1. Advocacy Affordable Care Act, the Supreme Court and What Lies Beyond James Fasules, MD, FACC

2. 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

4. “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)

5. Supreme Court Decision Anti- 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

6. 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.

7. 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

8. 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 Yes * Based on 2013 data

9. 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

10. Reform and the ACC 2000 ACC Principles for Health System Reform and the Uninsured 1.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

11. 2008 Blue Ribbon Panel 1. 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

12. 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

13. 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

14. 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 testing Because we should; not because we can ABIMF Choosing Wisely Campaign Improve cost effectiveness of CV care

15. 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)

16. The 2013 “Rule”

17. 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

18. “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%

19. Plenty of Other Issues (DOJ)

20. Politics and The Big Issues

21. “You can lead a man to Congress, but you can’t make him think.” Milton Berle Political Climate of the 112 th

24. “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

25. 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

26. "It's tough to make predictions, especially about the future." -- Yogi Berra Change will happen Episode groupers? Entitlement reform? ?????????

27. ACC Strengths: Quality, Tools, and Education Personal Lifelong Learning Portfolio

28. 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

29. 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