experts on health care and our lawmakers need us to get up-to-date on the different issues.” She discusses how important it is for the cardiovascular team to contact their lawmakers about the proposed 2010 Physician Fee Schedule before the August 31 comment deadline. Read the post in full and comment.

Registration Closes Today! ACC’s 2009 Legislative Conference
Today is the registration deadline for ACC’s 2009 Legislative Conference, to be held Sept. 13 – 15 at the Fairmont Hotel in Washington, D.C. Given the drastic payment cuts proposed by CMS, as well as efforts to pass overarching health reform legislation, don’t miss this opportunity to help educate Congress about the important work the ACC is doing in the areas of quality improvement and medical imaging. Even more importantly, you can help advocate for fair reimbursement and sound, unobtrusive policies that will ensure that cardiovascular professionals can continue to practice medicine in a manner that provides the greatest benefit for their patients. Click here to register now!

   The BOG Steering Committee will convene during Legislative Conference on Sunday.

   If you have issues for the Steering Committee to address at this meeting, please contact Jayne Jordan (jjordan@acc.org) at
  202.375.6609, or any of your BOG leadership.

September 2009 • Comment Deadline Approaching for Proposed Fee Schedule • Year of the Patient Update: Little Patients, Big IMPACT • Public Comment Period Open for PCI, ICD Outcomes Measures • Call for Applications: ACCEL Editor in Chief Comment Deadline Approaching for Proposed Fee Schedule The deadline for public comments on the Centers for Medicare and Medicaid Services’ (CMS) proposed 2010 Medicare Physician Fee Schedule is August 31. If you haven’t already contacted your respective members of Congress and urged them to stop the drastic cuts from being implemented, please do so before the deadline. Congress needs to hear about the impacts of these proposed cuts as they relate to practice viability and patient care. To read more about how the cuts will affect one of your colleagues, check out this great opinion piece from the Oregonian, in which ACC Oregon Chapter President Michael Widmer, M.D., F.A.C.C. says the proposed cuts will “lead to reduced access and quality care for patients with cardiovascular disease,” as well as reduce the free care provided to the uninsured and indigent and forgo participation in quality improvement activities. We have been hitting the media hard with our message. The ACC conducted a satellite media tour on health care reform from the National Press Club, reaching 15 stations across the country. During that tour, ACC CEO Jack Lewin conveyed our message about pay cuts to many of the markets. We also spoke a few times with Robert Pear of the New York Times about the proposed cuts; he is thoughtful and interested in this topic — exactly the kind of reporter we need on our side. Finally, we’ve shared our message on the cuts with Alex Nussbaum from Bloomberg and Kiera McCaffrey from The Hill. The College has been active on the advocacy front, as well. In the House, Reps. Charles Gonzalez (D-Texas) and Mike Rogers (R-Mich.) are circulating a letter to HHS Secretary Kathleen Sebelius, expressing concerns regarding the proposed rule and the data used to justify the practice expense cuts. We believe we have about 12 House members ready to sign on. ACT NOW! Help us stop these onerous cuts from happening. For help with scheduling in-district meetings while members of Congress are home on recess contact Molly Nichelson at mnichels@acc.org. Patient materials are available for download at www.acc.org/can. Year of the Patient Update: Little Patients, Big IMPACT The Wall Street Journal in August published a spot-on article about the plight of congenital heart disease (CHD) physicians and patients who grapple with a lack of both evidence and technology. Of course the ACC is out ahead on this issue, developing a brand new NCDR® registry that will track outcomes among CHD patients who undergo catheterizations. Gerard Martin, M.D., F.A.C.C., was quoted in the article discussing the soon-to-launch IMPACT Registry™: “We hope IMPACT will become the standard by which safety and quality are judged for hospitals” treating congenital defects. This was a great article on an important topic, and outstanding coverage of how the ACC is helping to advance safety and quality for all cardiovascular patients — big and small. Another article about IMPACT will appear in the September issue of Congenital Cardiology Today. Watch for it. Public Comment Period Open for PCI, ICD Outcomes Measures The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE) to develop two cardiac outcomes measures based on registry data and designed for potential use in public reporting and pay for reporting of hospital quality. Working in partnership with the ACC, YNHHSC/CORE is developing the following measures: Complications following Implantable Cardioverter-Defibrillator (ICD) implantation. This measure uses data from the ACC’s NCDR® ICD Registry™ for risk adjustment and Medicare Part A inpatient and outpatient administrative claims data to assess complications. Re-admission following Percutaneous Coronary Intervention (PCI). This measure uses data from the ACC’s NCDR CathPCI Registry® for risk adjustment and Medicare Part A inpatient and outpatient administrative claims data to assess re-admissions. CMS is requesting public comments on both of these measures still under development. While all measure comments are welcome, CMS is particularly interested in the following areas: Outcome definitions and time period of assessment Risk adjustment strategy Technical Expert Panel (TEP) feedback Comments on the measures must be received by August 25, 2009, 5 p.m. ET. To access the CMS public comment system, go to: https://www.cms.hhs.gov/apps/QMIS/publicComment.asp. A summary of all the comments received will be posted in the Downloads area approximately four weeks after the public comment period closes. Call for Applications: ACCEL Editor in Chief The Digital Products Committee is seeking applications for the Editor in Chief of ACCEL, the College's audio journal. The successful candidate will be an innovative, creative individual open to new ideas and collaborations to make this excellent product even more successful and attractive to an even broader base of physicians. Qualifications: Broad knowledge of the field of cardiovascular medicine and science Substantial experience with producing content for audio, video and new media Demonstrated achievement in administration and leadership Understanding of and appreciation for research Demonstrated ability and innovation in education and communications Intention to cultivate ACCEL as a major component of his or her professional career Information and Application: The Editor's term will begin March 1, 2010, with a four-month overlap with the current Editor, and will continue for five years, with the possibility of re-appointment for one additional five-year term. To apply, please submit a letter of application addressing your qualifications for the position, along with a brief statement of your vision for ACCEL. Letters of application should be addressed to Pamela Douglas, M.D., and Michael Kienzle, M.D., Co-chairs of the ACC Publications and Digital Products Committee, and sent via e-mail to Elizabeth Wilson ewilson@acc.org. Deadline for submission of applications is September 30, 2009. Finalists will be expected to present their ideas and participate in an in-person interview on Saturday morning, November 14 in Orlando. Overview of Role and Responsibilities of Editor-in-Chief: Work with the Publications and Digital Products Committee (PDPC) to set strategic direction for ACCEL. Provide administrative and editorial oversight of all ACCEL activities in conjunction with staff and contracted partners. As an ex officio member of PDPC, participate in setting strategic direction and oversight for all ACC print and digital projects. Work closely with the Editors of other ACC publications and products to identify opportunities for collaboration, content sharing and product extension, to ensure synergies and best uses of educational materials. Develop innovative formats and approaches to reaching and expanding ACCEL audience. Create a workable editorial structure and convene and conduct meetings of the editorial board, as necessary. With input from members of the ACCEL Editorial Board, identify topics to be covered, experts to be interviewed, and innovative and efficient means to develop content. Select content to be published in ACCEL issues; ensure topics are covered appropriately and content gaps are addressed. Review all ACCEL programming to ensure quality of content and presentation. Work with staff to develop production schedules to ensure the timely delivery of content. Ensure that ACCF's best practices related to CME are followed. Thank you for considering this important role.