acc board of governors business meeting thad f. waites, m.d., f.a.c.c., chair sunday, september 11,...

ACC Board of Governors Business Meeting

Thad F. Waites, M.D., F.A.C.C., Chair

Sunday, September 11, 2011


Dipti Itchhaporia, M.D., F.A.C.C., Chair-elect

BOT Update


American College of CardiologyBoard of Trustees Update

Dipti Itchhaporia, MD, F.A.C.C.Chair-Elect, Board of Governors

BOT Discussion Topics

1. Review of the Environmental Scan Report-Dr Laslett.

2. Financial Perspective-Dr Chazal, Mr. Fitzpatrick-Kiosk-Wallmart, leveraging our resources-(database/Registries)

3. Patient Centered Care, CardioSmart- DR Walsh and Dr Foody

4. Healthcare Reform topics and the Wisconsin Project

International Strategy

1. Jeff Kindler, former CEO of Pfizer, spoke on Globalization Trends in Healthcare.

2. Dr Huon Gray, Chair of the International Committee discussed ACC’s international strategy. International membership has been trending upwards- ACC-3902 members in 2008 and 4,366in 2010. The percent of total revenue generated by international attendees has remained a driver of success for the Annual Scientific Sessions.

3. ACC currently has 11 international chapters

Education, Maintenance of Certification

.Evolution of knowledge Systems and Life-Long Learning.

Dr Nishimura discussed long and short range vision to support members in maintaining certification and adopting life-long learning behaviors through Lifelong Learning Portfolio.

The entire learning agenda is undergoing a transformation to address proficiency gaps, linked to outcomes and performance data from actual practice.

Important Voices in Cardiology

1. Dr. Braunwald-Cardiology is a scholarly profession based on science. The Four flags that are in front of the heart house- signify respect for community, education, science and advocacy.

2. Dr. Califf- We are at the helm of the #1 cause of death and disability. It is a global issue. ACC’s role is to guide the cardiologists and take the lead to professionalism.

3. Dr Fuster-Science and education have to be integral to what we do.

BOT Prioritization of Initiatives

1. Develop a Competency-Based Curriculum

2. Affirm the International Strategy and Examine Governance Structure

3. Facilitate Value-Based Purchasing by Accelerating NCDR Business Intelligence Capabilities (ICD and ACTION-GWTG Registries)

4. Invest in Improving the CardioSource User Interface including Mobility and Device Specific Capabilities & Establishment of Oversight Group

BOT Prioritization of Initiatives

5. Invest in the Capability to Move NCDR Registry Data into the LLP and Facilitate MOC- look at individual report cards . Translate guidelines to clinical practice (NCDR is an example)

6. Affirm Current CardioSmart Direction and Examine Potential Expansion of Patient Engagement Efforts

7. Affirm Wisconsin SmartCARE Project and Explore Other Potential Localities

8. Develop In-House Data Analytics Capabilities

BOT Initiatives In Motion

1. Build NCDR TAVI/TAVR module and Advance ACC’s Capabilities and Credibility in FDA, CMS Post Market Surveillance

2. Work with ABIM in “Choosing Wisely: The Five Things Campaign”- Kickoff is 2012

3. ACC Participation in Coalition Addressing Fundamental Tort Reform

4. Work on Payment Reform models

5. Improve Co-sponsored CME Approach

6. Continue to launch and Early Work of Educational Quality Review Board (EQRB)

Things are moving fast but we the BOG can be the drivers…


Searching and Learning at the Point of Care

Dino Damalas, CIO ACC


Staying Current

“Suppose a truly diligent and hard-working physician goes home after work every night, 365 days a year, and reads 10 journal articles. By any standard, this would be a prodigious and laudable effort, warranting admiration and respect. But by reading a mere 3,650 articles each year, for the biomedical literature published last year alone, he or she would already be 160 years behind.”

~ Don Lindberg, director of the National Library of Medicine

Staying Current• The body of medical knowledge will triple over the next

10 years

• How does a Cardiologist stay on top of latest medical advancements, best practices, and engage in continuous learning?– Journals– Guidelines– Appropriate Use– Self Assessment Programs– Clinical Trials– Expert Consensus

• MOC / MOL (quagmire of testing and recertifying)

Staying Current

• How do you stay current?

• How much time do you spend per week learning and keeping up-to-date?

• How maintain your certification and licensure?

JIT Clinical Knowledge• In short, you must

– Read volumes of clinical information– Retain that knowledge in memory– Apply knowledge at the point of care– All while juggling 30 or more patients per day

• Knowing everything at the POC is just not possible– What will you do?

• Google it?• Best Guess?• Research after work and on weekends?• Ask a colleague?• What do you do now?

The Problem• Knowledge exists in a vast library of clinical documents!

Getting to it a timely fashion is next to impossible.

• Physicians need answers to clinical questions while working with patients (the episode of care).

• Answers to these questions are often deeply embedded in large documents.

• Traditional search engines are effective at locating the document, but offer little help in locating the answer within the document.

The Solution (Point of Care Searching)

1. Perform semantic analysis on trusted documents.

2. Analyze the clinical question, then locate documents with candidate answers.

3. Perform relevance evaluation of candidate documents to locate the most probable answer.

4. Present the most relevant parts of the document

Trusted Documents

• Clinical Guidelines (43)• Consensus Documents (121)• SAP Learning Modules (12)

Analyzing the Clinical Question

Search Term Significance

Relevance

• Information that is closely related to the clinical question– Appropriate source (Trusted)– Must have the necessary and appropriate

parts (Complete)– Comprehensive without superfluous detail

(Concise)

Assessment

• Four clinical scenarios were randomly given to a group of 19 cardiology fellows using actual cases of ACHD.

• Fellows developed 68 clinical questions based on review of the cases.

• Fellows were asked to use Google and CardioCompass to locate answers to questions.

Assessment

• For questions where users were able to find answers with both tools, they were asked to rank answers based on completeness, conciseness, and relevance.

• Responses regarding their preferred tool were captured using a Likert scale (1=Strongly prefer standard, 2=Prefer standard, 3=Neutral, 4=Prefer semantic; 5=Strongly prefer semantic).

Assessment Results – Site Preference

Assessment Results – Completeness

Assessment Results – Relevance

Application in the real world• Use a computer or mobile device to ask a

clinical question• Most relevant resources returned and

highlighted for review• Optimal memory performance occurs when

relevant information is available at the point-of-need. (Yerkes-Dodson law)

• Integrate the searching into a continual learning and certification process (MOC)

Maintenance of Certification

Enhanced / POC Search - Vision

Provide Point of Care (POC) tools through CardioSource•Semantic search (ask a question)•Find specific answer within trusted clinical documents•Opportunities for MOC•Provide broader search of entire cardiovascular body of knowledge

Annual M

eeting 2012

Enhanced / POC Search – Current Status• Phase I: Replace Current CardioSource.org search engine

– Requirements Completed: March 2011– Development Completed: April 2011– Testing Completed May 2011– Implementation: June 2011

• Phase II: POC Search (CardioCompass)– Requirements: In Progress– Development Complete: August 2011– Testing Complete: September 2011– POC Advisory Group Feedback– Implementation: Q4, 2011

• Phase III: POC Learning (Integration with Learning Portfolio)– Preliminary Target: March 2012

Enhanced / POC Search – Expectations• By Annual Meeting 2012

– Enhanced general site search (available now)– Integration of CardioCompass to search trusted clinical

documents– Pilot mobile version for use with iPhone, iPads, and other

smart phone devices

• Not included for Annual Meeting 2012 launch– MOC

• Initially slated for delivery, but requires additional business processes

• Need to tie in competencies and build refine process• Should be delivered in 2012

The Future

• Integrate Maintenance of Certification• Evaluate other clinical document and sources to

incorporate into search• User feedback and sharing• Tighter work-flow integration (Mashups)

– Personalization– Change notification at appropriate time– Patient context from EMR

Demonstration


Cardiology Landscape in Canada: A Health Policy and Practice Review

Christopher Simpson, M.D., F.A.C.C., John Mancini, M.D., F.A.C.C., Rodney Zimmermann,

M.D., F.A.C.C.


Why should ACC be International? (based on presentation to the ACC Board of Trustees, August 2011)

Huon Gray, MD, FACCChair, ACC International Council

John BournasSenior Director, International, ACC

Summary of International Strategy (1)

ACC will always remain, first & foremost, a US professional society and will never lose sight of the importance of the needs of its domestic membership, which represents 88% of total membership.

Summary of International Strategy (2)• ACC has high prestige abroad and many want to be part of its

mission FACCs present in over 100 countries Overseas membership growing around 6% per annum recently Particularly from economically emerging countries

International Membership

Historic Membership - US and International

US International% Change

International Total

2001 22,988 2,979 N/A 25,967

2002 24,804 3,042 2% 27,846

2003 25,688 3,080 1% 28,768

2004 27,126 3,169 3% 30,295

2005 28,949 3,564 12% 32,513

2006 30,009 3,583 1% 33,592

2007 31,329 3,716 4% 35,045

2008 32,761 3,903 5% 36,664

2009 33,735 4,005 3% 37,740

2010 34,936 4,366 9% 39,302

2011 35,211 4,654 7% 39,865International Membership has increased on average 4.7% per year

2500

3000

3500

4000

4500

5000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Membership

Includes Fellows, Masters, Associate Members, Affiliates, International Associates, CCAs, Practice Administrators, Fellows in Training (July 1, 2011)

Av. 6.1% growth pa

in last 3 years

Av. 2.4% growth pa

in last 3 years

ACC – Membership Base by Region

Statistics not counting US membership

Source: iMIS ACC Membership Database

2008 2011

Region 2008 Count

2011 Count

Africa 81 106

Asia 1038 1519

Europe 925 859

Canada 932 994

Oceania 170 195

Latin America 446 599

Summary of International Strategy (2) ACC has high prestige abroad and many want to be part of its

mission Overseas membership growing around 6% per annum recently Particularly from economically emerging countries FACCs present in over 100 countries

ACC will soon have 20 overseas Chapters, offering great opportunities for “twinning” and exchanges

ACC International Chapters

ACC International Chapters(n=14)

ACC Chapters requested(n=6)

Malaysia

Great Britain & Ireland

Brazil

China

Israel

Germany

Turkey

Saudi Arabia

Pakistan

Greece & Cyprus

Mexico

Egypt

Caribbean

Venezuela

Chile

Italy

Argentina

Russia

Canada

Lebanon




60% of revenue from the ACC annual meeting is consistently derived from international participation (2008-11) and 60% of delegates at NY Fuster course are international

ACC’s international activities make a net contribution to the ACC of almost $5m per annum currently

International Contribution to Bottom Line

Digital Products: $455,000

Total 2010 International Net Benefit to ACC was USD $4.86 million

Membership: $677,000

Live Programs: $431,000

Annual Meeting: $1,509,000New York

Cardiovascular Symposium: $954,000

Royalty from JACC: $1,341,000

Revenue Shown – Staff Expense = 4.86M




60% of revenue from the ACC annual meeting is consistently derived from international participation (2008-11) and 60% of delegates at NY Fuster course are international

ACC’s international activities make a net contribution to the ACC of almost $5m per annum currently

We can ALL learn from one another, and this will benefit patients worldwide

BOG LISTSERVE

Cardiology landscape in Canadaa health policy and practice review

Presented by: Dr. Chris Simpson, Dr. John Mancini and Dr. Rodney ZimmermannSeptember 11th 2011Washington, D.C.


Chris Simpson, MD FRCPC FACC

G. B. John Mancini, MD FRCPC FACC

Rodney Zimmermann, MD FRCPC FACC

September 11th 2011

Outline

1. Health Policy in CanadaChris Simpson, MD, FRCPC, FACC

2. Departments of Medicine in CanadaG. B. John Mancini, MD, FRCPC, FACC

3. A day in the life of a CardiologistRodney Zimmermann, MD, FRCPC, FACC

1. Health Policy in CanadaChris Simpson, MD, FRCPC, FACC

Health Policy: Outline

• How has Medicare evolved over time?

• What are the key components of the health care system

• What are the basic economics and some of the key challenges?

• Who are the key stakeholders and how do they influence health policy?

Constitutional Responsibility for Health: Canada, 1867POWERS OF (FEDERAL) PARLIAMENT

11. Quarantine and the Establishment and Maintenance of Marine Hospitals.

EXCLUSIVE POWERS OF PROVINCIAL LEGISLATURES (92)

7. The Establishment, Maintenance and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals.

EDUCATION (93)

In and for each Province the Legislature may exclusively make Laws in relation to Education, subject and according to the following Provisions….

Legacy of the Constitution• 14 health systems – 1 for each province/territory + Health Canada

In terms of spending, Health Canada is the 5th largest system

- provider of supplementary health benefits to 750,000 First Nations and Inuit peoples

- direct provider on reserves and isolated locations

Canada’s Health Care System: It Wasn’t Built Overnight!

• Hospital Insurance and Diagnostic Services Act, 1957

• Medical Care Act, 1966

• Establishment of payment and tax point transfer system, 1977

• Canada Health Act, 1984

Principles of Canadian Medicare

1. Public Administration – administered and operated on a non-profit basis

2. Comprehensiveness – must insure all insured health services

3. Universality – 100% of insured residents must be entitled on uniform terms and conditions

4. Portability – coverage moves between provinces and territories

5. Accessibility – no financial barriers (i.e., user fees)

Canada Health Act: Insured Services

“Insured health services” means hospital services, physician services and surgical-dental services provided to insured persons, but does not include any health services that a person is entitled to and eligible for under any other Act of Parliament or under any Act of the legislature of a province that relates to workers’ or workmens’ compensation.

Governance in the Canadian Health Care System

Federal Government- Canada Health Act- collection and provision of health data (CIHR, CIHI)- major funding of research- health protection

- (direct service provider to select population)Provincial/Territorial Government

- policy-setting (e.g., def. of insured services)- funding envelope- health professional regulation- regulation of hospitals

Governance in the Canadian Health Care System (Cont’d.)Regional Health Authorities

- funding allocation- needs assessment

Hospitals and Agencies*- program delivery- quality assurance- physician privileges

Professional Regulatory Bodies- licensure- discipline

*Note these would be subsumed under regional health authorities in most jurisdictions.

Canadians want PM to place priority on health care

Survey asked more than 1,200 Canadians to rate on a scale of 1 to 5 how highly they viewed nine possible priorities for this government. Here are the average scores each priority earned:

• Working with the provinces on health care - 4.32 • Creating jobs through training - 4.01

• Eliminating the deficit - 3.98

• Cutting taxes - 3.69

• Investing in research and development - 3.63

• Getting tough on crime - 3.58

• Focusing on new trade opportunities around the world - 3.48

• Strengthening Canada's armed forces - 3.05

• Reforming the Senate of Canada - 2.99

Source: Nanos Research, Institute of Research on Public Policy poll June 2, 2011

Practicing Physicians (including residents and excl admin/res) per 1,000 pop, 2008

2.0

2.3

2.4

2.6

3.3

3.6

3.6

4.2

2.2

3.0

0.0 1.0 2.0 3.0 4.0 5.0

Mexico

Japan

Canada

U.S.

U.K.

Belgium

France

Germany

Czech Republic

Italy

Source: OECD Health Data, 2010

Canada, France and Italy include those in admin and research

Canada ranks 25 out of 30

Physicians per 100,000 populationCanada, 1982 to 2008

150155160165170175180185190195200

19

82

19

84

19

86

19

88

19

90

19

92

19

94

19

96

19

98

20

00

20

02

20

04

20

06

20

08

Ph

ysic

ian

s p

er 1

00,0

00 p

op

n

Source: Supply, Distribution and Migration of Canadian Physicians, CIHI

Number of Physicians and Specialty Canada, 2011

FAMILY PHYSICIANS 36,199

MEDICAL SPECIALISTS 24,990 Cardiology 1,149

SURGICAL SPECIALISTS 8,879 Cardiovascular/Thoracic Surgery 340

ALL PHYSICIANS 70,088

Source: January 2011, Canadian Medical Association

68% 66% 64% 62%58%

51% 48%

0%

10%

20%

30%

40%

50%

60%

70%

80%

1990 1995 1998 2000 2002 2004 2007

Percentage reporting 90%+ fee-for-service remuneration

Source: 1990 to 2002 CMA Physician Resource Questionnaire; 2004 & 2007 National Physician Survey (CFPC, CMA, RCPSC)

90%+ f-f-s 90%+ salary 90%+ capitation

90%+ sessional 90%+other blended

not stated

f-f-s salary capitation

sessional service contract blended

not stated

Actual Mode Preferred Mode

Remuneration Modes

n= 19,239 n= 7,347

Source: 2007 National Physician Survey (CFPC, CMA, RCPSC)

31% 48%

51%

23%

Economics

Health Expenditures: Canada and the OECD 2007

Indicator Canada Ranking OECD Average

Total Health Expenditures 10.1% 6 8.9%

as a % of GDP

Public Health Expenditures $2,719 9 $1,983

Per Capita US $

Public % of Total Health 70.3% 21 71.2%

Expenditures

Source: OECD Health Data 2010

Public Health Expenditure as a Percentage of GDP, U.S. and Selected Countries, 2008Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011)

Canada: A Single Payer System?

Selected Category % Public Funding 2009

Hospitals 90.8

Other Institutions 71.5

Physicians 98.9

Other Professionals 7.0

Prescription Drugs 45.0

Capital 83.0

Total Health Spending 70.2

Source: CIHI National Health Expenditure Trends 1975 to 2009

Health Expenditures by Selected Category Canada, 1984 and 2009Selected Category 1984 2009

% of total

Hospitals 41.8 27.8

Other Institutions 10.7 10.0

Physicians 15.0 14.0

Other Professionals 10.0 10.9

Prescription Drugs 6.1 13.9

Capital 4.1 4.8

Public Health 3.7 6.2

Hospital/Physician Subtotal 56.8 41.8

Source: CIHI National Health Expenditure Trends 1975 to 2009

Federal Contribution to Health Canada, 2009

% of Total Public

$ Millions Exp.

Canada Health Transfer 22,987 18.7

Federal Direct Exp. 6,616 5.1

Subtotal 30,603 23.8

Total Public Exp. 128,597.3 100

Source: CIHI and Finance Canada

Federal-provincial health accord expires in 2014

• Canada spent $192-billion on health care in 2010.

• The federal (Canada Health Transfers) CHT will reach $27 billion in 2011-12 and will reach over $30 billion in 2013-14.

• CHT cash levels are set in legislation up to 2013-14 and grow by 6 per cent annually as a result of the automatic escalator.

• Provinces and territories also receive CHT support through a tax transfer. CHT tax transfers amount to $13.6 billion in 2011-12, and will continue to grow in line with the economy.

2. Departments of Medicine in CanadaG. B. John Mancini, MD, FRCPC, FACC

Overview

• There are 16 Medical Schools– 2 are French-speaking (Sherbrooke, Laval; both in Quebec)

• Only one Medical School in each province except for Ontario, Quebec and Alberta

• Generally affiliated with the largest, urban tertiary/quaternary care hospitals as the main teaching site(s)

• There has been a huge push to affiliate with as many community hospitals and community clinics as possible to enhance overall training/teaching needs

• Major emphasis on Family Practice, General Internal Medicine and General Surgery

• There is a general shortage of Family Practitioners (and specialists) across Canada

General Structure of Departments• University Department of Medicine (made up of all faculty at all teaching

hospitals)

– Heads/Chairs would have a “city-wide” or “region-wide” role for teaching and research matters but a variable role (none to a lot) in service issues

– Reports to Dean (but also directly/indirectly to Hospital CEO[s])

• Hospital Department of Medicine (located at a specific hospital)

– Head/Chair/Physician-in-Chief would have main focus on service issues and support roles for academic missions

– Reports to Hospital CEO

– May serve as Associate Chair for the University Department

– reports to/collaborates with University Chair

• Roles can be combined (eg University Chair of Medicine and Physician in Chief of Hospital XYZ)

Faculty Members• “Academic”/”GFT” – subject to the rules and regulations of the university

regarding academic productivity and promotion– Receive a SALARY from the university as established by a faculty association– Other typical benefits (academic office, matched retirement funding, extended

health care, executive health programs, secretarial support etc but highly variable)

– Subject to a tenure decision; tenure may invoke financial obligations from university in perpetuity or not (eg. “grant” tenure is based on soft money)

– Faculty association is essentially a union that lobbies for a pay scale, COL and merit increases, conflict resolution (eg regarding promotion/tenure)

– Pay scale is not generally discipline specific (docs, lawyers, astrophysicists, language profs etc etc all considered the same)

– Most are M.D.’s and, therefore, have obtained hospital privileges (separate process) and practice in their discipline

Faculty Members (con’d)• Clinical/Adjunct/Community etc

– Practitioners also engaged in academic activities (mainly teaching)

– Do NOT get university salary/benefits but might get honoraria/stipends from university for specific university-related tasks

– Promotion (if applicable) largely dependent upon teaching or practice innovation

– May have hospital privileges without having a university appointment (but would then be excluded from teaching – rare circumstance)

Departmental Funding Sources• University Budget – allocated through Dean, generally about 5-10% of entire money

flux, may include endowments– Excluding endowments, funds originate from a government ministry (eg Ministry

of Advanced Education)• Grants (salary support)

– Canadian Institute of Health Research, Heart and Stroke Foundation etc– Industry (subject to overhead that translates into discretionary dollars for

Dean/Hospital CEO and may assist to achieve academic goals)• Hospital Budgets – largely committed to delivery of care, small amounts for

administrative stipends, occasionally applied to assist in recruitment/retention– Funds originate from a government ministry (eg Ministry of Health) and is part of

a global, hospital budget and part of a yearly hospital-governmental negotiation• Hospital Foundation – theme-specific fund-raising, often for equipment, sometimes

for medical personnel, may include endowments

Departmental Funding Sources (con’d)• Fee-for-service: 90-95% of monetary “flux”

– Almost all funds come from a government ministry (eg. Ministry of Health ie “single payor” model)

– Rare instances of privatization

– Small amounts from other governmental budgets (eg. Workman’s Compensation Board, RCMP etc)

– “on call” funding is commonplace but under threat

• Practice Plans are common but not universal

• Practice Plans may be Departmental (tithe goes to Department Head) or Divisional (tithe goes to Division Head and stays within Division)

• Residents/Fellows – numbers are very tightly controlled and paid for by government (eg. Ministry of Health)

Departmental Funding (con’d)• Some Departments/Divisions are on “AFP” (Alternative Funding Plans

– full salary from government, originally offered to very low paying but essential services eg infectious diseases)

• Almost all Departments are exploring AFP’s – largely out of frustration over low/absent funding for academic activities, lack of co-ordination of budgeting between separate ministries such as the Ministry of Health and the Ministry of Advanced Education, in institutions where Practice Plans are not in place, or when contemplating offering poorly funded new services (eg. Cardiology/cancer chemo)

• “Pressure points” - # of GFT’s, shadow billing, productivity/efficiency incentives, COL, funding of new services, resistance to paying for academic activity, practice autonomy etc.

3. A day in the life of a CardiologistRodney Zimmermann, MD, FRCPC, FACC

Practice Style

• Private Practice– Responsible for own office operation/overhead/staff– Fee-for-service (in some locales, practice plan on salary)– Responsible for own professional dues, CPD– Self-determined time off (in cooperation with colleagues) for vacation

and CPD– Research as able or interested– No pension plan– Option of Professional Incorporation

• Taxes on 1st 500K income at about 16%– Teaching Stipend with Clinical University Appointment– Administrative Roles paid with modest stipends

Consultant Life

• Call – generally as part of rota, in cooperation with other physicians in a section

• Responsible for own patients at all times unless transferred responsibility– Variability dependent on subspecialty– Stipend in most provinces

• $180K per year per call position• For new or non-assigned patients

• Hospital Care– Service teams (ie wards, CCU) or longitudinal care, dependent on facility and

preference• Difficulties in assigned responsibility and balance of access to patients,

procedures, access to testing (in fee-for-service group)– All hospital care billed on fee-for-service basis

Consultant Life - 2

• Referrals– Most Cardiologists choose to practice a consultant based practice with no

primary/direct access patient care– All physicians can choose to whom they refer a patient

• Generally to the on-call person after hours• Otherwise as requested by patient or referring physician• Some group practices have ‘pooled’ referrals for efficiency

• CPD (continuing professional development)– Requirement by RCPSC of 400 hrs in 5 years to maintain designation as a

FRCPC (formula of hour types)– Requirement by provincial licensing authorities to be enrolled in a recognised

program– No requirement for recertification with the RCPSC

Diagnostic Procedures

• Cardiologists have option of referral to hospital or private testing (ECG, EST, Echo, Risk)– Choice usually dependent on wait-times, expertise, self-referral (currently of

some controversy)– Technical fees can be billed for private testing; interpretation fees set and the

same for hospital or private testing– There is no specific requirement for location of testing and is predominantly

physician choice.• Hospital Procedures: nuclear, exercise, echo, cath-based

– All responsibility for equipment, staffing, etc. responsibility of the health district authority

– All professional fees billed to provincial authority– Access generally distributed by rota, need, privileges, skills (potential for

conflict)

What works Well

• Emergency and Acute Care– STEMI care comparable to any urban center in North America

• Access to urgent testing and procedures• Development of National Waitlist Guidelines for all aspects of

Cardiology Care by CCS• Independence and Autonomy

– Practice style– Diagnostic testing and treatment– Capitation on a yearly basis in fee-for-service is a single

province experiment from the 1990’s

Issues of concern• Waiting lists for non-urgent care and testing

– Access usually determines testing choice– Operating Room assignment

• Bed availability

• Emergency Room Overcrowding• Budget issues, new programs, new technology

– Denial of testing is not an issue but new programs may be difficult to introduce

– Some pharmaceuticals under controlled access and may be limited in use based upon pre-determined criteria

– Conflict: concept of hospital/system vs patient needs• Appointed (physician) administrators responsible for budget and programs

• Limited budget• New programs have funding vacuums and uncertainty leading to ‘creative

funding’

Medical Malpractice

• Canadian Medical Protective Association– Principle to defend all cases, and only settle when

expert opinion finds physician likely at fault• Results in over 90% successful defence in trial

– Fees are based on award history/likelihood of lawsuit in 3 geographical areas : Ontario, Quebec, rest of Canada

• Annual Cardiology fee for all cardiology specialties is $1764, all-inclusive

– Currently Partially or Fully-reimbursed by Contract Negotiation

Billing Fee-for Service

• All billing to single payor (Government Agency)– Internet/electronic based– Immediate payment for correct submission on 2-week

cycle – generally 4 days later– No pre-authorization required– Minimal staff time required for billing – 2-3 hrs per

week per physician– Special cases – armed forces, RCMP, 3rd Party – all

with separate negotiated fees and separately billed

Provincial Contracts - 1

• Negotiated by a Provincial Medical Association with the Government (arms-length) Authority– Single All-inclusive Dollar Package– Retention Packages– On-call Stipends– Special Programs– Maternity/Paternity– Malpractice Reimbursement– CPD fund


• Subsequently taken back to the Medical Association for Distribution– Entirely Physician Controlled– Parity Index:

• Formula based on FTE, interprovincial specialty variability, provincial interspecialty variability, overhead

– Recent allocation: contract increase of 13.99%, Cardiology received 6.84%

• After Specialty Allocation completed, goes to Specialties– Individual fee-code allocation

• Consult, procedure, hospital care, etc• Oversight but minimal interaction from Payor• Past use/predicted use determines cost


• Other Specialty funds– Retention Fund– New Technology– Modernization– CPD fund

– Payment and Allocation based on cooperative discussion with a committee of balanced representation


• Cardiology in one province:– 50-75 %tile income - (excluding expenses, overhead,

adjusted for surcharges)• $755,724

– Internist : $428,784– GP (metro group) : $289,704; (rural group):

$317,951– General Surgeon : $507,033

Welcome to the USA and Farewell:5 Anecdotes

• 1980 – “Dr. Mancini, is it broken?”• 1982 – Is it mitral stenosis or acute IHD?• 1980 – late 80’s – “Mad Dog” Mancini – why is

he postal?”….and then came M-Care.• 1991 – When will you discharge Mrs. Jones from

the U of Michigan CCU? • 1991 – Migration towards the middle ground.

Everything takes longer than it takes.


Presented by: Dr. Chris Simpson, Dr. John Mancini and Dr. Rodney ZimmermannSeptember 11th 2011Washington, D.C.


SMARTCare Wisconsin

Tim Bartholow, M.D., Tom Lewandowski, M.D., F.A.C.C. and Joseph Allen, ACC Staff


SMARTCare

Smarter Management and Resource Use for Today’s Complex Cardiac Care Delivery

A Collaboration To Deploy at the Site of Care:Evidence Based Guidelines

A Method to Reduce VariationShared Decision Making

Stewardship Over Health Care Resources

September 11, 2011

Question #1

• If Administrative and Clinical data that we possess suggest that some receive more or less cardiology treatment than they need,

• Can we make a tool and a process that will assist physicians to provide the best, most consistent cardiology care for our communities, including all of us and our families?

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Question #2

Who should define what clinical quality is?

• Federal government?

• State government?

• Payers/Insurers?

• Employers?

• Doctors?

We should define clinical quality together, but physicians have to be willing to lead.

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Feb 19, 2011

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Capital BuildingMadison, Wisconsin

Like Others, WI Population Grows Older…and Will Need Intense Resources

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Orszag, March 2009

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International Comparison of Spending on Health, 1980–2007

Note: $US PPP = purchasing power parity.Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

0

1000

2000

3000

4000

5000

6000

7000

8000

1980 1984 1988 1992 1996 2000 2004

United States

Canada

Netherlands

Germany

Australia

United Kingdom

New Zealand

Average spending on healthper capita ($US PPP)

$7,290

How Did We Get Here?WI Works Toward Value

• Public Reporting of Quality Measures: Wisconsin Collaborative Healthcare Quality (WCHQ) 2003, Formed to respond to purchasers’ demand for transparency of healthcare quality data

• Resource Use: Wisconsin Health Information Organization (WHIO) 2005, Formed to become more aware of health care cost: 5th Data Mart Version with 3.7 of 5.6 million residents and $29.9 billion in total standardized cost

• WI Medical Society/Physician/Employer/Consumer WHIO Data Study Teams 2010-2011 demonstrate variation.

• Payment Reform: Partnership for Health Care Payment Reform (Formerly Wisconsin Payment Reform Initiative) 2010

• ACC has unique clinical databases, and has aggressively developed appropriate use criteria

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All Payer Claims Databases Emerge Across US

https://apcdcouncil.org/sites/apcdcouncil.org/files/2010_sci-all-payer-claims-report_1.pdf 122

WHIZ-CIDs:WI Health Improvement Zone- Care Improvement Dialogs

Physician Data Study Teams – example: Cardiology• 10 cardiologists• 5 primary care doctors• Employer• Consumer (Nurses Association, AARP)• National specialty representative• Similar groups for orthopedics, GI, Behavioral Health. One hour

telephone conferences per month, Jan to May 2010, repeat groups in 2011

Findings• Specialist is 10% or less for all ETGs we have studied so far• Orthopedics, Cardiology, Behavioral Health, and Gastroenterology

comprise about 50% of total standard cost in the WHIO database.

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“The Specialist” is 5-10% of Resource Use for these Expensive Areas

Can Physicians Judiciously Authorize the Other 90%?

Episode Treatment Group: Ischemic Heart

Disease with Angioplasty

Inflammation of the Esophagus, without Surgery

Joint Degeneration, localized - Knee and

Lower Leg, with Surgery

Mood Disorder, Depressed

Total Episode Standard Cost, DMV4 $243 M $195 M $287 M $499 M

Specialist Cardiology Gastroenterology Orthopedic Surgery Psychiatry

Total $ $23 M $10 M $28 M $23 M

% of Episode $ 9.5% 5.1% 9.8% 4.6%

Facility, IP & OP

Total $ $187 M $76 M $229 M $149 M

% of Episode 77% 39% 80% 30%

Primary Care

Total $ $3 M $13 M $2 M $22 M

% of Episode 1% 7% 1% 5%

Prescription Drugs

Total $ $5 M $63 M $2 M $174 M

% of Episode 2% 32% 1% 35%

Intensive Care

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Purchasers’ Concerns(Also Every Patient’s Concern)

Evidence Based Guidelines

A Method to Reduce Variation

Shared Decision Making

Fiscal Stewardship

129

WHIZ-CIDs: Experience with Claims only Data• Analysis demonstrated variation exists• Did not provide insight into:

• Why variation exists• If the variation is appropriate • What needed to change in order to reduce that variation.

• Challenges in Clinical Applicability of Claims Data exist,

• Attribution: Physician, and Location• Outcomes• Clinical risk adjustment• Different coding practices of each institution

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Without clinical context, information is not actionable by clinicians

“You might as well guess what will improve process”

Only predictor of cost was length of stay, which is often dictated by patient’s condition at time of presentation

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“Science tells us what we can do;

Guidelines what we should do;

Registries what we are actually doing.”

Registries what we will be doing!

“Treatments, Trends, and Outcomes of Acute MyocardialInfarction and Percutaneous Coronary Intervention: A Report

from the National Cardiovascular Data Registry (NCDR)”JACC JUNE 2010

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Hospital Variation in Non-Acute

PCI Inappropriateness

Chan, PS, et.al

144,737 (28.9%) of All PCIs: 50.4% Appropriate

38.0% Uncertain11.6% Inappropriate

(Urgent Stents: 98.6% Appropriate)

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133

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Differences in Coding?Incomplete Data Entry?Patient/Family Preference?Practice Cultural Differences?Individual Practice Style?Knowledge Gap?

Purchasers’ Concerns(Also Every Patient’s Concern)

Evidence Based Guidelines

A Method to Reduce Variation

Shared Decision Making

Fiscal Stewardship

136

SMARTCare• Continues focus on the overall most expensive area under

our control: Workup and treatment of Stable Ischemic Heart Disease

• Knits together Clinical tools already developed and in use,

– Registries: CathPCI and PINNACLE

– Decision Support: FOCUS and PRISM

– Shared Decision-Making

• Mechanism for clinician feedback and quality improvement NEW

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138

1

2 2

3 2

Abnormal Result or Decision to Go Further

Need for Revascularization(PCI or Surgery)

1: Focus Decision Support2: Shared Decision Support3: Prism Decision Support

2

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SMARTCare:

Goals of Project:• One standardized process for all payers (Medicare, Medicaid, employer-based insurance)• Process of assessing care developed by the physician’s using most

trusted data• Provide “safety net” for Quality of Patient Care and Doctor Patient

Relationship as payment reform continues

Implementation:• 4 to 6 pilot sites throughout the state• Independent Practice not represented

Demonstrations

• Decision Support (Diagnostic Studies) 1• Shared Decision Making 2• Decision Support (Intervention) 3• Dashboard• Payment

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Payment Challenges• Appropriate use/shared decision making different than under use

measurement

– Can’t aim for 100% compliance

– Success may produce savings for payer but costs and lost revenue for the health care system/physicians

• Pay for performance bonuses don’t work as well here; need to share in savings

• New savings not generated every year; only inflationary factor saved after first few years. Risk of increasing costs with technology or increasing utilization.

• Difficult to establish sufficient bundled payment rates after savings already gained during first few years

• Need new tool to detect and measure underuse when using bundled or episode payment rates

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Payment ChallengesPayment Model Pros Cons

Fee for Service Known; linked directly to clinical procedures

Rewards clinical procedures less than quality and cognitive care

Pay for Performance Reward higher quality; linked more directly to patient outcomes

Teach to test; not well suited for appropriate use/SDM

Bundled Payment Can support treatment choices and reward overall care management

Difficult to determine trigger; outlier patients can be costly

Episode Groupers Can help understand average costs Attribution; not clinically oriented

Shared Savings Can incent efficiencies Savings are not sustainable year after year

Capitation Can support coordination across diseases/conditions

Difficult to estimate population cost; can lead to underuse

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Payment Proposal• Don’t have all the answers; need to experiment or will have to

accept grouper claims approach

• Proposal builds on CMMI proposed bundle models for inpatient

– FFS during first year but with bundle target(s) to help in transition to episode payment

– Pre-procedure, procedure, and overall bundle targets

– Overall average episode bundle target that allows for shared savings

– Can be used to establish future bundle rates

– Quality adjustment (reward/reduction to payment rates)

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Next Steps• Are our organizations willing to identify, but more

importantly find solutions to, the problems or barriers within this proposal?

• Will we physicians lead with the databases that we have developed and the tools to discern between those that will and those that will not benefit from the next considered procedure or course of therapy?

• As the project proceeds, are there stakeholders willing to bring the required other assets to this project?

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Necessary for Project Replication• Strong Physician Leadership

• Passion about Quality and Patient Care

• First Listen– Evaluate from other stakeholder’s point of view

– What are their stress points and plan for relief?

– If you don’t like their plan, better think of an alternative!

• Stick to Issues on Quality and Patient Care– Don’t talk about money

• Align with those with same concerns on Quality and Patient Care– Business Community and Patients

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Necessary for Replication

• Don’t get Angry

• Don’t accept, “It can’t be done,” or, “It won’t work.” ‘We have to make this work, so help me find a solution.’

• Multi-stake Holder Conversations, Don’t Let Anyone Walk

• Have Lots of Patience –You WILL fight the same battles repeatedly

–(My hair grows faster than this moves)

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Cardiology Practice Improvement Pathway

Dick Kovacs, M.D., F.A.C.C., David May, M.D., F.A.C.C.


Program Update andPractice Experience

D. Kovacs

D. May9/11/2011

CV Practice Solutions for Quantifying Quality

Housed on CardioSource.org Provides a platform for continuous quality improvement Approved through ABIM for Part IV MOC

Practice submits CPIP data to apply for recognition Practices that achieve quality thresholds established jointly by BTE and

ACC are eligible to receive health plan incentives

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2010 BOG CPIP Challenge

13 States with Practices that have achieved Recognition or are participating in CPIP

29 additional States with Practices that are thinking about participating in CPIP

50 Practices from 50 States: Where we are today

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ACC Member Value Standardize the methodology for how cardiology

practices are assessed and recognized Provide a platform for practices to evaluate

themselves against quality goals and targets established by the ACC

Scorecards provide practices with power to demonstrate quality and negotiate on value

Informs ACC priorities for developing resources and tools aimed at quality improvement

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Value Proposition for Changing Healthcare Environment

Nationally consistent methodology Evidence-based measures Transparent process Specialty-focused Aligned with nationally-recognized measures Clinically relevant Designed to encourage improved quality Sampling methodology and minimum reporting

requirements provide an unbiased, all-payer assessment of a practice’s performance

Administered and audited by objective 3rd party

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Cardiology Practice Recognition Payment Model Opportunities

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Making It Easier for Practices to Participate

Developing CPIP for PINNACLE Registry Users for implementation in 1Q12

Entering Clinical Data for first 30 practices who request assistance

Targeting specific markets to implement meaningful incentives for achieving recognition—will be calling on chapters in those markets to hone strategy and engage in purchaser discussions

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Why Do CPIP?

Demonstrating practice quality will translate into enhanced patient care

CPIP guides you through a careful review of your practice performance and helps you understand how you are doing on key metrics.

Use CPIP outcomes to receive preferred provider status and perhaps enhanced reimbursement

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Estimated Practice Time Investment to Complete CPIP Stage A by Domain

Practice Size 1-7 cardiologists 8-20 cardiologists 21 or more cardiologists

Total Time 4 hours + 12.5 hours per physician

7 hours + 7.5 hours per physician

12 hours + 6.5 hours per physician

Practice Assessment:Data Collection

2 hours per practice

Practice Assessment:Data Entry

15 minutes per practice

Patient Assessment:Identify Sample

2 hoursper practice

5 hoursper practice

10 hoursper practice

Estimated sample sizeper physician

45-50 total patient records per physician

~27 total patient recordsper physician

18-25 total patient records per physician

Patient Assessment:Chart Abstraction

~6 hoursper physician

~ 4 hoursper physician


Patient Assessment:Data Entry

~6 hoursper physician



Individual Assessment:Data Collection

20 minutes per physician

Individual Assessment:Data Entry

10 minutes per physician

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Data Requirements

Practice Assessment-- up to 34 data elements to calculate 10 structural measures

Patient Assessment -- up to 59 data elements per patient to calculate 32 clinical measures

Individual Assessment-- up to 31 data elements to calculate 10 professional measures

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CPIP Structural Metrics Results

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CPIP Clinical Measures Results

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How My Practice Benefited from CPIP

Immediate feedback on performance Better understanding of practice patterns New appreciation for quality monitoring Identified opportunity for improvement in

documenting care CPIP methodically measures quality in practice BTE Cardiology Practice Recognition differentiates

our practice

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Special Recognitionto

Drs. David May and Jere Hines for

Board of Governors

CPIP Pioneer Award

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EHR Incentive Program AssistanceMCAG

Jack Lewin, M.D., CEO ACC


EHR Incentive Program Assistance• Medicare Electronic Health Record (EHR) Incentive Program will

provide incentive payments to eligible professionals, hospitals and CAHs that demonstrate meaningful use (MU) of certified EHR technology

• Up to $44k per EP over 5 years from program

• Up to $63,750 per EP over 6 years from the program

• Must begin participation by 2012 to get max. incentive payment

• Applying for incentive funds can be complex, time-consuming and intrusive

• ACC and MCAG are partnering to provide eligible professionals with assistance in applying for incentive funds

ACC/MCAG Meaningful Use Solution

Meeting MU requirements is complex and time consuming.MCAG offers a low risk solution that will help to ensure that you will receive

MU incentive dollars you deserve.• MCAG MU Monitor • MCAG Service Representatives• MCAG’s solution also retains MU data to prepare clients for an audit by CMS and will be

your partner for all stages of the EHR Incentive Program• MCAG retains approx. 15-18% of the money recovered for clients as payment for services

• Contingent fee model minimizes risk and relieves you from the need to adjust or amend budgets.

• No fees unless MCAG retrieves money for you• Your organization has committed significant resources toward meeting the requirements of

MU. Do not let those resources go to waste. • Deadline is approaching quickly• Partner with MCAG to ensure you receive your piece of the program’s $19 billion in federal

funds

ACC/MCAG MU Solution FAQs

• Is this an EMR/EHR system?– No: MCAG’s MU Solution is a supplemental tool to an EHR that is

certified for MU. It provides the service and support to help with the complex tasks of meeting MU requirements and successfully obtaining funding.

• Does this mean a provider needs a different software solution and

implementation in order to use the MCAG MU solution? – No: MCAG’s MU Solution is a web based dashboard that sits apart

from your EHR tool and shows you where you need to make corrections or take additional steps to ensure you are eligible for funds. MCAG is there throughout the MU process with a dedicated account team that provides clear and effective actions. Our clients benefit from a service that does not require additional staff or extra up front fees to ensure that you are getting what you have earned from your EHR.

ACC/MCAG MU Solution FAQs

• Will the MCAG MU Solution automatically update as I use my EMR/EHR? – Yes: The MCAG MU Solution is running in the background, reflecting up to

date use of EHR tools and efforts to meet MU requirements.

• What happens if I am not meeting the requirements for incentive payments? – MCAG will work with you to identify where the weaknesses are and where

you or your providers need to take further action to qualify for incentive payments. That is the nature of the MCAG service – you are not alone in your efforts and you will get support every step of the way.

• I don’t want to be bouncing back and forth between my EMR/EHR provider and MCAG. Will this be a problem I have to deal with? – MCAG will work directly with your EMR/EHR provider to make the use of

our solution as seamless as possible. Once you have registered for the MCAG MU Solution and MCAG has begun to review your EMR/EHR data then you will be guided as to how to ensure that you receive your Meaningful Use payments without having to jump through another layer of complications with your software provider.

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