ACC Board of Governors Meeting Washington DC September 12, 2010

1. ACC Board of Governors Meeting Washington DC September 12, 2010 Ralph Brindis, MD MPH FACCPresident, American College of CardiologySenior Advisor for CV Disease, Northern California Kaiser PermanenteClinical Professor of Medicine, UCSF

3. Stormy Waters • Continued Reimbursement Cuts • Medicare Imaging, Consultation code, & Procedures – CMS and Payers • SGR Continuing Saga • Imaging “Substitution” Payer Strategies • Increasing pre-authorization Strategies • Migration to Hospital Practice Integration Models • Competency- MOCs, Accreditations • Demand for Quality Reporting • Demand for Public Reporting & Transparency • EHR and Meaningful Use Adoption • Demand for Appropriateness Evaluations • Maryland State and DOJ Alleged Fraud investigations

4. Societal Perceptions of Clinicians Knights ???

5. Societal Perceptions of Clinicians Knaves???

6. Societal Perceptions of Clinicians Pawns???

7. If Clinicians are Knights • “Knighthood” the definition of Professionalism • Stewardship for Healthcare system in our hands • Trusted to practice Appropriate Use of resources • Champion of patients and policies to support our work • Save and improve lives, financial gain is secondary • Continuing education and clinical and basic research • Respected advisor for policy and payment when policy affects health of public Jain & Cassel JAMA 2010;304:1009-1110

8. If Clinicians are Knaves • Policy, management and educational efforts designed to combat and work against clinicians and not for them • Self-interest/financial gain first; patents secondary • Need rewards and incentives to motivate • Monitoring for abuse, fraud and waste required • Learn new techniques/procedures for personal gain • Research for self-glorification and narcissism • Health care system functions in spite of … not due to them • Regulations guard against malfeasance and need for public protection Jain & Cassel JAMA 2010;304:1009-1110

9. If Clinicians are Pawns • Systems to ensure pawns do “right” as can’t be trusted on their own • Pawns behaviors unpredictable, a function of practice environment • Policy makers/regulators must decide clinical priorities and guidelines • Pawns study because licensing and board exams require they do so • Do more or less testing based on external requirements not clinical need • Pawns adapt to local culture and expectations in any practice setting • Health policy and regulations guides every pawn’s behavior due to lack of personal agency and judgment to reliably do what is right Jain & Cassel JAMA 2010;304:1009-1110

10. Clinicians viewed as Knaves & Pawns NOT Knights - Implications Behavior tied to rising healthcare costs and increased scrutiny over quality of care: • Clinician viewed an obstacle not an enabler to functioning health care system • Rather than by our professional ethic, “need” to be guided strict regulations or incentive payments • Subjected to periodic exams to demonstrate competence

11. Clinicians viewed as Knaves & Pawns NOT Knights - Implications • Views of unwarranted variations in care, evidence of waste and occasionally fraud • The modern US clinician now regarded as a Knave or a Pawn - rarely as a Knight !!

12. ACC Theme 2010-2011The Knighthood of Professionalism • Commitment to: • Professional Competence • Honesty with Patients and Patient Confidentiality • Improving Quality of Care • Improving Access to Care • A Just Distribution of Finite Resources • Scientific Knowledge • Maintaining trust by managing conflicts of interest • Professional responsibilities • Courage to lead and take a public stance

13. Professionalism: Current ACC Core Values • Professionalism • The interests of patients are primary • Knowledge • The College must promote growth, dissemination and application of knowledge about cardiovascular medicine. • Value of the cardiovascular specialist • The cardiovascular profession makes a distinct contribution to medical care that should be recognized and enhanced. • Integrity • Honesty, compliance with legal requirements, and ethical behavior are essential in all activities. • Member driven • The College and its major activities must be led by active members and must promote volunteerism. • Inclusiveness • The College involves a broad range of volunteers that reflects the composition of its membership.

14. ACCKnighthood of Professionalism • Relationships with Industry • Health Care Reform • ACOs/Patient-Centered Home • Team Based Health Care • Payment Reform Pilots • CREDO- Disparities • CARDIOSMART • CV Physician Leadership Institute

15. ACCKnighthood of Professionalism • Education • Life Long Learning • Innovation in Guidelines- Vivisio/CardioCompass • CVRP/CPIP • MOC and PIMS • PI-CME • Cardiosource/ACCEL innovations • Simulation

16. ACCKnighthood of Professionalism • Science and Quality • FOCUS and Appropriate Use Implementation • PINNACLE • Expanding Registry Portfolio • ACE initiative – CathPCI and Carotid Stent CQI & AUC • H2H, D2B, Sustain the Gain, ML • CER Grants- ASCERT and more • Participate and promote CER development • Radiation Safety

17. ACCKnighthood of Professionalism Advocacy- ACC HCR Principles • Universal coverage • Provides coverage through an expansion of public and private (pluralistic) programs • Focuses on patient value — transparent, high quality, cost-effective, continuous care • Emphasizes professionalism, the foundation of an effective partnership with empowered patients • Ensures coordination across sources and sites of care • Payment reforms that reward quality and ensure value

18. Dr. James Dove, MACC “PINNACLE” ACC Professional

19. The Challenges of ACC Presidential Plane Travel

20. ACC State Chapter Visits • California Puerto Rico • Oregon Florida • Washington State New Mexico • Texas Arizona • Wisconsin Michigan • Ohio Georgia • Alabama Indiana • Illinois

21. National & International Travel • DC and HeartHouse > 20 trips/year • AHA, ACC, ESC, QCOR, DC “ThinkTanks” (AHRQ, NHLBI, FDA, Duke), ESC-HeartHouse, WHF, SCAI, ACC-PAC, etc. • Malaysia, Saudi Arabia, Spain, Japan, Canada, England, Russia, Brazil, Sweden, France, Argentina, Uruguay, China, & more

27. The Future of Cardiology post Affordable Care Act Finding the answer to the Holy Grail or: ACC Skating to where the puck will be!!!

28. ACC, HCR and the Holy Grail • Meetings (“skating!”) with: • HHS, AHRQ, OMB, CMS, MedPAC, NHLBI, NQF, AMA, WHCC, AAMC, Senators and Representatives, Medical and Subspecialty Societies, AHA, AHA!, AHIP, Hispanic Alliance, Consumers Union, Business Roundtable, Business Group on Health, Spirit of Women, SEIU, Family Coalition on Health, and more

29. Victorious USA Harvey Cup Team: Douglas, O’Connell, Conte, Califf, Williams, Stevenson, Ullyot, Ohman, Wolk, O’Gara, Brindis (Missing)- King, Smith

31. Desperate Housewifes Seers of the Future: Desperate Housewives & Dr. Steve Nissen

33. Saudi Arabia Health Minister

35. Dr. ValentinFuster,DirectorCentro Nacional de Investigaciones Cardiovasculares

37. The POTUS

38. The Answer: Paul the Octopus for Direction of HCR !!!

39. ACCKnighthood of Professionalism!!! “We understand thatgreatnessis never a given. It must be earned. Our journey has never been one of shortcuts or settling for less. It has not been the path for the fainthearted … .” - President Barack Obama Jan. 20, 2009