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Amy Murphy amurphy@acc.org,
(202) 375-6476
November
7, 2009
American College of Cardiology Comments on H.R. 3962 Under
Debate Tonight on House Floor
Cardiologists Question Some Policies, Support
Others
Washington, DC – The American College of Cardiology
(ACC) commends the House for positive reforms but also questions
many of the policies in H.R. 3962, The Affordable Health Care
for America Act.
The ACC’s CEO, Dr. Jack Lewin is available for interviews
while the House continues debate on H.R. 3962 tonight.
The ACC sent the below letter to Speaker Nancy Pelosi.
Dear Speaker Pelosi:
On behalf of the American College of Cardiology (ACC), representing
37,000 cardiovascular specialists, I am writing to commend
you on the many positive reforms included in “The Affordable
Health Care for America Act” (H.R. 3962) and express
the ACC’s support for “The Medicare Physician
Payment Reform Act of 2009” (H.R. 3961).
The ACC is pleased that H.R. 3962 attempts to extend coverage
to every American and includes many provisions to strengthen
the Medicare program. While the ACC supports many of the policies
included in H.R. 3962, the College has concerns with a few
of its provisions. The ACC strongly supports repeal of the
flawed sustainable growth rate formula as included in H.R.
3961.
The ACC believes targeted reform of the current health care
delivery system is essential and looks forward to working
with you and your colleagues to enact reforms this year. As
you may know, the ACC is also focused on an issue separate
from health reform, concerns with the systems and processes
of the Center for Medicare and Medicaid Services (CMS) that
are slated to substantially reduce payment for cardiovascular
services in the 2010 Medicare Physician Fee Schedule Final
Rule, and will be in touch with you about it soon.
Division A- Affordable Health Care Choices
Coverage Expansion and Insurance Reforms
The College supports initiatives to provide coverage to the
more than 46 million uninsured, and applauds the efforts in
H.R. 3962 to expand insurance to all Americans. The ACC appreciates
your efforts to reform the insurance market, promote the availability
of more coverage options, and prohibit discrimination based
on health status.
Division B- Medicare and Medicaid Improvements
Misvalued Codes under the Physician Fee Schedule (Sec.
1122)
The ACC supports the development of rational, equitable payment
policies for Medicare physician services. CMS has proposed
several strategies for implementing an ongoing review of the
relative value units (RVUs) assigned under Medicare’s
RBRVS. The College supports the American Medical Association’s
Specialty Society Relative Value Update Committee’s
(RUC) efforts to identify potentially misvalued services and
believes this methodology will serve to address concerns raised
about overvalued codes in the fee schedule. The ACC urges
Congress and CMS to avoid making the assumption that all services
for which utilization has grown rapidly are misvalued. In
many cases, rapid adoption of a service reflects its clinical
benefits and evidence-based clinical innovations becoming
part of common medical practice. The ACC also urges Congress
and CMS to phase in any significant changes that occur as
a result of identifying misvalued codes.
Modifications to the Physicians Quality Reporting Initiative
(Sec. 1124)
The ACC is pleased that H.R. 3962 extends physician quality
reporting initiative (PQRI) incentive payments through 2012
and believes the PQRI improvements within your legislation,
including timely feedback and an appeals process, are necessary
and strongly supports them. The College notes that more timely
feedback is extremely difficult through claims-based reporting,
but is possible through clinical data registries, such as
the ACC’s National Cardiovascular Data Registry®
(NCDR).
Payment for Imaging Services (Sec. 1146)
The ACC believes there is insufficient data available to
accurately reflect the amount of time imaging equipment is
in use, which is likely to vary by setting and modality, and
opposes the change in the utilization rate assumption for
advanced imaging equipment.
Imaging has become a valuable tool in the diagnosis of disease.
While much attention is focused on the rapid growth of imaging
from 2000 to 2006, the rate of imaging volume growth in Medicare
has been slowing since 2005 and imaging spending dropped significantly
from 2006 to 2007. In fact, in 2008, imaging growth was at
or below overall growth in physician services.
The ACC is proactively responding to the growth in cardiovascular
imaging through the development of appropriate use criteria
that define when and how often physicians should perform a
given procedure or test. The ACC strongly supported Congress’
enactment of a Medicare demonstration project to test the
use of appropriate use criteria and mandatory imaging laboratory
accreditation in the Medicare Improvements for Patients and
Providers Act (MIPPA). The ACC believes the MIPPA provisions
will have a positive impact on the quality and appropriateness
of imaging services under Medicare.
The effect of numerous already-implemented policy changes
on imaging volume growth and pricing accuracy should be assessed
before additional changes are enacted so that patient access
to these diagnostic services can be ensured.
Reducing Potentially Preventable Hospital Readmissions
(Sec. 1151)
The ACC is working to be part of the solution to the high
number of avoidable hospital readmissions. The ACC recently
launched Hospital to Home (H2H): Excellence in Transitions
with the Institute for Healthcare Improvement, which is a
national quality improvement initiative to improve the transition
from inpatient to outpatient status for individuals hospitalized
with cardiovascular conditions. More than 2,000 launch participants
committed to the goal of a 20 percent relative reduction in
the national 30 day all-cause risk adjusted readmission rate
for those patients discharged with a diagnosis of heart failure
or acute myocardial infarction by December 2012.
Physician-Owned Hospitals (Sec. 1156)
The ACC opposes the prohibition on physician ownership in
hospitals. The ACC supports physician ownership in facilities,
equipment or services that benefit patients through the delivery
of appropriate, high quality medical care. The ACC believes
all facilities should strive to enhance quality of care, efficiency
and patient access, while ensuring that ownership interests
are directed to improving the delivery of care through implementation
of quality systems and measures.
Institute of Medicine Study of Geographic Variation in
Health Care Spending and Promoting High-Value Health Care
(Sec. 1159)/Implementation, and Congressional Review, of Proposal
to Revise Medicare Payments to Promote High Value Health Care
(Sec. 1160)
The ACC believes that recommendations to change Medicare
payment systems should be piloted prior to being implemented.
Accountable Care Organization Pilot Program (Sec. 1301)
The ACC supports opportunities that allow entities to virtually
integrate and share savings and strongly supports pilots to
test different payment incentive models, including accountable
care organizations (ACOs). While many ACC members could readily
participate through their larger medical groups, IPAs, and
existing integrated systems, the ACC is interested in accountable
care and shared savings models that will allow physicians
in small independent practices—the vast majority of
the practice environment—to participate.
Payment Incentive for Selected Primary Care Services (Sec.
1303)
The ACC supports efforts to bolster primary care, including
incentives to encourage physicians to choose primary care
and remain in primary care. The ACC encourages you to recognize
that the care coordination and office visits provided by general
cardiologists who manage patients with complex heart disease
have the same value as a similar service provided by a physician
who is practicing as a primary care physician. The appropriate
medical management of cardiovascular disease can save money
and improve care by avoiding hospitalizations and more complex
interventions.
Comparative Effectiveness Research (Sec. 1401)
The ACC supports a well-funded, national commitment to comparative
effectiveness research (CER) with the goal of providing the
data necessary to better inform physician/patient decision
making and supports the CER provisions in H.R. 3962. The College
is pleased that it recognizes the need for practicing physicians
to serve on the Commission and puts emphasis on the need to
disseminate the research findings and to consult with stakeholders
on the types and formats of dissemination products/methods.
The ACC appreciates the support of clinical registries and
encouragement of the development of CER data networks from
electronic health records as it will expand clinical data
sources beyond randomized controlled trials, helping to answer
the grey areas of knowledge and focusing research on the "need
to know" information related to quality care.
Quality Measurements (Subtitle C)
The ACC supports provisions in H.R. 3962 to provide more
resources to the Department of Health and Human Services (HHS)
to further strengthen and improve quality measurement and
development processes. It is important to have an established,
trusted consensus-based process in place to develop, test
and maintain performance measures.
The Quality Alliances such as the AQA, Hospital Quality Alliance,
Pharmacy Quality Alliance, and the Surgical Quality Alliance
provide a forum for various interests to convene and develop
implementation strategies related to performance measurement,
reporting, and improvement. While the National Quality Forum
(NQF) is critical in its role of endorsing performance measures,
the Quality Alliances play an equally vital role in providing
an open forum for discussion and consensus related to implementation.
AQA is open to large segments of the delivery system, including
physicians, health plans, employers and other clinicians and
has a track record of developing consensus-based principles
related to public reporting, use of appropriate use criteria
and performance measurement.
There is a need for strong coordination among the various
quality organizations to ensure effective development and
use of performance measures and reporting. The NQF can play
a significant role. All of the Quality Alliances, however,
through the Quality Alliance Steering Committee, must have
a voice and a strong link with the NQF to ensure that physicians,
hospitals, nurses and patients all have a venue for open and
honest discussion.
Physician Payment Sunshine (Subtitle D)
Reports on Financial Relationships
The ACC supports efforts to set appropriate rules that allow
for greater transparency in the relationship between health
care professionals and industry. The ACC has taken several
steps on a voluntary basis to foster such transparency among
the College’s membership.
Study of Practice Patterns in Advanced Diagnostic Imaging
Many specialty physicians, who have knowledge of specific
organ systems and disease states, use imaging services for
prevention, early detection, diagnosis and treatment of diseases.
While the ACC does not oppose a study of physician ownership
of equipment, the ACC believes resources would be better spent
supporting efforts that help physicians order appropriate
tests through the use of appropriate use criteria and decision
support tools.
Medicare Graduate Medical Education (Title V)/Workforce
(Title II)
The ACC appreciates the provisions of H.R. 3962 to address
physician workforce concerns. There currently is a shortage
of 1,700 general cardiologists and more than 40 percent of
general cardiologists are over age 55 and nearing retirement.
The cardiology workforce will need to double to keep up with
demand in the next 20 years.
Establishment of Center for Medicare and Medicaid Innovation
within CMS (Sec. 1907)
The ACC strongly supports your proposed Center for Medicare
and Medicaid Innovation (CMI) to test innovative payment and
service delivery models to improve the coordination, quality,
and efficiency of health care services. Under the Center,
the ACC encourages the testing of quality physician networks,
through which cardiovascular practices would report to and
receive feedback from the ACC’s outpatient registry,
PINNACLE Network™, and receive incentives for meeting
quality measures and improving patient outcomes.
Implementation of Best Practices in the Delivery of Healthcare
(Sec. 2401)
With years of experience in the development of guidelines,
performance measures, and appropriate use criteria, the ACC
supports this provision to help implement best practices.
Medical Liability Reform (Sec. 2531)
The ACC supports the provision of H.R. 3962 to establish
an incentive program for States to adopt and implement alternative
medical liability reforms. The College appreciates that the
legislation ensures that current states’ reforms are
protected and that other states will not be prevented from
pursuing effective reforms in the future. The College is disappointed,
however, that it does not allow incentives to be used for
caps on lawyer fees and non-economical costs.
National Medical Device Registry (Sec. 2571)
While the ACC supports the goals of analyzing postmarket
safety and outcomes data, the College is interested in more
details on how the medical device registry would be designed,
where the data will reside, how the registry would function,
and how it would intersect with other similar efforts. The
ACC believes a unique patient identifier would be necessary
to link data from the multiple sources as described in this
provision.
Conclusion
The College looks forward to working with you and your colleagues
in the weeks ahead to achieve meaningful, broad-based reforms.
ACC’s CEO John C. (Jack) Lewin, M.D., and Senior VP
for Advocacy James (Jim) Fasules, M.D., F.A.C.C., offer the
ACC as a resource to you. Thank you for considering the ACC’s
views.
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About the ACC:
The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 37,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. More information about the association is available
online at www.acc.org .
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