1. Increased Awareness of Legislative and Regulatory issues Impact on your practice Get involved C. Richard Schott, MD, FACC Vice Chair PMS Board of Trustees Chair, PMS Specialty Cabinet

2. National Advocacy Medicare fee schedule reductions 20% reduction scheduled for 2010 Need to fix SGR Formula ICD 10 Codes Presidential Candidates Plans for Health Care Reform

3. Advocacy Agendas National Advocacy Agenda Pennsylvania Advocacy Agenda Political Advocacy Practice Advocacy Patient Advocacy PMS-Specialty Society interfaces

4. A proposal by tbe U.S. Department of Health & Human Services requiring all physician practices and other providers to adopt a new ICD-10 code set by 2011 would dramatically increase costs for physician practices and clinical laboratories, according to a new cost study initiated by a group of provider organizations and conducted by Nachimson Advisors. According to the Medical Group Management Association, the costs associated with implementing ICD-10 in such a short timeframe are markedly higher than what CMS has estimated and will place a major burden on providers, taking valuable time away from their patients and straining other resources needed to invest in health information technology. The total estimated cost for a 10- physician practice to move to ICD-10 would be $285,240; while the total cost for a small, three-physician practice is estimated to be $83,290; and for a large, 100- physician practice the estimated cost to implement ICD-10 is more than $2.7 million. Medical Group Management Association, October 14, 2008

5. AMA and PMS oppose timeline for ICD-10 implementation The US Department of Health and Human Services has proposed implementing new ICD- 10 code sets by Oct. 1, 2011, and new HIPAA electronic transaction standards by April 1, 2010, a time frame opposed by both the AMA and the Pennsylvania Medical Society.

6. Pennsylvania Advocacy Agenda Mcare Abatement Retirement of the Mcare fund Unfunded Liability = $1.7 Billion Physician Retention Fund - $600,000,000 Cigarette Tax and Auto Cat Fund Excess Contribution/Physicians and Hospitals Estimate=$112,000,000

7. Practice Advocacy – Reimbursements PMS State of Medicine 2005 Pennsylvania physicians’ operating costs as a percentage of revenue are similar to the rest of the country—60.3% for Pennsylvania and 59.59% nationally Physicians in the eastern region of the US— including Pennsylvania—are among the lowest paid in the country Pennsylvania’s private commercial insurers pay at some of the lowest levels in the country for E&M services

8. Practice Advocacy - Results Independence Blue Cross (IBC) will increase physician reimbursement by a weighted average of 9 percent for in-network primary care physicians and specialists effective Dec. 1, 2008. Highmark-IBC Merger

9. Mcare Political Considerations Governor: Tied Mcare Abatement to Uninsured Cover All Pennsylvanians PA-ABC AdultBasic – Add Psych and Prescription Coverage Senate: Linked to PHC4 Concerns over Sustainability Hospital Association: Opposed reduction in Disproportionate Share Organized Medicine: Unity – Penna. Ortho. Society Concern with increased costs for Non-High Risk Physicians

10. Failed Mcare Negotiations Failed to Reach Compromise Negotiations between the administration and Senate Republicans failed to reach a compromise on health coverage for the uninsured, MCARE abatement, or PHC4 reauthorization The administration rejected what it said was a verbal offer from the Senate Republicans to add $50 million to the state's low-cost insurance program, adultBasic, which would have added about 14,000 people to the program that has a waiting list of 118,000 uninsured Pennsylvanians. In an earlier letter to GOP leaders, Rendell had proposed adding at least 100,000 people to adultBasic and expanding the program benefits to include prescription drugs and mental health coverage

11. House Bill 2648 2 year abatement Restores HC4 Senate has acted on this version In House Rules Committee If House action (without amendment) would not require additional Senate approval Still threat of Governor’s veto Considered a “long shot”

12. Covering the Uninsured Pennsylvania’s 800,000 uninsured = 9%-25% by Counties National Average = 15% PA Facing a $3 Billion Budget Deficit this year Massachusetts “Universal Coverage” Experiment cost = $21 Billion/1 st three years -> $25 Billion for next three years Currently 5% uninsured California = 6.7 Million uninsured 4 out of 5 from working families $7Billion budget deficit this year

13. Massachusetts “Universal Coverage” Experiment For the first time, oncology, neurology and dermatology specialties all reported shortages, according to the annual Massachusetts Medical Society workforce study. That’s in addition to nine other specialities dealing with ongoing shortfalls in talent: emergency medicine, general surgery, neurosurgery, orthopedics, psychiatry, urology, vascular surgery, internal medicine and family medicine. Massachusetts Medical Society More than 440,000 Massachusetts residents became newly insured over the past year and are looking for primary care doctors. The study found that 2008 was the third consecutive year that both internal medicine and family medicine specialities were in short supply.

14. Presidential Candidates Plans for Healthcare Reform:

15. Presidential Candidates Plans: Obama’s Plan: Shifted from Single Payer Universal Health Care Bigger Government – Mandates, Regulations, and Subsidies “Play or Pay” Regulations and restrictions on Third Party Payers

16. Presidential Candidates Plans: McCain’s Plan: Levels playing field for Employer vs. Private Based Insurance Tax Credits: $5,000 Help for those not covered at work $5,000 Tax Credit-Offset for Taxable Benefit Net saving: 15% Bracket (up to $63,000)=$3,200/year 25% Bracket (63.7-128.5K) =$2,000/year Savings into Health Savings Account Purchase insurance across State Borders

17. Other Important Elements Needed Accessibility Affordability Portability Pre-existing clauses eliminated or modified Break down Insurance Monopolies Blues – non-complete provisions

18. PMS-Specialty Society interfaces Expansion of the Board – 14 Specialty Members includes 3 Cardiologists: (Vice Chair, Cardiology Representative, Young Physician Representative) Association Management Services=$133,000/yr. – 25% reduction in cost PMS Specialty Cabinet Medical Imaging – Cardiology and Radiology – Resolved at Specialty Cabinet Certificate of Need /Physician Self Referral – HB 305 Phyllis Mundy (D- Luzerne) Collaboration with Orthopedic Society and Hospital Association on Mcare CME Group Tracker

19. PMS Publications On Line www.pamedsoc.org Capital Insights Patient Connection Vital Lines Consult Intouch PAMPAC eNews Studies in Patient Safety Member Opinion Panel

20. GET INVOLVED! National Level: Cardiology PAC AMPAC Pennsylvania: PAMPAC Endorsed: Attorney General Tom Corbett – Reelection Kim Ward (Senate-Westmorland – Husband is Nephrologist PAMPAC Supported Candidates A Good Return on Your Investment

21. CMS Releases Final 2009 Medicare Physician Payment Rule The Centers for Medicare and Medicaid Services (CMS) yesterday released the final 2009 Medicare Physician Fee Schedule, which includes some good news for cardiology in terms of administrative burden, but some unfortunate news about physician payment. While ACC staff continues to review the rule in detail, highlights include the following: IDTFs: CMS is deferring a final decision on its proposal to require physician practices that provide diagnostic testing services to register as IDTFs. The ACC, working in coalition with other cardiovascular societies, has opposed the proposal because it would create significant administrative burdens on practices without necessarily increasing the quality of diagnostic testing provided. CMS explained that the passage of the Medicare Improvements for Patients and Providers Act (MIPPA) in July 2008 was one reason that it decided not to finalize this proposal at this time. MIPAA includes accreditation requirements for providers of the technical component of advanced imaging in order to be paid for services provided to Medicare patients beginning in 2012. The ACC strongly supported this component of MIPPA. Payment Rates: Although MIPPA put in place a 1.1 percent update to the Medicare conversion factor, CMS projects that overall Medicare payments to cardiology will fall by 2 percent in 2009. This cut results primarily from two policy changes. First, the third year of the four-year transition to a new formula for calculating practice expense relative value units (RVUs) will reduce payments for a number of cardiovascular imaging services. Second, MIPPA requires that the current budget neutrality adjustment applied to work RVUs be incorporated into the conversion factor. As a result, payments for services with a significant practice expense element (imaging procedures, in-office procedures) will receive a reduced payment. Conversely, services with more physician work elements (evaluation and management, interventional cardiology and electrophysiology procedures performed in a hospital) will have payments increase by more than 1.1 percent. Coding Changes: CMS also announced the payments for a series of new codes related to cardiac device monitoring, as well as new bundled codes that describe transthoracic echocardiography with spectral and color flow Doppler and stress echocardiography with stress ECG monitoring. The ACC and MedAxiom are holding a special Webinar to address these changes on Nov. 14. Click here to register.Click here The final rule also includes detailed requirements for the 2009 Physician Quality Reporting Initiative (PQRI) and electronic prescribing (e- prescribing). The final rule increases the bonus payment for PQRI participation to 2 percent and adds additional reporting methods, including using the ACC's IC3 Program as a reporting alternative. Physicians in 2009 may also receive a separate 2 percent bonus for qualified e-prescribing, as created under MIPPA. The ACC is developing educational tools to assist members in learning how to participate in each of these programs. Watch www.acc.org and upcoming issues of Cardiology magazine for additional information on the final rule and upcoming Webinars explaining the various provisions.www.acc.org

22. Register Now for Cardiac Device Monitoring Webinar In 2009, cardiovascular health care professionals will see a fundamental shift in coding for cardiac device monitoring services, including pacemaker and ICD interrogations and programming sessions, remote monitoring, ICMs and ILRs. CPT 2009 includes 23 new codes for reporting these services. To help members understand the new structure, the ACC and MedAxiom will hold a Webinar on Nov. 14 from 2:00 to 3:30 p.m. ET to discuss the changes. The Webinar is designed for physicians, practice administrators, coders, and clinical staff and will feature presentations by physicians who wrote the new codes. Register now! http://wcc.webeventservices.com/view/wl/r.htm?e=124603&s=1&k=513D47BE12 AC09B7CFFE567F36EEA942&cb=genesys The Webinar will also available by dialing (866) 847-7863. In related news, the Centers for Medicare and Medicaid Services (CMS) later this week will release the final 2009 Medicare Physician Fee Schedule, which is likely to include revisions to the anti-markup rule, RVUs, echocardiography services, cardiac device monitoring services, the 2009 Physician Quality Reporting Initiative, as well as interim regulations on electronic prescribing. Watch ACC.org for more information following the release of the final rule.ACC.org

23. Working Harder Working Smarter Working TOGETHER TOGETHER WE ARE STRONGER!

24. THANK YOU!