What Do Working Cardiologists Really Think About the ACC's CMP Pathway?

What do US cardiologists and electrophysiologists REALLY think about the American College of Cardiology's (ACC) heavily-promoted collaboration with the American Board of Internal Medicine (ABIM) to create their "Continuous Maintenance Pathway" (CMP) for continually maintaining their ABIM board certification?

That's a question I wanted to know, so I helped create a quick 5-minute survey on the matter open to US cardiac electrophysiologists, cardiologists, and heart failure specialists.

I hope to have the results compiled by the Heart Rhythm Society in May, 2019.

I look forward to your responses and thoughts. Additional comments regarding the CMP program not covered in the survey can be left in the comments on this blog post.

Thanks-

-Wes

On the ACC's Response to ABIM’s MOC Requirements

The American College of Cardiology (ACC) recently issued a response to the American Board of Medical Specialties (ABMS) and American Board of Internal Medicine's (ABIM) recent change to their Maintenance of Certification (MOC) requirements. The ACC's response was based in part on the results of a completed member survey that was distributed through their state chapters in the spring of 2014. The survey was completed within four weeks by over 4,400 members (12 percent of the total solicited). Nearly 90 percent of respondents opposed the changes to the American Board of Medical Specialty (ABMS)/American Board of Internal Medicine (ABIM)'s new Maintenance of Certification (MOC) requirements, citing, among multiple concerns, higher than expected costs. Nearly a third of respondents indicated that the changes will affect their future career plans and will likely accelerate career decisions such as early retirement, part-time work, or transition to non-clinical work. Approximately one-quarter of physicians in practice for 15 years or more specified that early retirement was a probable outcome.

If true, the implication of this change to MOC has significant implications for patients everywhere.

This must have prompted the leadership of the ACC to throw their considerable weight into the discussion with the ABIM. In their statement, the ACC promised to:

• Have "ongoing discussions" with ABIM leadership, in partnership with other cardiovascular professional organizations whose members are similarly affected, to review these issues and to explore changes in MOC requirements that will result in more meaningful outcomes and less onerous burdens for ACC members (Editor's note: To date, MOC has never been shown to alter outcomes, so we are left to wonder what this statement really means.)
• Request for ACC representation at ABIM to participate in discussions involving MOC, including its educational and financial aspects (Editor's note: What financial aspects might they mean? Does the ACC want in on this cash cow, too? Or might they want to strike a deal offset some of the fees since they want to keep their educational MOC-preparation income stream coming?
• Review of the evidence base underlying current recommendations (Editor's note: Let me help: there are none. Any positive articles are likely authored by those standing to profit from the endeavor or research paid for by the ABMS. Negative articles are also suppressed from publications sympathetic to the regulatory world. And we should recognize that we have never developed a definition of the "quality" physician. Quality to whom? Is "quality" following rubrics and care pathways? Or might "quality" be something very different, like empathy, listening skills, interpretative skills, or surgical skill? The reality is, if you can't agree on what defines quality, you can't define how to measure it.)
• Investigation of impact of MOC changes on non-ABIM certified members (Editor's note: I strongly agree with this - it is unethical to impose MOC mandates of any kind without first understanding how they negatively affect doctors, especially if a doctor should not pass and is unable to practice their vocation on the basis of a 180-question timed test)
• In the interim, ACC will support its membership by:
  • Free provision of web-based MOC modules and navigation tools to ACC members
  • Expansion of Part IV MOC modules through ACC programs such as the NCDR’s inpatient registries and the PINNACLE Registry
  • Creation of mechanisms for ACC members by which patient safety and patient survey requirements can be efficiently fulfilled
  • Bidirectional communication with and engagement of membership through Chapters, Sections and Councils.
  (Editor's note: It's okay to make MORE MOC modules available to us? Is that what doctors want? How many more hours must we spend on this drill and for how much time in lost revenue? "Free" is in the eye of the ACC, not those who have to endure these processes.)

The good news (if there is any with the ACC's announcement), is that front-line doctors are starting to be heard. While the ACC's actions might be a step in the right direction (one can hope), it is disappointing that their statement still sides with the ABIM's requirements for the unproven MOC process in the first place, the busy-work requirement for "Practice Improvement Modules" (especially when quality measures are already required by hospitals), and for permitting a private organization to monopolize the ability of physicians to practice their trade. Furthermore, the ACC's statement does nothing to insist upon changes to the ABIM's non-transparent and self-serving Conflict of Interest policies that keeps conflicts confidential except to certain chosen individuals within the ABIM.

Unless the ACC can convince the ABMS and ABIM to come clean on these important issues, significant physician resistance to this process will remain. Furthermore, the lack of involvement by other subspecialty boards in resisting the ABMS/ABIM's MOC process is concerning. Hopefully, other subspecialty boards will be encouraged by the ACC's example.

After all, cardiologists aren't the only ones frustrated by this change in MOC policy.

-Wes

Why Do Most Medical Professional Societies Call Chicago Home?

Professional medical societies "concerned" about physician education, advocacy and quality appear to have multiplied at an alarming rate over the years. Interestingly, it seems many of the professional offices of these societies are based in Chicago.  On my review, no other city in the United States hosts more of them (not even Philadelphia).

Why is this?

First, there is the grand-daddy of all physician professional societies: the American Medial Association based at AMA Plaza, 330 N Wacker Drive, Chicago. 

Next, there's the American Board of Medial Specialties (ABMS) (who boasts its supervisory role over 24 subsidiary specialty medical societies across the nation, including the American Board of Internal Medicine and the American College of Cardiology among others) that has it's home at 222 North LaSalle Street in Chicago, just blocks away from the AMA building.  

Next, there's the little-known Council on Medical Specialty Societies,  who also seemed to be concerned with physician "quality" located just across the Chicago river at 35 E. Wacker Drive.

And let's not forget the Acceditation Council on Graduate Medical Education who oversees all graduate medical education in the United States located at 515 North State Street in Chicago.

Makes you wonder why all of these societies are within blocks of each another in Chicago. 

Maybe it's so they can have lunch together.  Maybe it's because of all of the academic medical centers located here in Chicago who have retiring professors that need a place to land.  Maybe it's because of the state's political leanings.  Or perhaps it's just because of Chicago's fairly central US geographic location? 

One thing's for sure, it certainly isn't because of low real estate prices or low taxes.

-Wes

When Scientists Accept "Flawed" as "Reassuring"

A recent essay entitled "Understanding the Customer and the New MOC Changes" by David May, MD, PhD, chair of the Board of Governors and secretary of the Board of Trustees for the American Board of Cardiology, was published online and tugs at our heartstrings by describing the Maintenance of Certification (MOC) secure examination in Cardiovascular Diseases as "flawed but reassuring measure of our competence for the real customer here … our patients and their families who trust us with their very lives."

I read this piece after recently completing the MOC process in both cardiology and cardiac electrophysiology for the third time.  After devoting hundreds of hours preparing for an impersonal timed computer test yet again, I couldn't help but wonder if physician scientists should ever accept a "flawed" process as acceptable for our ourselves or our patients. Imagine the implications to scientific inquiry and the process of challenging (and thereby improving) the educational process if we did:  we might have to accept media reports to justify the process so we can make it even bigger.

Patients deserve transparent quality metrics of care provided by their doctors and the American College of Cardiology (ACC) has been a unique leader in bringing measurable care metrics to the public with the development of their NCDR databases. Yet instead of turning to these real life metrics of care delivery, it seems the leadership of the ACC also feels compelled to sell a "flawed" educational testing construct to its members too. Is this decision based on a self-imposed imperative to dispense social justice at the bedside or more for the direct financial renumeration received by the officers of the College or it's parent, the American Board of Medical Specialities?

I believe there is merit to becoming Board Certified in a subspecialty once. A baseline of knowledge is assessed by this process. But the move to the current model of "maintaining" certification through complicated, costly, and unproven methods of survey completion, administrative and academic busy-work, followed by a timed multiple-choice computerized test overreaches into unproven areas of quality assurance.

To me, a better measure of physician competence and quality would be this: Board Certification once followed by disclosure of the total number of patients treated or the total number of procedures performed pulled from databases akin to the NCDR databases in development.  Such a method would align with current documentation requirements for assuring quality patient care and would avoid alienating busy physicians already faced with unprecedented regulatory scrutiny, steep pay cuts and loss of autonomy.

Pretending that the MOC process is a better method to assess competence rather than one's clinical experience in delivering real, live, clinical care feeds unrealistic expectations and may even promote a false sense of security to our patients.
 
What patients and their doctors deserve (and need) is verifiable data, not propaganda.

-Wes

The American College of Cardiology Gets a New CEO

Since when does a pharmaceutical executive become CEO of the American College of Cardiology (ACC)?

Since now.

Call me crazy, but does this strike anyone else as strange?  Are physicians now officially incapable of leading the ACC or any other major professional doctor organization?  Have we not learned anything about the appearance of co-mingling pharmaceutical or medical device company executives with doctors? 

Oh, wait...

Maybe this is happening thanks to our grand health care reform efforts underway.  Maybe cardiology future battles will not be fought at the bedside, but rather in the boardroom or the halls of Congress.  When government calls the shots, lobbying is king, not 60-minute door-to-balloon times.

Need more Regulations?  Check.  Need some Appropriateness Criteria?  Check.  Guidelines?  Check.  Steering committees?  Check.  Ways to keep industry at scientific sessions?  Check.  Need an industry thoughtleader to write white papers on physician payment reform?  Check.

What was I thinking?  After all, pharmaceutical executives have "unique skills" and are accustomed to back-room deal-making, facing regulatory hurdles, basking in paperwork, and getting great benefits for themselves!  They know how to schmooze and mollycoddle the political class much better than doctors do, so why not turn to them for advise?  I get the plan - it's brilliant!  Who needs clinical cardiologists for leadership positions in their professional societies?

Seriously, what could possibly go wrong?

-Wes
 

Finally: Doctors Push Some Lawyers Around

Hard to believe, but true:

Ogletree Deakins will vacate its current D.C. office at 2400 N St. NW.

The labor and employment law firm is on the market for a new space because the owner of its building, the American College of Cardiology Foundation, wants to expand into Ogletree’s space. The nonprofit bought the Class A, 177,380-square-foot building in 2005 for $67 million, according to D.C. tax assessment records.

You've got to love this: our one chance to push around 450 lawyers!

On a more serious note, do fund raising, guideline development, lobbying efforts and scientific meeting organization on behalf of our specialty really require that much space?

-Wes

Live Blogging the ACC.10 Meeting

It's official.

I've been asked by the ACC to help live blog portions of the ACC.10, i2 Summit in Atlanta March 14-16, 2010 that includes a Health Information Technology spotlight session.

There will also be a lively session entitled “U.S. Health System Reform: Where are we headed?” on Sunday, March 14 from 12:15 to 1:45 p.m. with both sides of the political aisle represented by Chris Jennings, Deputy Assistant to the President for Health Care Policy and Congressman Paul D. Ryan Jr. (R-Wis.). No doubt it will be as productive as yesterday's White House Health Care Summit.

There will also be a session on insights into the tort reform controversy from Richard Anderson, M.D., CEO of The Doctors Company. Trial lawyers are particularly invited to this session (I need news, after all!)

Needless to say, while electrophysiology remains my passion, I'll see if there's some new gadget, gizmo, controversy or cardiovascular policy issue that stretches beyond the typical fray.

You can follow the posts on this blog or via Twitter (@doctorwes).

For full disclosure, the ACC is paying my registration fee, but transportation and housing are on me. I am NOT industry sponsored for this event and the ACC only asks that I refrain from using four-letter words.

I'll try.

-Wes

JACC to Appear on the Kindle

This Christmas, I bought my wife, an unmitigated book-lover, a new Kindle 2 from Amazon. While she's a bit of a Luddite when it comes to technology, she has quickly become a believer - uploading three books at a time to bring with her on weekend trips. (She's even one of my three subscribers to this blog on the Kindle!) My only regret is hearing the soft "*click* ... (pause) ... *click*" in bed as she turns electronic pages at bedtime.

While hard copy books will still be great permanent reference sources, the plethora of fast-moving printed journals seem ripe for electronic disruption. I wouldn't be surprised to find that most journals as we know them eventually go the way of the dinosaur. As proof comes this from the ACC:

The Journal of the American College of Cardiology (JACC) will be available on the Amazon Kindle e-book reading device starting this March. JACC is the first cardiovascular journal on the Kindle platform and the second medical journal after the New England Journal of Medicine. Visit the Kindle store on amazon.com beginning on March 12 to order and learn more. Also, bring Kindle to ACC.10 in Atlanta to download the meeting abstracts and final program.

Welcome to the 21st Century!

-Wes

Doctor Paycut Suit Score: HHS 1, ACC 0

It's hard to bring a suit against lawyers. As case in point, from ModernHealthCare.com:

A U.S. District Court judge in Fort Lauderdale, Fla., has denied the American College of Cardiology's request for a preliminary injunction to block a scheduled Medicare reimbursement cut for cardiology services.

The ACC, its Florida chapter and other cardiology organizations filed a lawsuit against HHS Secretary Kathleen Sebelius on Dec. 28, seeking to stop the pay cut on the grounds that is based on the “erroneous and flawed” Physician Practice Information Survey. The ACC said Medicare payment cuts for 37,000 cardiologists are being based on the practice expenses of 55 doctors.

In addition to denying the injunction, Judge William Dimitrouleas denied a request for expedited discovery and canceled a scheduled hearing.

“We are deeply disappointed in the judge's decision not to hear our case on the preliminary injunction based on his opinion that the federal courts do not have jurisdiction to review Medicare physician payment determinations,” ACC CEO Jack Lewin said in a news release.

And from the ACC Advocate newsletter:

Basically, the judge refused to hear our case on jurisdictional grounds, finding that statutory language governing the Medicare program precludes judicial review of the relative value units and the methods for determining the RVUs in the Medicare fee schedule.

Interesting. So it seems that federal courts don't have jurisdiction over a federal program like Medicare's labyrinthine processes. Then who does?

(Maybe a sympathetic lawyer out there could explain this ruling to us not so legally inclined.)

-Wes

Getting Ready for the Cardiology Cuts

There are potentially plenty of ways cardiologists will see their payments decline next year: from the loss of Medicare inpatient consultation code payments to the 2010 physician fee final rule issued last week by the Centers for Medicare & Medicaid Services (CMS) which threatens to cut to cardiology practice procedural payments an average of 27 percent.

For those who want to calculate the potential impact to their practice, the American College of Cardiology has prepared a nifty Practice Impact Calculator that contains two worksheets: one for your practice and the other for the impact that loss of consultation codes will impart. Just enter this year's volumes and the calculator will do the rest.

Try not to get too depressed filling it out and consider sending your results to the ACC.

Oh, and more good news: please keep in mind that the proposed 2010 payments shown on the spreadsheet do not include the across the board 21.5% cut to the Medicare conversion factor that will take effect on January 1 if Congress fails to prevent it. Also, remember that this spreadsheet shows only the impact on Medicare payments. Many private payers follow along with Medicare’s payment trends, so reduced Medicare payments could be only the beginning.

-Wes

Photo credit.

What Doctors Do at National Meetings

Here's a cool time-lapse movie of the comings and goings at the ACC in New Orleans in 2007:



Kind of reminds me of Brownian motion in the physics lab.

-Wes

Looking in the Mirror

The left-leaning National Physicians Alliance blog has decided to take on the American College of Cardiology.

Now as a Fellow in the American College of Cardiology, I don't agree with these guys on many things, but I think regarding the above post, they are right on the money as they describe the complicated interplay between the pharmaceutical and medical device industries and those of physicians' need for continuing education.

It was interesting to note that the ACC heavily promoted their "Quality First" initiative at this year's meeting and solicited input from physicians to garner "our feedback" in a survey distributed to the doctor-attendees. I found the survey hidden amongst the multitude of pharmaceutical swag and program outlines residing inside my handy-dandy co-branded Lipitor-ACC.08 shoulder bag. (I regret that I did not get the 1 GB USB drive they promised to the first 500 survey participants as I never saw this survey until I arrived home).

But their list of "key features" embodying the ACC's Quality First Campaign were presented unilaterally, without physician discussion. On the surface, they seem so necessary. What right-minded doctor would not want these things?

Here's what we were asked to rank (from "not important" to "very important") and my initial thoughts as I read these features in italics:

• "Provide universal access through an expansion of public/private financing" (What? Does this mean "support universal health care?" - a buzz-word of the Dems? Does expanding public/private financing mean promote Health Savings Accounts - a buzz-word of the Repubicans? Hellllloooo, people! What the hay are we talkin' 'bout here?)
• "Increase patient value through the delivery of evidence-based, high quality care" (Excuse me, isn't that what we're already doing? Are you asking for another 74 "quality measurements" to keep track of (like shorter door-to-balloon times) with even more bureaucracy and documentation so we can pat ourselves on the back and be on the "100-best hospital list" one more time?
• Manage care by disease state and across sources and sites of care (Huh? I never liked "managed care." Is this what you mean? Or are we promoting the EMR here?)
• Implement a payment system that rewards quality, value, and coordinated care management (Oh, my God! Pay for Performance! eeeeeeekkkkk! Please, lets call this covert rationing scheme what it is: "Less Pay for Performance," okay?)
• Involve patients as partners in their own care Uh, excuse me, who has more of a vested interest in their care than the patient with the health problem? What the heck is this supposed to mean?

So what is the ACC's policy direction with these questions? Are they really interested in physician's input and a two-way discussion? Or are such surveys really manipulations of doctors for political intent? How, exactly, will this survey data be used? I can hear it now as our ACC leaders stand before congressional subcommittees and extol: "According to our carefully-conducted (and coerced survey through the use of a 1GB USB storage drive), 65% of surveyed physicians want pay for performance initiatives."

Finally, is our "quality" in cardiology so bad? Haven't we seen a dramatic decline in the incidence of cardiovascular morbidity and mortality over recent years?

Increasingly, large meetings struggle to balance marketing, policy, and educational missions in the backdrop of the medical industry's Big Money. But given the covert and conflicted issues at play, disclosure of these conflicts might no longer be enough: disentanglement of interests might be the better norm.

Maybe first re-evaluating our real priorites regarding the objectives of these meetings should be the "key feature" of the ACC's next Quality First Initiative.

After all, others already have taken the lead and I like the other guys' meeting space better.

-Wes

Nothing is Sacred

Wow, the REVERSE Trial studying the benefits of cardiac resynchronization therapy on asymptomatic (New York Heart Association Class I) to minimally-symptomatic (NYHA Class II) are set to be presented at 10:30 today here in Chicago at the ACC Meeting, but this press release of the results is available at 09:00 CST on-line.

This pre-release reporting continues to undermine any reason doctors might want to attend these meetings any longer - it's more efficient to sit at work and surf the 'net.

-Wes

"Entrepreneurial Guidelines" SHAPE Up Poorly

Namby pamby. That's what Robert Lindeman, MD (aka the infamous former blogger, Flea) called us bloggers.

A bunch of wimps.

And you know what?

Many of us are. Perhaps for self-preservation. Perhaps to avoid having our words used against us in the court of law later.

But we're not the only ones. Our own professional societies including the AHA and ACC have been namby pamby, too, in my book - especially when it comes to refuting the "entrepreneurial" guidelines proposed by the "Association for the Eradication of Heart Attack (AEHA)." This group, with reportedly altrustic intent, has been so riddled with conflicts of interest, it makes one's head spin.

And now this group wants to MANDATE that insurers HAVE to pay for atherosclerosis screening tests, of which their organizer, Dr Morteza Naghavi, has a significant financial interests as founder and shareholder of Volcano Corporation and Endothelix, Inc.:

Later this year, Texas House Representative Rene Oliveira plans to introduce—for the second time—his bill into state legislature that would mandate insurers to cover screening of asymptomatic atherosclerosis using calcium scanning and carotid ultrasound, as set out in the SHAPE initiative.

Everyone was namby pamby except Peter D. Jacobson, JD, MPH, of the Center for Law, Ethics, and Health, University of Michigan School of Public Health.

He had balls. Big ones. In his editorial in JAMA, he called the practice of accepting unvetted self-initiated "entrepreneurial guidelines" into question, and wondered why the AHA, ACC, and National Institute of Health have been so namby pamby about refuting an initiative so ripe with conflicts of interest.

(theHeart.org) As reported by heartwire, the controversial SHAPE task-force report was published as a Pfizer-sponsored supplement in the American Journal of Cardiology and initiated by the Houston-based Association for Eradication of Heart Attack (AEHA), founded by Dr Morteza Naghavi (American Heart Technologies, Houston, TX). While a number of prominent cardiologists were on the writing group and editorial committee for the SHAPE report, which explicitly billed itself as "a new practice guideline for cardiovascular screening in the asymptomatic at-risk population," neither the ACC nor the AHA—both of which have released their own cardiac imaging guidance documents in the past few years—were involved in the SHAPE recommendations.

In interviews with heartwire when the SHAPE publication first came out, representatives from the ACC, AHA, and the National Heart, Lung, and Blood Institute all distanced themselves from the SHAPE document. In an editorial published in August 2006, shortly after the SHAPE report came out, Journal of the American College of Cardiology editor-in-chief Dr Anthony DeMaria called the SHAPE guidelines "a proactive effort . . . for a strategy for which the evidence of efficacy remains unestablished". He also noted that the contribution of "several individuals who hold or have held leadership positions in national/ international medical societies" to the SHAPE report might convey the impression those organizations "approve" of the guidelines. "This is obviously not the case," DeMaria stated.

From opinion to law?

Oliveira first filed his Texas Heart Attack Prevention Bill in February 2007, his first full day back in office after CABG surgery, a procedure he underwent after a CT scan indicated severe coronary blockages. According to his chief of staff JJ Garza, the first time around, the heart-scan bill was rolled into an omnibus bill that was ultimately voted down, although no one actually objected to the heart-scan portion of the proposed legislation. Oliveira intends to introduce his bill again, as standalone legislation, when the legislature meets again in January 2009, although he may opt to "prefile" his bill in November 2008 after compiling the "latest scientific evidence," Garza told heartwire. Garza also emphasized that the bill "is not the SHAPE recommendations," takes other scientific research into account, and may even be redrafted to reflect new evidence before being filed. "The universe covered by the legislation is smaller than the universe SHAPE outlines," he stated.

In the meantime, Jacobson, in his JAMA commentary, points out that there is no proof that adopting the SHAPE guidelines will do more good than harm, particularly since they were neither peer reviewed nor endorsed by the major professional societies in the US or the European Society of Cardiology. The problem here, he argues, is that while clinical practice guidelines form the backbone of evidence-based medicine and are "flexible instruments" that are or should be subject to rigorous scientific analysis, legislative mandates, by contrast, are "inflexible, static, and not as easily changed as science advances" or may prematurely support unproven strategies.

So kudos to Dr. Jacobson for having the gonads to call a spade a spade. But then again, maybe the ACC's ties to Big Pharma had something to do with their namby pamby attitude toward others with similar conflicts of interest.

Let's hope not.

-Wes