Physician Accountabilities in Health System Reform: A View from the ACC Jack Lewin, M.D., CEO The American College of Cardiology

Jack Lewin MD I have no disclosures to note.

"It's tough to make predictions, especially about the future.“   ~Yogi Berra

“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” ~ Charles Darwin

“You can lead a man to Congress, but you can’t make him think!” ~ Milton Berle

ACC Health Reform Priorities Universal Access Public and private system Quality (value) definition, measurement Coordination of care systems Payment reform evolution Professionalism

The Bullish Forces

ACA The beginning or result of health reform?

Percent of median family income required to purchase family health insurance Source: Author’s calculations, using KFF and AHRQ premium data, CPS income data, plus projections from Carpenter and Axeen, The Cost of Doing Nothing, 2008. 13

Medicare is unsustainable now (percent of GDP, projected) Source: Medicare Trustees Report:, 2009. 14

The pressure for cost containment and fair competition in a global economy

The pressure for integration and consolidation Physicians, hospitals and insurers ACOs Employer and consumer groups Vertical vs. horizontal integration

The pressure for physician employment AMA, ACC estimates Lifestyle preferences of young physicians Vertical vs. horizontal integration

Changing Cardiology Practice Landscape 14% The majority of private CV practices (excluding solo practitioners) – 60% – have engaged in integration/merger activity. CV practices are more likely to integrate into a hospital setting than merge with another practice (38% vs. 14%). The ACC’s 2010 Practice Census was conducted from May 5 through August 9 by e-mail and telephone. A total of 2,413 unique practices from 49 states and Puerto Rico participated in the study. The response rate was 31 percent.

The pressure to move away from fee-for-service reimbursement Payment reforms PCMH (patient centered medical home) HOPPS Government strategy

The pressure for delivery system reform EHRs and Meaningful Use Team care PCMH vs. minute clinics Specialty hospitals Prevention and disease management Care coordination, H2H, etc.

The pressure to measure and report on quality improvement Public reporting expectations Who measures Q in payment reform? Claims vs. clinical data The importance of registries Measurement at the point of care

The pressure to create patient financial incentives related to health care costs Employer actions Government actions Co-pay incentives Preferred networks, Centers of Excellence and CV Practice Improvement Program (CPIP)

The pressure to improve population health

ACC 2011 Top Advocacy Priorities Feedback from CCO, Leadership Forum and BOG

Likely 2011 Top Priorities ACA and HSR issues Payment reform issues Private practice protections State advocacy issues Innovation and science Meaningful use and HIT Public reporting

The Most Important? Payment reform Tort reform The ongoing nuts and bolts: SGR, RUC, CMS regulations, insurers, state legislatures

Other Key Issues Reducing disparities (and expanding access) Public reporting (& clinical data vs.claims data) Medicaid reform issues (especially peds cardiology) Workforce and changing demographics and generational influences Team practice and delivery system models Public health and prevention Technology and ability to share social tools Monitoring self referral protections under Stark, including CV hospital employed contract issues

ACA Clean Up Priorities Payment Reform and ACOs Anti-trust relief Value-based reimbursement Level playing field? Physician regulation and the IPAC (HR 452) Major risk for physicians – hospitals, too? Tort reform (Gingrey) Medicare/Medicaid reimbursement issues HOPPS assault?

ACA Opportunities CMS innovation center grants -- $10 billion Workforce transitions Graduate medical education issues PCORI

Accountable Care Organizations ACOs What are they? Who governs them? Will payment incentives be real? A unified policy position for medicine? Hospital and physician alignment

Risks and Opportunities

Accountabilities

Uniting a fragmented profession

Train wreck at Montparnasse Station, Paris, 1895. Studio Lévy & fils.

Who will save us?