September 20, 2017 | Thad F. Waites, MD, FACC
Advocacy

Advocacy and the Young Cardiologist: What do FITs and ECPs Need to Know About the Future of Advocacy in Cardiovascular Medicine?

An Interview with Thad F. Waites, MD, FACC.

Thad F. Waites, MD, FACC, is the chair of the American College of Cardiology's Health Affairs Committee and is a past-chair of the College's Board of Governors. He was a member of the College's Board of Trustees. Additionally, he has served numerous other professional and governmental organizations and, notably, is currently the vice-chairman of the Mississippi State Department of Health. He practices clinical cardiology with a focus on interventional cardiology at the Hattiesburg Clinic in Hattiesburg, MS. Srinath Adusumalli, MD, a fellow in training at the University of Pennsylvania in Philadelphia, PA, sat down with Waites to discuss his thoughts on the growing interface between young cardiologists and the world of advocacy.

PART I

Before diving into the advocacy weeds, can you tell us a bit about how you became involved with the College at the state and national levels?

I first engaged with the College when I became a Fellow of the American College of Cardiology (FACC) in 1982. Initially, I had a busy clinical practice in New Orleans, so it took me several years to fully interact with the College. I moved back to my native Mississippi in 1987 and it was at that time I became involved in the state chapter there. I helped develop a shared chapter meeting with Alabama and worked on several other projects with both the College and the American Heart Association. Ultimately, I was asked if I would like to run for governor of the Mississippi ACC chapter and was eventually elected to the position. It was at that time (early-2000s) when things really started taking off in terms of advocacy and the ACC for me. We did a kind of slick project through which we introduced the concept of computed tomography calcium scoring to our state legislators. We offered free calcium scores to all of them via every capable center in the state. Through this project, we allowed our lawmakers to become familiar with calcium scores and identified some coronary disease, and even one large ascending aortic aneurysm in the process!

Ultimately, I served as the chair of the College's Board of Governors and was put on the Advocacy Steering Committee, now the Health Affairs Committee. I loved the committee and the wonderful advocacy staff at the College so much that I applied to be on it on my own accord and was eventually asked to chair the committee. It has been a truly wonderful experience working so closely with the staff, committee and Emerging Advocates program (which we will discuss later).

What does it mean to you to be an advocate for our patients, the College and the house of cardiovascular medicine?

I have forever wanted to know what was going on, and how to use that information to have an impact and make a difference. My main mentor in medical school called me "Junior Dean" because it just seemed like I always knew what was going on around the medical school and so forth. To be an advocate, I think one has to have an awareness of what is going on – in the legislative environment – and the willingness to make a difference for our patients. You can make a difference for your patient in the exam room, catheterization lab and echo lab, among other places. However, you can also make a difference for them in trying to make the healthcare system better through effective advocacy, which is the way I look at it.

Why is it important for Fellows in Training (FITs) and Early Career Professionals (ECPs) to care about advocacy?

Advocacy makes a huge difference in our daily lives. Whether we are talking about graduate medical education funding, provider reimbursement, the appropriate use criteria mandate or rising drug prices, someone has to advocate for our interests and those of our patients in these critical conversations. If we sit back and do not care, someone else is going to drive the conversation and the result will be one we will not like. Even with folks working hard on the advocacy front, the result is not always perfect – imagine what the medical world would look like without College members engaged in advocacy. As the saying goes, "if you are not at the table, you are on the menu." Additionally, as a chapter governor once said, the addendum to that is, "if you are at the table, you also don't want to be the last one that the cannibal is going to eat." So, engage in the advocacy process, get to the table, and speak up early and often.

PART II – We continue our conversation with Thad F. Waites, MD, FACC, chair of the College's Health Affairs Committee. In this portion of the interview, we discuss how FITs and ECPs can engage in advocacy in collaboration with the College. Waites also gives us his thoughts on the future of advocacy in cardiovascular medicine.

What do you think is the best way to drive a culture of advocacy among young cardiologists? Do you think advocacy competencies need to be built into graduate medical education training programs?

I do think we need to incorporate advocacy skill-building and competencies into training programs. This is also important for the faculty members for reasons we just discussed. Building advocacy skills does not have to take up a tremendous amount of time; however, trainees and their mentors should be exposed to basic concepts about the legislative process as part of their education. From there, folks should engage with their local chapters to learn about legislative priorities and gain practical advocacy experience. Some of the larger state chapters, such as those in Pennsylvania, Georgia and Florida, are fantastic examples of groups highly engaged in advocacy. The main message should be that we must advocate for ourselves and our patients because no one else will.

What are the best ways for FITs and ECPs to plug into the College's advocacy efforts?

The first, and most obvious, way is to attend the College's Legislative Conference each September. Go to the Legislative Conference and attend the breakout sessions. Meet the College's advocacy leaders – go right up to them and say, "I'm a FIT/ECP and I am so glad to be here." While you are at the conference, be a visible and vocal member of the team and be sure to participate in the Hill visits. In my experience, the FITs and ECPs who have attended the conference have become fired up about what they saw and have wanted to continue work in the advocacy/leadership space. There are also many opportunities outside of the Legislative Conference to become engaged in advocacy; including 1) applying to the College's Leadership Academy or Emerging Advocates program, 2) applying to be a member of the Health Affairs Committee, and 3) working with your state chapters on local legislative issues.

What do you think the next five years hold in terms of legislation related to cardiovascular medicine? How about the next 10 years?

First, we need to do something with the healthcare system itself. We have to get the insurance problem solved and I do not know what the right answer is. I think a single-payer system may be where we are going; however, we will be working on that problem for the next several years (hopefully not ten years). To that end, one of the Health Affairs Committee members, Gilead Lancaster, MD, has been advocating for a tiered "single-system" healthcare reform plan called EMBRACE, which includes elements of private health insurance and other innovative payment models. We may even be able to look to other countries for inspiration. More specifically, I think we could adopt elements of the Swiss system, as detailed in the book The Healing of America, and apply them in this country.

On a smaller scale, we have to work on how to post-approve devices and drugs. I know the College will be advocating for the National Cardiovascular Data Registry to be a large part of that – the Food and Drug Administration already does this for some devices. Additionally, I think new requirements to use clinical decision support mechanisms, especially in the context of the appropriate use criteria mandate, will be on the advocacy agenda for the next several years.

Finally, starting this year, the College is going to be advocating for what some are calling the "Fourth Aim" amendment to the Institute for Healthcare Improvement's "Triple Aim." This aim focuses on taking care of the provider by taking steps to increase provider wellness and reduce burnout, all in service of improving the quality of healthcare delivery. A large part of this will include advocating for improved usability and interoperability of electronic medical records. Although the federal government has done a good job of increasing the uptake of electronic medical records, it remains to be seen whether they can regulate those systems from the usability and interoperability perspectives.

Many of us have heard about recent modifications to regulations involving the Episode Payment and Cardiac Rehabilitation (CR) Incentive Payment Models. What other regulatory changes do you think may be on the horizon? How should FITs and ECPs prepare for these changes?

First off, FITs and ECPs need to be prepared for the implementation of MACRA and the associated Quality Payment Program. MACRA was a bipartisan, bicameral effort – its provisions will remain intact. More information about MACRA can be found at ACC.org.

With regards to episode payment models or "bundled payments," although the current Secretary of Health and Human Services, Thomas E. Price, MD, is against mandatory bundles, I suspect he will not be against voluntary bundles. Many organizations that have already prepared for bundled payments may go ahead and proceed with voluntary bundles.

Finally, with regards to the CR Incentive Payment Model, even if it is cancelled, the College is going to strongly advocate for the implementation of some its provisions, including the ability for advanced practice providers to supervise CR programs. That topic will be a priority during this year's Legislative Conference.