1. DC update Karen Collishaw Associate Executive Vice President Advocacy, American College of Cardiology Bethesda, MD

2. Practice expense portion of fee schedule has been undergoing transformation over the last couple of years. Initial HCFA proposal had cuts of up to 24% in cardiology payments, but a change in methodology has allowed for the transition to a new system. This transition was to have taken 4 years. Medicare practice expense (i) ACC legislative priorities

3. 2 years into this transition and the refinements have still led to cuts in specialty medicine. The ACC and other specialty groups have brought forward a new proposal to congress, that the transition be halted at this point. Any proposal requires good averaging of all practice expenses that MD’s incur delivering service to Medicare beneficiaries. Medicare practice expense (ii) ACC legislative priorities

4. The new proposal would exempt from this transitional halt all office visit and consultation codes that are scheduled to increase by 2002. All provider groups are asking congress for some relief from “balanced budget” cuts made several years ago. MD’s are forwarding a proposal that aims to help everyone. Medicare practice expense (iii) ACC legislative priorities

5. The new proposal results in a net positive impact for almost every specialty, including primary care. The AMA has also adopted this policy. All cardiovascular specialists need to write to their member of congress highlighting a need for change in the practice expense methodology. Medicare practice expense (iv) ACC legislative priorities

6. This issue is represented in the Patient’s Bill of Rights. Both the house and the senate passed bills last year that yet need to be reconciled in conference committee. During an election year, resulting laws may be weak, but touted as amazing achievements, or may simply be vetoed. There is a pressure for each party to “do something”. Managed care reform (i) ACC legislative priorities

7. Regarding a proposed Patient’s Bill of Rights, the managed care conference committee has had difficulty in determining: (1) the scope of the bill (ie, coverage of all Americans or just those in protected plans) (2) whether HMO’s should be held accountable (and liable) for decisions made in treatment Managed care reform (ii) ACC legislative priorities

8. Democrats in general have been very supportive in getting the bill passed. The house bill is endorsed by the ACC and all medical groups, including the AMA and is stronger than the senate bill. In June, the Democrats attempted to pass a new senate bill that mirrors the house bill, but were unsuccessful by 1 vote. Managed care reform (iii) ACC legislative priorities

9. Renewed attention has been given to this issue, in part because of the election year. The ACC is working with a coalition of interested groups to put together a proposal in the next few years. Coverage for the uninsured ACC legislative priorities

10. Attention is focused on a new Medicare outpatient ambulatory patient classification (APC) scheme. In the past, outpatient services were classified according to a retrospective cost analysis. The new APC system is prospective, and analogous to the DRG system in hospitals. Like services will be grouped together in the outpatient setting. Ambulatory patient classifications (i) ACC legislative priorities

11. The new scheme has been made effective as of August 1. The new APC has an indirect impact on cardiologists and cardiovascular specialists. At the current time, there appears to be no logical relationship between the proposal to pay in an outpatient setting versus the proposal to pay in a physician office setting. Ambulatory patient classifications (ii) ACC legislative priorities

12. The scheme allows for a “pass-through”, where new devices and drugs are to be treated differently (ie, an interim payment). The new plan also requires all angioplasty performed on an outpatient basis to have “immediate surgical backup”. The exact definition of these terms has yet to be determined and implementation of this rule awaits the results of an ongoing debate at the ACC regarding surgical backup requirements in angioplasty. Ambulatory patient classifications (iii) ACC legislative priorities

13. At the ACC, 2 documents are currently being updated: - guidelines for cardiac catheterization (in conjunction with the AHA) - catheterization laboratory standards HCFA is awaiting the outcome of these documents before proceeding with the enforcement of what may be a relative distinction. “Immediate surgical backup” ACC legislative priorities

14. The APC scheme also denies payment for observation care, and this directly affects chest pain observation centers. Chest pain centers may avoid costly admissions by taking the time to observe patients with some symptoms of acute myocardial infarction. HCFA does acknowledge that the literature shows chest pain centers to improve efficiency and save costs. Chest pain observation centers ACC legislative priorities

15. If the Democrats win the presidential election, there will be a greater chance of passing the Patient’s Bill of Rights, and the issue of the uninsured will be brought to the forefront. If the Republicans win the presidential election, there will be a greater opportunity to pull back the regulatory burden that HCFA places on everybody participating in Medicare, and tort reform may gain prominence. Election year outcomes

16. Several state action doctrines allow MD’s to collectively negotiate with managed care companies. A number of MD specialty groups are working in coalition to pass a similar measure, the Campbell bill, at the federal level. Prompt payment issues have also passed. Kentucky was able to ban “all-product” clauses in insurance company contracts. Collective negotiation Payer advocacy issues

17. The College is attempting to work primarily with state medical societies and focus on local issues. State medical societies and the AMA have approached insurance agencies who may be using unfair tactics and all-product clauses, in order to bring pressure onto the payers. The federal trade commission may also become involved. Anti-competitive behavior Payer advocacy issues

18. Cardiologists should keep themselves informed of the issues at a very high level so that they may have a say while the issue is still in play. Become involved both locally and federally. Read Advocacy Weekly, from the ACC. The most effective advocacy programs combine grassroots advocacy with regular access to legislators. Communicate with your state official or member of congress on important issues. How to get involved