Advocacy and Continued Survival in the New Healthcare Environment

Advocacy and Continued Survival

in the New Healthcare

Environment

Advocacy Panel Discussion

Florida Chapter

American College of Cardiology

Panel Discussion Overview

• State Issues•FMA Meeting Update•Florida Legislative Review 2011•Florida Chapter ACC – newly formed State PAC

• Federal Issues•CMS 2010, 2011, 2012 Rule•Legislation Impacting Cardiology in 112th Congress•SGR Repeal – Medicare Reform •HR 5, HR 1700, HR 1476 •FCACC Innovation Grant

•ACC ADVOCACY – Now and Future•State Advocacy•National Advocacy

State Issues

• Florida Legislative Review – 2011

• FMA Meeting Update

• Florida Chapter ACC – Newly formed State PAC

2011 Florida Legislative Session

•HB 479: Most Significant advancement in Florida medical liability laws since 2003.

•Requires DOH to issue expert witness certificates to certain physicians & dentists licensed outside of state; •requires Board of Medicine & Board of Osteopathic Medicine to adopt certain patient forms specifying cataract surgery risks;•provides for execution & admissibility of patient forms in civil & administrative proceedings; •creates rebuttable presumption of disclosure; •deletes requirement that medical malpractice insurance contracts contain certain information; •provides that certain insurance information is not admissible as evidence in certain actions; •requires that certain expert witnesses meet certain licensure or certification requirements; •excludes health care provider's failure to comply with or breach of federal requirements from evidence in certain cases; requires claimant for medical malpractice to execute authorization form; •allows prospective medical malpractice defendant to interview claimant's treating health care provider without presence of claimant or claimant's legal representative; requires 10 days' notice before such interviews; •authorizes defendant to take unsworn statements of claimant's health care provider; •requires that presuit notice for medical negligence claims be accompanied by authorization for release of protected health information; •authorizes health care facility to use scientific diagnostic disease methodologies that use information regarding specific diseases in health care facilities & that are adopted by facility's medical review committee; requires dismissal of claim if such authorization is not completed in good faith; •provides immunity for volunteer team physicians.

State Issues




Florida Medical Assoociation Annual Meeting

•“Helping Physicians Practice Medicine”

•Florida Chapter ACC sends 8 delegates to House of Delegates at the Florida Medical Association Annual Meeting

•FCACC representatives participate in caucus meetings with all other medical specialties as well as participating in House of Delegates debate on key resolutions that impact Cardiology

Florida Medical Assoociation Annual Meeting

•Resolution 11-308: FMA seek legislation that would require any physicians making health insurance coverage recommendations regarding approval or disapproval of diagnostic imaging procedures or any other patient care decisionis, be licensed in the state of Florida, and disclose upon request the guidelines used to make a negative recommendation.

•Passed House of Delegates – now moves to FMA legislation committee to formulate a legislative action plan

•All resolutions are online at: http://www.celebratemedicine.com/files/2011_Reference_Committee_Reports_I-IV.pdf

State Issues




Florida Chapter ACCNew State Political Action Committee (PAC)

•Florida is the founding state chapter of the ACC and has historically lead the nation in Education, Quality, and Advocacy.

•A FCACC state-wide PAC would provide a method for the FCACC under current election laws to participate more directly in the political process.

•As in the national ACC PAC, candidates would be carefully vetted and funds allocated to candidates without regard to party affiliation. All PAC deliberations would be transparent.

•Maximum donation for state PAC to candidate is $500 for primary and $500 for general election.

Marnie L. George and Michael P. Harrell, FCACC State Lobbyists

Florida Cardiology PAC

•Federal relationships begin long before members are elected to Congress. Most of FL’s Congressional Delegation started out in the Florida Legislature.

•For 27 cents a day ($100/year) there’s no better investment you can make to protect your profession.

•The 2012 election cycle will be very contentious with every legislative district (all 160 seats) up for election due to redistricting.

•Medicine’s adversaries raise enourmous sums of money to keep pro-medicine candidates out of office.

•PAC Dollars Count ! Helps good candidates WIN !!!

•Your PAC supports candidates for the state legislature who support the medical profession

Marnie L. George and Michael P. Harrell, FCACC State Lobbyists

Federal Issues

• CMS 2010, 2011, 2012 Rule

• Legislation Impacting Cardiology in 112th Congress

• SGR Repeal – Medicare Reform

• HR 5, HR 1700, HR 1476

• Radiology Benefit Management – ACC FOCUS

• FCACC Innovation Grant

CMS 2012 Rule

•Overall Impact on Cardiology: -1%

•Specific issues being addressed by ACC include:– Potentially Misvalued Codes– Ultasound Equipment adjustment to professional component– Preventative visit payment expansion– PQRI review and expansion – Maintenance of Certification = +0.5%– eRX Penalities – CMS Medicare Provider Directory website = “Physician Compare” based on PQRI participation– “Value Based Purchasing” => adjustment of physician payments based on quality measures– CMS proposal to decrease payments on the technical component for hospital-owned practices

•All of these changes with negative impact are STRONGLY OPPOSED by ACC

Federal Issues

• CMS 2010, 2011, 2012 Rule

Legislation Impacting Cardiology in 112th Congress


• HR 5, HR 1700, HR 1476



Federal Issues

• CMS 2010, 2011, 2012 Rule



• HR 5, HR 1700, HR 1476



SGR – (Un) Sustainable Growth Rate Medicare Payment Reform

•SGR remains the #1 priority of the AMA and every Specialty Society (incld ACC)

•All physicians face an immediate 29.5% reduction in reimbursement on Jan 1, 2012 unless acted upon (again) by Congress.

•Notably, the Budget Control Act of 2011 did address the SGR. The cost of the SGR fix is approx. $300B and conflicts with the cost-cutting objectives of the “committee of 12”.

•Rep. Michael Burgess, MD (R-TX) has emerged as the leader of the Congressional Health Care Caucus and together with House Budget Chair Paul Ryan (R-WI) have far reaching plans to fix SGR coupled with Medicare Payment Reform…..

Federal Issues

• CMS 2010, 2011, 2012 Rule



• HR 5, HR 1700, HR 1476



HR 5 – Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act

• Sets conditions for lawsuits arising from health care liabiltiy claims regaridng health care goods or services or any medical product cut affecting interstate commerce.

• Sets a statue of limitations of three years after the date of manifestation of injury or one year after the claimant discovers the injury, with certain exceptions.

• Limits noneconomic damages to $250,000.

• Makes each party liable only for the amount of damages directly proportional to such party’s percentage of responsibility.

• Allows the court to restrict the payment of attorney contingency fees. Limits the fees to a decreasing percentage based on the increasing value of the amount awarded.


•Allows the introduction of collateral source benefits and the amount paid to secure such benefits as evidence. Prohibits a provider of such benefits from recovering any amount from an award in a health care lawsuit involving injury or wrongful death.

•Authorizes the award of punitive damages only where (1) proven by clear and convincing evidence that a person acted with malicious intent to injure the claimant or deliberately failed to avoid unncessary injury the claimant was substantially certain to suffer and (2) compensatory damages are awarded.

•Limits punitive damages to the greater of two times the amount of economic damages or $250,000.


•Denies punitive damages in the case of products approved, cleared or licensed by the FDA or otherwise considered in compliance with FDA standards.

•Provides for periodic payments of future damages.

•SPONSOR: Rep. Phil Gingrey (GA)

•Committee Assignments: Judiciary

Energy and Commerce

HR 1700 – Medicare Patient Empowerment Act

• Balance Billing: “To establish a Medicare payment option for patients and physicians to freely contract, without penalty, for Medicare fee-for-service items and services, while allowing Medicare beneficiaries to use their Medicare benefits”.

• Currently, physicians that see Medicare patients must accept one of two Medicare rates based on whether the physician is submitting charges to Medicare (PAR) or if the patient is submitting charges to Medicare (Non-PAR) . However, both types of physicians are limited in total patient charges.

• Balance billing would be a return to indemnity insurance common before the advent of Medicare or managed care.


• Patients would have the OPTION to receive Medicare payments (and secondary insurance payments) directly and be responsible for payments to physicians, clinics, labs, etc. From the patient’s perspective, this would be an opportunity to choose physicians and other medical services based on quality and costs.

• Patients would benefit from the option of seeing the physician of their choice – “this bill will not prohibit a patient from seeing a PAR or NON-PAR physician for any service.”

• Patients are protected by a signed contract establishing all payments for services, and the patient will be held harmless for any charges in excess of agreed charges under the patient-physician contract. Payment to the patient shall not render the physician as a PAR or NON-PAR physician. including the current PAR type physician.


• Physician would be allowed to contract with patients for services with payments to be made to EITHER the physician or to the patient – with the provision that the services and payments would be agreed in advance of services performed.

• Importantly, if the physician-patient contracts for Medicare payments to be made directly to the patient, than this shall not render the physician as a PAR or NON-PAR physician. (A dramatic change from current law)

• SPONSOR: Rep. Tom Price (GA)

• Committee Assignments: Energy and Commerce , Ways and Means –Health Subcommittee

HR 1476 – Integrity in Medicare Advanced Diagnostic Imaging Act

• Exclude certain advanced diagnostic imaging services from the in-office ancillary services exception to the prohibition on physician self-referral. (“Prohibition for self-referral refers to any physician who has any ownership, investment relationship or compensation arrangement with an entity from referring a patient to the entity for certain advanced diagnostic imaging services for which a Medicare payment otherwise may be made.”)

• Advanced diagnostic imaging services include: MRI, CT, PET and “such other diagnostic imaging services as specified by the Secretary”

• SPONSOR: Rep. Jackie Speier (CA) and Rep. Anthony Weiner (NY)

• Committee Assignments: Energy and Commerce , Ways and Means –Health Subcommittee

Federal Issues

• CMS 2010, 2011, 2012 Rule



• HR 5, HR 1700, HR 1476


Federal Issues

• CMS 2010, 2011, 2012 Rule



• HR 5, HR 1700, HR 1476


Innovation Grant ProposalCommunity Based Disease Management of Ischemic Heart Diseasein Florida: Providing Appropriate and Timely Cardiology Care to Improve Patient Outcomes while Reducing Medoicare Costs

• The 2010 Affordable Care Act (ACA) providing funding for research in INNOVATION with respect to patient delivery and patient payment systems for Medicare beneficiaries.

• FCACC leadership met with senior CMS (Medicare) officials in the offices of Health and Human Services to discuss the feasibility of a state-wide innovation grant proposal.

• Over the summer 2011, an ad hoc committee chaired by Juan Aranda, MD has worked on the details of an Innovation Grant to be submitted to CMS by September 1.

• Jonathan Blum, Senior Director of CMS has promised a rapid review of the innovation proposal, as well as offered to visit Florida to discuss ongoing issues with FCACC Cardiologists.

ACC Advocacy Now and the Future

• Florida ACC Advocacy Committee

• Florida ACC State PAC

• Florida ACC Day in Tallahassee

• National ACC Advocacy Committee

• National ACC PAC

• ACC Legislative Conference

American College of Cardiology Legislative Conference Sept 11-13

Fairmont Hotel and ACC Heart House

Washington, DC

“Silence gives consent” Canon Law

“We must all hang together, or we will all surely hang separately” Ben Franklin

“Politics is a marathon not a sprint” Steve West, MD

"Even a little dog can piss on a big building." Jim Hightower

“We in America do not have government by the majority. We have government by the majority who participate”

Thomas Jefferson, 1787

ACC Advocacy Now and the Future

Take Action!• Up-to-Date Information: www.cardiosource.org/Advocacy

• ACC Advocate Newsletter online: www.cardiosource.org/Advocacy/newsletter

• ACC Political Action Committee: www.accpacweb.org

• ACC Florida Chapter Advocacy: www.accfl.org

Advocacy Efforts• Chapters mobilized, Florida leading the way• Massive campaign to contact Congress• Op-eds placed in newspapers across the state• New web site www.savefloridahearts.org• ACC Legislative Conference sent 350 people to

Capitol Hill, December Fly-in had 39 FCACC members attend and other states sent delegations

• Online/print ads ran in Hill Publications

Recent Advocacy and Legal Actions

• December 4 2009. FCACC meets with CMS

• December 8 2009 FCACC lobbies Congress to cosponsor Gonzalez bill

• December 28 ACC, FCACC, and others sue CMS

• January 1, 2010 CMS 2010 Rule starts• January 13, 2010 Legal injunction is thrown

out

“Silence gives consent” Canon Law

“We must all hang together, or we will all surely hang separately” Ben Franklin

“Politics is a marathon not a sprint” Steve West, MD

"Even a little dog can piss on a big building." Jim Hightower

"To accomplish great things, we must not only act, but also dream; not only plan, but also believe." Anatole France

“We must all hang together, or we will all surely hang separately”

Ben Franklin

“We in America do not have government by the majority. We have government by the majority who participate”

Thomas Jefferson, 1787

Advocacy Issues 2010 - 2011 • Balance Billing:

• CMS would continue to have fiscal control on overall Medicare expenditures. This bill would potentially decrease Medicare expenditures while physicians would maintain more independence in reimbursement. It would also allow CMS to establish rates more independently while giving physicians the ability to establish rates with lower rates, the physicians with wealthier clientele to charge more, it could squeeze poorer Medicare beneficiaries out of the system if only half (for example) of the cost of physician services were covered.

• in private contracting can charge whatever you want but patients can’t send bill to Medicare). They are not allowed to charge more than that. Balanced billing would allow the physicians to charge the difference between the Medicare payment rates and whatever they wish to charge. This issue has been widely supported by organized Medicare for years, but has been politically untenable particularly with the Democrats in power.

Advocacy Issues 2010 - 2011

• Change in Cardiology Practice Demographics:

• Full results embargoed until presentation at legislative conference, but you can say that our FACC “census” indicates up to 70% of large practices have sold or are in negotiations to sell to hospitals. The number is less for small practices – instead they are reducing the number of Medicare patients they see.

Advocacy Issues 2010 - 2011• Continued Legislative Effort on 2010 Fee Schedule Cuts:

• H.R. 4371, legislation introduced by Rep. Charlie Gonzalez (D-TX) to mitigate the 2010 Medicare Physician Fee Schedule Final Rule payment cuts to cardiology, has 125 bipartisan cosponsors. The ACC continues to seek new cosponsors, while using the legislation to educate lawmakers about the impact the rule cuts are having on private practice cardiology.

• In addition, this summer Rep. Gonzalez lead a letter by 65 members of Congress to CMS urging the agency to phase-in cuts to nuclear cardiology services in the 2011 physician fee schedule proposed rule.

• Chairman Waxman was also interested in the phase-in for nukes and wrote CMS twice but was rebuffed. Were now working with Mr. Waxman and Mr. Gonzalez on possible legislation for the lame duck session.


• Reform Implementation:

• The College is closely monitoring the implementation of the Affordable Care Act (ACA), signed into law earlier this year. The College will seek opportunities to work with Congress to repeal or improve several provisions of ACA, including:

• · The creation of the Independent Payment Advisory Board, or IPAB

• · Prohibitions on new and expanded physician-owned hospitals

• · The release of Medicare claims data for public reporting

• · Penalties for not participating in the PQRI program starting in 2015

• · Adjustment of Medicare physician payment for quality in 2015


• SGR:

• Congress approved a six month Medicare physician payment update of 2.2 percent in late June and must act again by December 1 to stop a 22 percent payment cut from taking effect. So far this year Congress has approved multiple temporary physician payment “patches,” failing to enact a permanent repeal of the flawed sustainable growth rate (SGR) formula.

• The ACC and the rest of medicine continue to advocate for a permanent repeal of the current formula. The College urges Congress to provide stable, positive updates and cover the increase in the cost of providing care.

• The ACC is participating in a AMA SGR Task Force, a select group of state medical societies and national physician groups, working to address ending the SGR and looking at long term payment reform

National ACC Advocacy Efforts – 1

• Submitted detailed comments to CMS by Aug. 31 deadline

• ACC initiated meetings with key Congressional leaders, CMS staff and Obama Administration officials

• Worked with oncology and other CV societies to generate support for “Dear Colleague” letter on Hill (Gonzalez-Rogers letter with broad bipartisan support)

• Encouraged other members of Congress to send communication on CMS issue to HHS

• To date, over 1/3 of Congress has gone on record with a letter to Sec. Sebelius opposing the 2010 CMS cuts

• THOUSANDS of comments, predominantly emails sent to members of Congress and CMS by ACC members as well as emails and fax communication from Cardiology patients

National ACC Advocacy Efforts - 2

• Chapters mobilized• Op-eds placed by ACC leaders in newspapers

across the country• Massive ACC member communication

campaign • ACC Legislative Conference sent 350 people to

Capitol Hill• Online/print ads ran in Hill Publications • “Dear Mr. President” ad in the Washington

Post, New York Times, Chicago Tribune and USA Today

Florida ACC Advocacy Efforts – 1 • Florida Advocacy Committee initiated efforts to get 21

out of 25 members to sign a Florida specific letter to HHS Secretary Sebelius

• Florida ACC participation in August 21 Rally in downtown Orlando

• Florida ACCPAC event with Representative Kosmas during Florida ACC Annual Meeting

• ACC members met personally with almost all members of Congress (House and Senate) during the August recess to educate Congressional members on the effects of the CMS rule

• Massive ACC member communication campaign – emails, letters, faxes from Cardiologists and patients

Florida ACC Advocacy Efforts – 2 • National ACC Legislative Conference – Florida very well

represented, and Florida ACC members personally met with both Senators as well as almost all House members/staff

• National ACC Legislative Conference – FLorida ACC members have two separate meetings with CMS officials

• Florida ACC letter signed by almost 1000 FL Cardiologists delivered to Secretary Sebelius

• Appeal made to Governor Crist to intervene on behalf of Florida Seniors

• Florida ACC advocacy committee and FCACC leadership continue to work with national ACC on all efforts to persuade HHS Secretary Sebelius

Documents

Advocacy and Continued Survival in the New Healthcare Environment