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Naviga&ng the New Health Care Horizon: Report from the
American College of Cardiology
West Virginia Chapter-‐ACC 10th Annual Mee&ng Charleston, WV May, 16 2015
Mary Norine Walsh, MD, FACC
Vice President American College of Cardiology
John Denver singing Country Roads at the opening of Mountaineer Field September 6, 1980.
Naviga&ng the New Health Care Horizon
Naviga&ng the New Health Care Horizon: What Issues Concern WV Chapter Members?
• Hospital integraJon concerns? • Advocacy issues? • Value based purchasing? • EHR? • Team-‐based care? • Prior authorizaJon? • MOC?
The American College of Cardiology Strategic Plan
Value Based Purchasing: a Primer
Hospital Value-Based Purchasing Overview
• Hospital VBP is part of the long-‐standing effort on the part of CMS to link Medicare’s payment system to improve healthcare quality, including the quality of care provided in the inpaJent hospital seVng.
• The program will implement value-‐based purchasing to the payment system that accounts for the largest share of Medicare spending, affecJng payment for inpaJent stays in over 3,500 hospitals across the country.
• Hospitals will be paid for inpaJent acute care services based on the quality of care, not just quan9ty of the services they provide.
• Hospital VBP seeks to encourage hospitals to improve the quality and safety of care that Medicare beneficiaries and all paJents receive during acute-‐care inpaJent stays by:
– elimina'ng or reducing the occurrence of adverse events – adop'ng evidence-‐based care standards and protocols that result in the best
outcomes for the most pa'ents – re-‐engineering hospital processes that improve pa'ents’ experience of care
Hospital Value-Based Purchasing
Measures (for FY 2015) • 12 Clinical Process of Care measures
• 8 PaJent Experience of Care dimensions (HCAHPS) • 3 -‐ 30-‐Day Outcome Mortality measures:
– Acute Myocardial Infarc&on (AMI) – Heart Failure (HF) – Pneumonia (PN)
• 1 Agency for Healthcare Research and Quality (AHRQ) Composite measure: – PaJent Safety Indicator (PSI-‐90)]
• 1 Healthcare Associated InfecJon: – Central Line-‐Associated Blood Stream InfecJon (CLABSI)
• 1 Efficiency measure: – Medicare Spending Per Beneficiary (MSPB)
CMS Value Based Purchasing
Clinical Process of
Care 20%
Outcomes 30%
Patient Experience
of Care 30%
Efficiency 20%
Payment Period FY 2015
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CMS is rapidly changing the weigh9ng of each Value Based Purchasing Domain as well as the content within each domain making systema9c and proac9ve performance improvement more difficult.
Payment Period FY 2014
Payment Period FY 2016
Hospital Readmission • In FY 2013 and 2014, inpaJent prospecJve payment system hospitals with
higher-‐than expected readmissions rates have experienced decreased Medicare payments for all Medicare discharges
• Performance evaluaJon is based on the 30-‐day readmission measures for MI, heart failure and pneumonia that are currently part of the Medicare pay-‐for-‐reporJng program and reported on Hospital Compare
• A hospital-‐specific readmissions adjustment factor is based on the number of readmiged paJents in excess of the hospital's calculated expected readmission rate or – 0.99 in FY 2013; 0.98 in FY 2014; and 0.97 in FY 2015 and beyond. – This means the largest potenJal reducJon for a hospital was 1 % in FY
2013; 2 % in FY 2014; and 3 % in FY 2015 and beyond. This reducJon applies to all Medicare discharges.
• CMS finalized the expansion of the applicable condiJons for FY 2015 to include paJents admiged for: – (1) chronic obstrucJve pulmonary disease (COPD) – (2) paJents admiged for elecJve total hip arthroplasty (THA) and total
knee arthroplasty (TKA)
Bonuses And PenalJes For U.S. Hospitals
H2H Core Concepts 1. Medica&on Management Post-‐Discharge
Is the pa9ent familiar and competent with his or her medica9ons and is there access to them?
2. Early Follow-‐Up Does the pa9ent have a follow up visit scheduled within a week of
discharge and is she or he able to get there?
3. Symptom Management Does the pa9ent fully comprehend the signs and symptoms that require
medical aMen9on and whom to contact if they occur?
ACC Patient Navigator Hospitals Advocate Sherman Hospital Elgin, IL
Aurora BayCare Medical Center Green Bay, WI
Bap&st Health Louisville Louisville, KY Barnes Jewish Hospital St. Louis, MO California Pacific Medical Center, San Francisco Centra Lynchburg General Hospital Lynchburg, VA
Chris&ana Care Health Services Wilmington, DE Einstein Medical Center Philadelphia, PA Fairview Hospital Cleveland, OH Huntsville Hospital Huntsville, AL Indian River Medical Center Vero Beach, FL Indiana University Health Methodist Hospital IN MedStar Washington Hospital Washington, DC Mercy Hospital Portland, ME Mercy Medical Center-‐ Des Moines, IA Montefiore Medical Center New York, NY Newark Beth Israel Medical Center, Newark, NJ Olathe Medical Center Olathe, KS
Providence St Vincent Medical Center OR Renown Ins&tute Reno, NV
Ronald Reagan UCLA Medical Center CA Scoc & White Healthcare Temple, TX St. Mary’s Hospital Waterbury, CT St. Vincent’s Medical Center Bridgeport, CT Mul&care Tacoma General Hospital Tacoma, WA Trident Health Charleston, SC University of Colorado Hospital Aurora, CO University of Utah Health Care Lake City, UT UT Southwestern Medical Center Dallas, TX
Vanderbilt Heart and Vascular Ins&tute TN VCU Pauley Heart Center Richmond, VA WakeMed Health and Hospital Raleigh, NC West Jefferson Medical Center Marrero, LA Western Maryland Health System Cumberland, MD Wyoming Medical Center Casper, WY
Brush JE Jr, Handberg EM, Biga C, Birtcher KK, Bove AA, Casale PN, Clark MG, Garson A Jr, Hines JL, Linderbaum JA, Rodgers GP, Shor RA, Thourani VH, Wyman JF. 2015 ACC health policy statement on cardiovascular team-‐based care and the role of advanced pracJce providers. J Am Coll Cardiol 2015;65:2118–36.
Advocacy • The West Virginia Chapter achieved three important victories in this year’s
legislaJve session. 1. LegislaJon was passed requiring public school students in West Virginia to
complete a course in hands-‐on instrucJon in cardiopulmonary resuscitaJon in order to graduate. West Virginia becomes the 21st state to enact such a law.
2. The state also passed shared use legislaJon which allows schools that choose to open their doors to community groups for recreaJonal purposes to do so and protects them against frivolous lawsuits. West Virginia becomes the 31st state to enact shared use legislaJon.
3. A bill strongly opposed by the West Virginia Chapter, the American Heart AssociaJon and the West Virginia State Medical AssociaJon was killed by the House Commigee on Health and Human Resources which refused to consider it. The bill, as passed by the Senate, would have exempted veterans’ organizaJons and acJve duty military organizaJons from county indoor smoking rules (West Virginia does not have a statewide Smoke Free law). The bill also would have permiged smoking in establishments restricted to persons age 18 years or older.
HUGE Advocacy Win: passage of the Medicare Access and CHIP Reauthoriza&on Act of 2015 (MACRA)
The bill permanently repeals the Sustainable Growth Rate (SGR), establishes a framework for rewarding clinicians for value over volume, streamlines quality repor9ng programs into one system, and reauthorizes two years of funding for the Children’s Health Insurance Program.
April 21, 2015
ACC Advocacy PrioriJes
• CreaJng a value-‐driven health care system • Ensuring paJent access to care and cardiovascular pracJce stability
• PromoJng the use of clinical data to improve care • Fostering research and innovaJon in cardiovascular care
• Improving populaJon health and prevenJng cardiovascular disease
What is the ACC Doing About MOC?
February 2, 2015
February 2, 2015
“ABIM will work with medical socieJes and directly with diplomates to seek input regarding the MOC program through meeJngs, webinars, forums, online communicaJons channels, surveys and more. The goal is to co-‐create an MOC program that reflects the medical community's shared values about the pracJce of medicine today and provides a professionally created and publicly recognizable framework for keeping up in our discipline.” Rich Baron President and CEO
ABIM
• Already cer&fied by an ABIM member board. • Valid, unrestricted license to prac&ce medicine in at least one US state.
• Must have completed a minimum of 50 hours of CME within the past 24 months.
• For interven&onal cardiology, electrophysiology, candidates must have ac&ve privileges to prac&ce that specialty in at least one US hospital .
• $169/2 years
ACC Policy Regarding MOC
• ACC Board of Trustee’s Policy since 2014 – Create and provide MOC II and IV opportuniJes for ACC members who elect to parJcipate in MOC
– AcJvely engage in discussions aimed at improving the MOC process
2014 BOG Survey: Change in MOC Effect on Future Plans
Q. Have these recent MOC requirements affected your planning for the future, specifically thoughts of re9rement, part-‐9me prac9ce or transi9oning out of the prac9ce?
21%
3%
7%
5%
10%
17%
32%
37%
0% 5% 10% 15% 20% 25% 30% 35% 40%
Not sure/No answer
Not applicable
Other
Work part time
Transition out of practice
Retire earlier
Total Yes
No
• Respondents are divided on how the change in MOC will affect their future plans with almost two-in-five (37%) saying the new requirements will not affect future planning while one-third report that they will retire earlier, work part time or transition out of practice; 21% are not sure.
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2014 BOG Survey: Recommended MOC Process Revisions
Q. If you were tasked with revising the MOC process for cardiologists, which of the following would you recommend? Please select all that apply.
5%
7%
3%
2%
13%
17%
21%
29%
38%
44%
0% 10% 20% 30% 40% 50%
Not sure/No answer
Other
Keep the revised current 2014 MOC Requirements in place/ No need to revise
Keep Part 3 and get rid of Part 2
Keep Part 3 and get rid of Part 4
Keep Part 2 and get rid of Part 3
Keep Part 2 and get rid of Part 4
Revert to the pre-2014 certification process andrequirements
Remove MOC as a requirement for practicing cardiologists
Have ACC assume certification responsibilities from ABIM
• Clearly members (92%) want the MOC process revised. Having ACC certify (44%) is most popular followed by removing MOC as a requirement (38%), reverting to the pre-2014 requirements (29%), and getting rid of Part 4 (28%) and Part 3 (17%). Only 3% want to keep current MOC requirements in place.
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The ACC and MOC • ACC Policy – Point # 1: Create MOC educa&onal opportuni&es to serve the needs of ACC members
– >1,200 MOC quesJons available for ACC members • MulJple specific subject modules are available on ACC.org • Most are free of charge
The ACC and MOC • ACC Policy – Point # 2: Engage in efforts to improve MOC
– March-‐November 2014, seven separate meeJngs and discussions held between ACC and ABIM leadership, documented in two JACC Leadership Pages:
• O’Gara PT, Oetgen WJ. The American College of Cardiology’s response to the American Board of Internal Medicine’s Maintenance of CerJficaJon requirements. JACC. 2014 Aug 5;64(5):526-‐7.
• O’Gara PT, Oetgen WJ. Follow-‐up on ABIM Maintenance of CerJficaJon. JACC. 2015 Jan 20;65(2):207-‐11.
– December 2014 – April 2015, four addiJonal meeJngs held
The ACC and MOC • ACC Policy – Point # 2: Engage ABIM in efforts to improve MOC
– ACC recommendaJons to ABIM to improve MOC • Create a dual pathway for recerJficaJon (+/-‐ secure examinaJon) • Harmonize CME and MOC points • Recognize ongoing hospital-‐based quality improvement projects as fulfilling Part-‐IV requirements
• Eliminate “double jeopardy” for CV sub-‐specialists (EP, IC, AHFTC) • Reduce fees • Improve ease of interacJon with ABIM website • Relax Jme restricJons for diplomates who fail the secure examinaJon • Expand MOC opportuniJes for clinically inacJve diplomates
The ACC and MOC • ACC Policy – Point # 2: Engage ABIM in efforts to improve MOC
– ABIM AcJons (in response to mulJple stakeholders) • February 2015 – for at least two years
– Suspended paJent safety requirement – Suspended paJent voice requirement – Suspended Part IV requirement – Froze fees – Changed website wording from “MeeJng MOC Requirements” to “ParJcipaJng in MOC”
• April 2015 – Allow most CME acJviJes to count for MOC
The ACC and MOC • ACC Policy going forward – BOT meeJng March 2015
1. ConJnue to create educaJonal resources 2. ConJnue to engage with the ABIM to improve MOC process
3. Consider creaJng a new cardiovascular board • ACC president Kim Williams has created two Task Forces to consider the second and third paths
The ACC and MOC • ACC Task Force on ABIM Liaison
• Charge: To liaise with the ABIM and the ABIM Cardiovascular Board for the purposes of: – (1) providing advice and direcJon for modificaJon of Maintenance of
CerJficaJon (MOC) processes and – (2) providing input for the topics to be included in cerJficaJon and
recerJficaJon procedures.
– Chair – Patrick O’Gara – Vice-‐chair – Richard Chazal – Task Force Members
• Mary Norine Walsh Robert Shor Carole Warnes • Paul Casale Richard Kovacs Deepak Bhag • Eric Williams Jeffery Kuvin Roxana Mehran • Jodie Hurwitz Eric Bates
The ACC and MOC • ACC Task Force on Cardiovascular Board AlternaJves
• Charge: To advise the ACC BOT on opJons and recommendaJons with regard to developing or parJcipaJng in a cardiovascular board outside of ABIM.
– Chair – Richard Chazal – Vice-‐chair – Mary Norine Walsh – TF Members
• Robert Shor Carole Warnes Patrick O’Gara • Paul Casale Richard Kovacs Deepak Bhag
Progress to Date • ACC Task Force on ABIM Liaison
• Discussions with: CEO, CV Board chair, ExaminaJon Board Chair • Points of discussion:
– Double jeopardy – Feasibility of dual pathways for MOC (modules vs. secure exam) – RelaJonship between CME and MOC – Assessment and reporJng of QI – Defining competence for pracJcing cardiologist – Understanding co-‐creaJon – Making secure exam more relevant to one’s area of pracJce – Fees – Hybrid model: ABIM provides cerJficaJon; ACC assumes recerJficaJon. Others? – Research into MOC/CME. How to do, endpoints, etc
Progress to Date • ACC Task Force on Cardiovascular Board Alterna&ves
• Discussions with Lois Nora, MD, JD, MBA, President and Chief ExecuJve Officer of the American Board of Medical SpecialJes (ABMS)
• Discussions with Rich Baron, MD, CEO of ABIM, clarifying ACC intent to pursue alternate opJons if ABIM acJons were not saJsfactory
• ConversaJon with Dr Teirstein soliciJng his parJcipaJon in upcoming meeJng of task force to provide insight and informaJon.
• 2015 BOG Survey • data being collected • Results available in mid-‐May
OpJons Available to ACC Members
• Ignore RecerJficaJon • Go with new board • “Wait and see”
Summary: Naviga&ng the Healthcare Horizon
• VBP – ACC providing guidance and naJonal QI to navigate the change
• Team-‐based care – Current policy statement. Others pending.
• MOC – ACC members should have opJons for recerJficaJon.
– ACC is engaged in evaluaJng potenJal opJons on behalf of its members.
– ACC expects this process to be thorough but Jmely.
Summary: Naviga&ng the Healthcare Horizon
• Advocacy – Important wins this year – The ACC PAC allows our Advocacy Team to focus on issues that mager
• ACCPAC NaJonal Fundraising for the 2016 ElecJon Cycle* – 2015: 629 Individuals Contributed $207,925 – Average ContribuJon-‐ $331
• We need WV parJcipaJon!