Contact: Amy Murphy, amurphy@acc.org, (202) 375-6476

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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