February 3, 2009
Dear NJ-ACC Fellow/Member:
I. Introduction
Next month will mark my last as the
President and Governor of the New Jersey Chapter of the American
College of Cardiology. While transitions are always bittersweet and
part of me will certainly miss the privilege of serving as your
representative to the Board of Governors, I am absolutely confident
that our Chapter will remain in excellent hands under the auspices
of President and Governor-elect Louis Teicholz, MD. For the past 12
months we have worked closely together on multiple projects intended
to improve quality of patient care and to ensure that the interests
and needs of the state’s cardiologists are not ignored. In this
final letter I wanted to review some of the challenges that face us
and offer some words of support.
II. Washington, D.C.
Legislative Conference
For the past two days Lou and I have
met with the other Governors and the senior leadership of the ACC at
the Heart House in Washington, D.C. Many topics were discussed, not
the least of which was the challenges facing our specialty and our
College. Some of those challenges are not new and are specific
solely to the organization and do not directly affect each of us
independently (at least at the moment) – competing subspecialty
societies, decreasing participation by younger physicians,
competition with the American Heart Association initiatives, etc…
Some of the challenges, however, affect each of us more personally.
The Economic Environment:
As everyone who walks the planet now
knows, the economy is not exactly thriving. What does this mean to
us as cardiologists? Let me try to put this is some perspective.
Healthcare now represents 16% of the American GNP with Medicare’s
annual outlay being $420 billion. The physician component of the
Medicare expense is $73 billion. Operating costs of a physician’s
practice increased approximately 9% over the past 12 months, or so,
while revenue increased only 1%. The net loss of income was thus
approximately 8%. If one takes general inflation into account, most
physicians were down in real dollars by approximately 10-11%. This
is no small number. Certainly, it could be offset by a 10% increase
in Medicare payments to the physicians, which using the numbers
above, would amount to approximately $7.3 billion. While this seems
like a lot, it is a relatively small figure in the overall scheme of
things, especially when compared to the bailout packages provided to
Wall Street. As an aside, it is also fairly small if one considers
how much money is siphoned off to insurance carriers and
investors/shareholders.
Failure to Get Our Message Out
Why have we, as physicians (all
physicians, not just cardiologists), failed to get our point across
to Congress? Clearly, there are multiple reasons. The first and
perhaps most obvious is that even now physicians are doing
reasonably well as compared to the average American citizen. By all
measures, physicians earn many times what the average American earns
and cardiologists, in specific, are earning on average more than
$350,000 - $400,000 per year.[1] This would not be
so bad but for one small problem – we (all physicians) are not doing
the job efficiently (or so we are told by those in a position of
authority). That conclusion is based upon comparative data. In much
of Europe, the cost of medical care averages only $3,500 to $4,000
per capita. In Australia, the average cost is even less at $3,000
per capita. In the United States, however, the figure is $6,800 per
capita.
Cost of Healthcare is
Disproportionately High in the U.S.
One might reluctantly accept the
increased cost of healthcare in the U.S. if our results were
spectacular, but they are not. By many measures of healthcare, we
actually do fairly poorly. In infant morality, for example, we are
ranked #19! I am not suggesting that American healthcare is
inadequate. In fact, I fully agree with Jack Lewin, MD, the CEO of
the ACC – “at its best, American healthcare is superb, but…”
Unfortunately, the “but” is a big one. Certainly, the United States
remains the one nation where much of the world still comes when
others offer no option. The irony is that while we can care for
others we often find ourselves incapable of caring for our own. The
publicly accepted number of uninsured Americans is now 47 million.
This number will increase as the recession persists. For every 1%
increase in unemployment (and it is expected to peak at 8-9%) there
will be an increase in the number of uninsured by 1.2 million. Like
it or not, this will impact each and every one of us. Some of those
uninsured will not be our patients but many of them will be. Will we
cease to care for them? Can we?
Alleged Overtesting Begets
Regulation / CareCore
It is said that a large part of the
alleged inefficiency relates to our over-testing. There may be many
reasons for this – one of which may be Congress’s refusal to
appropriately address tort reform. This, of course, is arguable.
What is clear, at least in New Jersey, is that we order more
tests/patient in this state than our colleagues do in other states.
It was partly in response to this issue that the state’s insurers
sought help from the radiology benefits managers (RBMs). The RBMs
were more than happy to oblige and today, as you all know, we now
have the challenge of dealing with CareCore. Part of the irony is
that the impact of CareCore is being felt by cardiology more than
others but we are not actually the guilty party. For example, 37% of
all Medicare patients have “CHF” as one of their diagnoses, however,
only 16% of those patients are cared for by cardiologists. That
means that 84% of all heart failure care is provided by other
specialists. Many of these specialists order echoes, stress tests,
and Holter monitors. Oftentimes, those studies are inappropriate and
when appropriate are often uninterpretable. When the patient is
finally referred to our office, we are denied the opportunity to
repeat the study.[2]
Dealing with CareCore has been a
major focus of the New Jersey, New York and Connecticut Chapters.
Paul Kligfield, MD (NY), Neil Lippman (CT) and I have worked
diligently for over two years on this one topic alone. We have met
on more occasions that I wish to remember. On some issues, such as
echocardiography and left heart catheterization we have succeeded
and convinced the carriers to place their pre-certification plans in
abeyance. With regards to SPECT studies and stress-echoes, however,
we have not succeeded and most of these studies still require
pre-certification.[3] In the long run, this is not
a local Chapter issue. It is an issue that needs to be addressed by
the National ACC, especially since the Chapters, themselves, really
have no staff to put to work on the project, while the National ACC
employs over 250-300 individuals including a full advocacy divison.
Advocacy
While the ACC may have a full
Advocacy Division, the challenges facing that division are not
small. Ultimately, advocacy (at least when it comes to dealing with
politicians) comes down to two things – the right message at the
right time to the right person and, of course, money. Let me start
with the latter. In the 2007-08 $1,253,737 was raised by the ACC
Political Action Committee (PAC) with an average contribution from
those who contributed of $463. Of that amount, $997,284 was
contributed to various candidates. 56% of the money was given to
Demcrats and 44% to Republicans. While nearly a million dollars may
seem like a lot, it really isn’t. The ACC was ranked #12 amongst the
different medical specialty societies. First, of course, was the AMA
followed by the anesthesiologists, dentists, orthopedic surgeons,
etc… This year, the ACC has set a goal of $1,000 from 1,000
cardiologists. I would strongly urge each of you to make some
contribution. Please email
mmorse@acc.org for more information.
Quality, the Year of the Patient,
and Public Report Cards
It should be obvious that we, as an
organization, don’t have enough money to make the difference that we
hope to make. Therefore, we must come to the table with something
other than just dollars. The something that national leadership has
opted to focus on is quality patient care. Personally, I think that
this is somewhat disingenuous. It suggests (perhaps unintentionally)
that quality was heretofore not a priority. Clearly, that was not
the case. Not a single physician that I know desires to provide or
deliberately provides poor quality care. Nevertheless, in line with
the quality initiative, 2009 has been designated by the ACC and its
soon to be new president – Fred Bove, MD – as the year of the
patient.
What does the year of the patient
mean? This remains to be seen. One thing that I do know, however, is
that it means increased transparency when it comes to public
reporting of outcomes. Please recognize that the idea of public
reporting of outcomes did not originate with the ACC. What did
originate to some extent at the ACC is the idea that if such
databases are going to exist (whether we like it or not) they ought
to be high quality and accurate databases. Only in this way can
those databases be used by others to evaluate performance and by
ourselves to provide feedback and education. To this end, the
National Cardiovascular Data Registry (NCDR) will probably be
adapted to allow some public reporting features. As I said,
increased transparency – for better or for worse – you be the judge.
Trade Organization or Professional
Society?
If you read between the lines, you
can see that the College is evolving. It is evolving from a college
of science and education to a college of advocacy; not only on
behalf of the cardiology community but on behalf of patients as
well. To advocate solely on behalf of our membership would be viewed
poorly by the world at large and would allow many to argue that we
have become a trade organization rather than a professional society.
To not remember our primary mission,
however, and the reason the College was established in the first
place would be very dangerous. That mission – as many of us still
see it – is to represent the interests of the cardiologists. The
National ACC is acutely aware of this and the New Jersey Chapter is
probably even more aware of this than National. In fact, I have made
this point not infrequently over the past few years. I have
proffered quite frequently that the National ACC must assist us when
dealing with insurance carriers and RBMs. We cannot meet the
challenges alone. Our Chapter simply does not have the resources to
address each and every threat.
III. Recertification/Boards
Examinations
One of the more recent challenges
facing the cardiology community is Board recertification. It seems
that we are now at a crossroads. Approximately half of the nation’s
cardiologists have time-limited certificates and half do not. Many
of the half that do not feel that all certificates should be
time-limited otherwise the situation is not only inequitable but
inconsistent and indefensible. If continuing education is good, then
it is good for all not just some. Obviously, the other half believes
that asking those with time-unlimited certificates to now recertify
is to change the rules in the middle of the game. To complicate the
picture further, those with certificates in EP or interventional
must maintain Board certification in General Cardiology even though
their practices are not general cardiology practices. No resolution
yet exists. It has been suggested that the most fair approach is to
require maintenance of certification (MOC) by everyone but to do so
with an ongoing process that does not require a formal examination.
The ACC will be meeting with the ABIM in the first week of June to
formally discuss this issue. Hopefully, Lou will be able to provide
you with additional information at that time.
IV. Potential Decline in
Membership
Yet another challenge facing the ACC
is the loss of the young cardiologist, many of whom feel more
connected to their subspecialty society – HRS, ISHLT, SCAI, etc…
than they do to the ACC. Many of these individuals question the
value of ACC fellowship. To this I can only say – “ask not what your
College can do for you but rather what you can do for the College…”
The activities of the ACC described in this letter, alone, should be
sufficient for our younger colleagues to understand the importance
of fellowship and the importance of a strong organization. If the
College fails to thrive, we will surely pay the price. Consider -
who is out there lobbying against the efforts of the American
College of Radiology to stop cardiologists from performing in-office
imaging – certainly not the AMA or for that matter the HRS, ISHLT or
SCAI. The answer is the ACC. While it may be hard to maintain
interest in a general cardiology organization when many of us
practice subspecialty cardiology it is clear that if we don’t
support it via fellowship, dues, and contributions to the PAC and
ACC Foundation, it will ultimately go the way of the AMA and the
American College of Physicians – wonderful organizations with good
intentions whose clout has become increasingly diluted.
V. State Activities
Reintegration of New Jersey
Subspecialty Cardiology Societies
Consistent with the concerns
described above, over the past few years I have tried to
re-integrate many of the local New Jersey subspecialty societies. I
have had some success. The New Jersey Society for Interventional
Cardiology recently dissolved and transferred their funds to the
NJ-ACC. Let me publicly thank Dr. Bunyad Haider, Dr. David Cohen and
Dr. Virender Sethi for their efforts in making this happen. We shall
designate those dollars for projects specifically related to
interventional cardiology. A specific plan, however, has yet to be
developed. In the next month, I shall reach out to the President’s
of the other subspecialty societies that exist within the state to
see if they too would consider re-integration.
CHAP
Not only does the NJ-ACC address
represent the state’s cardiologists on a national level but the
NJ-ACC also represents them on a state level through membership on
the Cardiovascular Health Advisory Panel (CHAP) of the Department of
Health and Senior Services and the CHAP Performance Subcommittee. It
was through the efforts of the NJ-ACC and the other members of the
CHAP that the state opted to abandon the requirement that all
interventionalists perform a minimum of 75 cases each year and to
instead monitor outcomes and quality using a modification of the
NCDR database.
Door to Balloon Initiative
Of all of the accomplishments that
took place during my tenure, the one that I am most satisfied with
was the D2B (door to balloon) project. While I do not have the final
data, I can confidently state that New Jersey was among the first
few states to have nearly 100% participation in the project. Our
door-to-balloon times have fallen significantly and may yet fall
further as we work collaboratively with the American Heart
Association’s Mission Lifeline project. This could not have been
accomplished without your help – for that – thank you.
Hospital Designation – Level 1,2,
and 3 Cardiac Centers
As a point of information, you should
be aware that the State has been exploring the idea of designating
hospitals as Level 1, 2, and 3 Cardiology Centers. Specifics have
yet to be worked out. The theory, however, is that patients should
be taken to the most appropriate hospital and not necessarily to the
nearest hospital. Obviously, there are significant ramifications to
a program such as this. Hence, it is unlikely to happen in the near
term but in the long run it is likely to happen.
VI. Conclusion
In summary, it has been a privilege
serving as the President and Governor of the New Jersey Chapter of
the ACC. I have done my best to represent our interests zealously.
However, it has become increasingly clear to me that for our Chapter
to excel, a greater level of involvement is required from the
membership. Each and every one of us needs to participate in local
activities, Chapter meetings, and volunteer on committees. To date,
the support of the membership has been less than optimal.[4]
This needs to change. Alone, none of us can achieve the goals we set
for the Chapter.
On behalf of all of the membership, I
wish Louis Teicholz much success with this endeavor and promise him
my full support. With that, I shall take my leave, move back to
Midland, Texas (oh, sorry, Newark, New Jersey) and start to fund my
library!
Sincerely Yours,
Mark Jay Zucker, MD, JD, FACC, FACP
President/Governor NJ-ACC
Director, Heart Failure Treatment and Transplant Program
Newark Beth Israel Medical Center
[1] Verbal
communication from senior staff at ACC. I did not independently
verify. Whether this is still true is not known to me. The data
could be old or it could be inaccurate in either direction.
[2] Do keep in mind
that those studies ordered by internists are being read by one of
our colleagues. In other words, we undermine ourselves.
[3] At a recent
meeting with senior management at one of the state’s largest
carriers the following data was provided. A total of approximately
51,000 studies were precertified. 68% were approved, 25% denied and
7% withdrawn. 39,920 of these requests were for SPECT studies - 71%
were approved, 22% denied and 6% withdrawn. Of the stress-echoes
requested – 46% were approved, 43% were denied and 11% withdrawn.
Lastly, of the 3,940 left heart caths (pre-certification required
for this carrier) – 86% were approved, 9% denied and 5% withdrawn.
20% of all CT angios were approved.
[4] I have reached
out on numerous occasions to the cardiologists in the Southern part
of the state and have held at least two meetings each year in
Forsgate and one meeting last year in Absecon. To those who attended
– thank you. Unfortunately, only 6 or 7 cardiologists attended.
