Advocacy

Affordable Care Act, the Supreme Court and What Lies Beyond

James Fasules, MD, FACC

ACA, SCOTUS and Beyond: Purpose

What the SCOTUS decision means

There’s more – lot’s more risks

Discuss ACC principles, and the uncertainty CV practices face

Discuss how best we support CV care

“It’s the Rules not Reform!!!”

Payment = [(Work RVU x Work GPCI) +

(Practice Expense RVU x Practice

Expense GPCI) + (Malpractice RVU x Malpractice GPCI)] x (Conversion Factor x BNA)

Supreme Court DecisionAnti- injunction Act not applicable 9-0

Individual mandate 5-4– Violates Commerce Clause 5-4– Allowed under Congress’ Taxing Authority 5-4

Medicaid expansion 5-4– Unconstitutionally coercive 7-2– Remedy: no withholding existing Medicaid $ 5-4

Medicaid and the Exchanges

Expansion to 133% FPL optional

“Lies, damn lies and statistics”– Will TX sacrifice billions when the “woodwork

effect” will be marginal?– Will Medicaid MD reimbursement decrease?– Medicaid at Medicare levels

Prediction – less talk about “socialize medicine”, “Gov’t take over” or holding out for block grants after the election.

Impact on Cardiology

Quality and Value Based Purchasing (VBP)

– Quality Modifier 2015– PQRS; extended bonus 4 yrs, added penalties

Public Reporting– MD feedback; QRUR in 4 states– Physician Compare (limited NCDR PCI and ICD

measures)

Sunshine Act, CMMI, PCORI, IPAB

Quality Modifier Starts 2015*

>25 MDs

0%

ppt in PQRS

-2.5%

Elect ppt in VBM

0% Performance Resource use/risk

adjustment

High quality,Low cost,High risk

+3%

Average quality,Average cost,Average risk

0%

Low quality,High cost,

Average risk-1%

No No No

Yes

* Based on 2013 data

ACA: What’s Still Missing

Improvements and “Technicals”– IPAB– Subsidies for only state run exchanges?

SGR fix

Medical liability reform

Delivery and Payment reform beyond ACOs and PCMH

Reform and the ACC2000 ACC Principles

for Health System Reform

and the Uninsured1. Healthcare coverage for all Americans

2. Infrastructure supporting individual and small group insurance purchasing

3. Public-private partnership

4. Shared accountability for improved health among purchasers, payers, providers, and patients

5. Emphasis on quality and administrative simplification

2008 Blue Ribbon Panel1. Universal coverage

2. Coverage through public and private (pluralistic) programs;

3. Focuses on patient value — transparent, high quality, cost-effective, continuous care;

4. Emphasizes professionalism; effective partnership with empowered patients;

5. Ensures coordination across sources

and sites of care;

6. Payment reforms that reward quality

and ensure value

2008 Principles Going Forward

Asked to reassess - are they still valid?•Reviewed by Advocacy Steering Committee, CQC and the “Reform Advisory Group”•Conclusion:

– Remain appropriate and current– Need updated article on ACC actions

•Request: – Reaffirmation and update report

What Direction Will Deficit Politics Take Healthcare Reform? “We basically

have two economic health care options:we can cut care; or we can improve care”Berwick

ACC Reform Leadership• Rational reimbursement and gain sharing

• Educate clinicians on their practice habits – “knowledge changes habits”• FOCUS• Registries - PCI, Pinnacle• Measurement, transparency, self study, LLP• Coordination with PCPs

• Emphasize clinical indications to drive testingBecause we should; not because we canABIMF Choosing Wisely Campaign

• Improve cost effectiveness of CV care

There’s More, Lot’s More!Pressures on practices

Regulatory– 2013 PFS rule – interim

• Multiple Procedure Payment Reduction (MPPR)• Transition of care • VBP

– HIPAA privacy rule (ARRA) – interim

– MU stage II – final; HITPC working on III

– ICD-10 – postponed

– Sunshine Act – final pending (interim a mess)

The 2013 “Rule”

MPPR – Multiple Procedure Payment Reduction

• Reduces the lesser Technical Charge(s) for multiple

procedures by 25% (in PFS, not HOPPS or IPPS)• E.g., Nuke/Stress -2%, ECG and ECHO -0.16%• Risk: CMS applying similar cuts to Physician

Charges in radiology; Picked up by payers; Bundling• ACC actions with the CV societies:• Comments - CMS really messed up

the codes– Possible year delay or refinement

• Legislative v. drawing attention

“1% here, 1% there it eventually adds up to real money”

• Penalties for nonppt in PQRS

-1.5%

• MPPR, 2010 phase-in -3%

• Transition care -1%

• Sequestration -2%

• HOPPS mean v. geom mean -5% for some services

• SGR -28%

• PCI, EPS/Ablation: if CMS accepts RUC -17.5%

Plenty of Other Issues (DOJ)

Politics and The Big Issues

“You can lead a man to Congress, but you can’t make him think.”

Milton Berle

Political Climate of the 112th

“Must dos” in the Lame Duck Session

• Budget – CR or Omnibus; $3.8T

• Sequestration; $1.2T

• Taxes: Bush tax cuts, AMT; $2T

• Deficit, Debt; $0.9-1.2T, $18.7T

• SGR $240B

Risks and Uncertainty for CV Care and Cardiology

• Budget Angst: H. Con. Res. 112, – H.R. 4966 Sequestration Replacement Act of 2012– House Subcom on HHS approps report out

• Military more mobilized than Medical

• SGR $240B along for the ride

• Cardiac services used as offsets – Imaging cuts, precertification, IOAS– GME, especially IME cuts

"It's tough to make predictions,

especially about the future." 

-- Yogi Berra

Change will happenEpisode groupers?Entitlement reform??????????

ACC Strengths: Quality, Tools, and Education

Personal Lifelong Learning PortfolioPersonal Lifelong Learning Portfolio

ACC Advocacy: Creating Change“We in America do not have

government by the majority. We have government by the majority who participate”

Thomas Jefferson, 1787

Summary

Change is inevitable

Uncertainty is more disruptive than change

Cardiology was disrupted by the 2010 rule, adapted and now well positioned with quality measures and tools to deal with future changes.

ACA = politics; 2010 & 2013 PFS rules = impact

ACC quality and education initiatives directed to better position cardiac care for the future no matter the setting or payment model