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Tales from the Swamp: Influencing Legislation That Influences Our Practice

2018; Elsevier BV; Volume: 31; Issue: 12 Linguagem: Inglês

10.1016/j.echo.2018.10.012

1097-6795

Jonathan R. Lindner, C. Michael Valentine,

Healthcare Policy and Management

C. Michael Valentine, MD, FACC, President, American College of CardiologyView Large Image Figure ViewerDownload Hi-res image Download (PPT) In July of 1798, President John Adams signed into law the “Act of the Relief of Sick and Disabled Seamen” which was the very first federal legislation in the United States that regulated healthcare. The “disabled seamen” act came about as a direct response to the Yellow Fever epidemic that had been decimating naval commerce. It called for a monthly tax of 20 cents per month on the salary of all commercial seamen to cover their healthcare costs, and was followed the next year with a similar tax on all Navy personnel, the proceeds from which were used to fund early military hospitals that were the precursors for the VA health system and the National Institutes of Health (NIH). The debate over a mandate for funding health coverage started in 1798 but continues to this day. Current healthcare policy debate also includes ideas on how to balance the well-being of our citizens with the well-being of our fiscal budget since, according to the Congressional Budget Office (CBO), health costs account for around 30% of federal spending, with the majority going to Medicare and Medicaid. In order to maintain some control of our own destiny with regards to policies that affect cardiovascular imaging, the advocacy arm of the ASE works in concert with an experienced lobbying firm, Mehlman Castagnetti Rosen & Thomas, based in Washington DC. Lobbyists are often mentioned in the same breath as using “the swamp” as a term to describe Washington DC. Yet, all derogatory terms cease when you observe how these lobbyists work with ASE leadership and our advocacy team. Lobbying is not simply “paying to play.” The benefits of retaining a lobbying firm include: (1) being constantly kept informed of activities on Capitol Hill that will influence healthcare, and cardiovascular imaging in particular; (2) having complex federal policy translated and distilled so that we are able to make sound decisions; (3) receiving guidance on how to best focus our efforts to influence legislation; and (4) connecting the ASE with key legislators and their staff on both sides of the political aisle to make sure our voices are heard and that we can advocate for our members and, more importantly, our patients. In early October, the ASE participated in the American College of Cardiology’s Legislative Conference 2018. Over several days, healthcare policy trends were discussed culminating in a day of coordinated visits with legislators. Participants focused on the representatives from their home state to build a repertoire on the issues from a grassroots level. I participated in my Oregon meeting with Senator Wyden’s office and then joined our lobbyists in appointments with the Senate Finance, House Energy and Commerce, and House Ways and Means Committees key healthcare committee staffers. With careful guidance from our lobbyists, Robin Wiegerink, Irene Butler, Vera Rigolin, and I were able to highlight the impact of echocardiography on patient health. In the bullet points below, I provide several of the important regulatory issues that were raised since they affect both the quality of care that we provide and the cost of practice.•Importance of Quality and Comprehensive Service. Most believe that echocardiography services are undervalued and reimbursement guidelines set forth by CMS seem perpetually under review for further cost reduction. We devoted time to educating staffers that while although ultrasound technology is the least expensive of the advanced cardiovascular imaging modalities, echocardiography provides a rich amount of information on cardiac structure and function that involves extensive quantitative analysis. We stressed that echo is one of the most vital tools in cardiovascular medicine and requires great expertise and time from both the sonographer and the interpreter.•Negative Impact of Site Neutrality. Proposals keep arising that would further reduce reimbursement for echocardiography performed in the hospital outpatient setting according to the CMS Hospital Outpatient Prospective Payment System (HOPPS). We countered with several lines of reasoning including: (a) higher complexity of disease seen in these settings (e.g., ACHD, rare diseases); (b) the need for more detailed or customized protocols (e.g., LVAD ramp studies); (c) the requirement for the latest technology (e.g., 3D for planning interventional procedures; strain for cardio-oncology and heart failure referral programs, contrast); and (d) longer time required for sonographers to perform these studies and for physicians to interpret them.•Utilization of Echo. In anticipation of the rise in utilization as POC Echo continues to gain traction and as users may submit billing for limited services as part of a physical exam, we elaborated on the difference in the scope, time, and expertise for brief POC echocardiograms versus comprehensive quantitative echocardiography.•Federal Spending on Medical Science. We expressed appreciation for not reducing federal commitment to medical science through the NIH budget for the past calendar year, the majority of which is directed to extramural research programs. We also mentioned that although the NIH encourages patient-oriented translational research, there is a pattern of financially disincentivizing the use of new technology once it is approved.•Short Cycle Length for CPT Code Re-evaluation. We encouraged congress to examine the process by which CMS revalues codes for imaging services. This ask was a response to a request from an undisclosed source for echocardiography re-evaluation less than a year since implementation of the AMA’s Relative Value Scale Update Committee (RUC) recommendations.•Multiple Procedure Payment Reduction (MPPR). This proposal is a component of the single payment Evaluation and Management (E&M) code that is being proposed for the Physician Fee Schedule Rule, and could jeopardize payment for same-day critical imaging services that do not overlap with either E&M services or other procedures. We advised that this proposal could jeopardize patient care, particularly those who live in rural areas and travel long distances for their care. Healthcare policy decisions are complex and the political landscape is difficult to navigate. We are lucky to have capable people within our society and advisors to our society who take great care in these issues. However, there is also a reason I write this message in partnership with Dr. Michael Valentine, who serves as the President of the ACC. Dr. Valentine went to great lengths at the ACC Legislative Conference to advocate for greater cooperation between the different societies in cardiology. The most impactful statement he made was that that when legislators hear many different opinions from the “house of cardiology,” then they hear none. Together, we both feel that we will benefit by setting aside minor differences and working together for a common voice on larger issues that affect us all. One of the ACC’s major goals is for all of us to have a unified message on quality patient care and to decrease clinician administrative burden which is key to our ability to provide that quality care. Although both Dr. Valentine and I are committed to these goals, it’s important that you also advocate for our role in providing quality care. Accordingly, I encourage everyone to periodically peak at the advocacy section of our website (http://asecho.org/advocacy) to stay abreast of the issues that matter.Jonathan R. Lindner, MD, FASE, is a cardiologist at Oregon Health & Science University where he is the M. Lowell Edwards Professor of Medicine, and is the current president of ASE. He serves as the Vice-Chair of the NBE writing committee and leads an NIH-funded multidisciplinary pre-clinical and clinical research team investigating molecular imaging, ultrasound-based therapy, and microvascular physiology.C. Michael Valentine, MD, FACC, is President of the American College of Cardiology. He is an interventional cardiologist at the Stroobants Cardiovascular Center, Centra Medical Group in Lynchburg, Virginia.