The New Rules of Engagement, Part II: Tennis Anyone? August 12, 2010

Back when I played competitive tennis, I learned that there were two distinct strategies between playing on grass and clay. On grass (a quick surface with lower ball bounces), a player needs to think at least one or two shots ahead– even though, despite the best efforts, most shots will be reflexive. To be successful on clay (a slower surface with higher, more unpredictable ball bounces), a player needs to think three to four shots ahead to win the point. We will need to use the clay court strategy with healthcare reform: Patient, but deliberately placed aggressive initiatives that ultimately build the foundation for self-sustaining policies.

Over the next few years, it will be crucial that the Heart Rhythm Society (HRS) continue the ongoing process of being an organization of both action and of reflection. Persistence will be the key. In trying to shape healthcare policy, I think it’s important not only to oppose existing policy, but to propose new policies. In this regard, here are a few approach shots to consider:

• Repeal or modify the Independent Payment Advisory Board (IPAB) provision. HR 4985: Medicare Decisions Accountability Act of 2010 and the more recent companion Senate Bill 3653: Health Care Bureaucrats Elimination Act both propose to repeal the provisions for the IPAB.
• Develop a separate subspecialty designation for electrophysiology to allow for improved access to care. As heart rhythm specialists, we will need to work closely with the Society (with or without an alliance) to promote the critical importance of the subspecialist in providing exceptional outcomes. There has been an overemphasis on the role of primary care in the reform process to date.
• Demand reform of the Medicare physician payment (i.e., Medicare’s unsustainable sustainable growth rate/SGR payment formula).There can only be so many “patches” on a gaping wound. The American Medical Association’s efforts have proven to be futile, despite promises by the administration.
• Require additional legislation that addresses medical liability reform. This measure would reduce the need for conducting testing in an overabundance of caution, and bend the cost curve. It will be a more cogent argument as more insurance carriers call for professional societies to establish Clinical Appropriateness Guidelines (criteria that will eventually incorporate clinical guidelines with patient co-morbidities to determine who will not qualify for reimbursed therapies).
• Clarify the role of the comparative effectiveness research initiative and how it will affect adoption of novel, emerging therapies. Early engagement by professional societies with Dr. Donald Berwick will be necessary in the nascent stages of its development.
• Consider limiting access to select Medicare patients. While this goes against all the principles we stand for as a medical community, it is not economically feasible to care for patients that will cost medical systems money. In my judgment, this should be considered an option of last resort.
  
• Forge closer relationships with local politicians. While HRS has endeavored to grow these relationships on Capitol Hill, members will need to take more initiative to closely engage their local politicians. The formation of regional HRS chapters might help expedite building these important relationships.
• Consider collective bargaining. In New York State, legislation (A.4301A, Canestrari/S.5204, Breslin) has been proposed that would permit physicians to engage in collective negotiation with health insurers under close state supervision. This bill aims to restore fairness to the current untenable situation, which allows insurers to virtually dictate all of the terms of their contracts with physicians and other health providers.
• Request additional legislation that effectively addresses patient accountability. Establishing relevant metrics will be difficult, but necessary. This will become an increasingly important issue in the upcoming era of value based purchasing. It will take two to tango to appreciably affect outcomes.
• Continue HRS and state society advocacy for swift rebuttals to denials for ‘standard of care’ treatments by third party payers. Additionally, several bills are currently being supported by Medical Society of the State of New York that address abusive health insurer auditing practices. A.10850 (Gottfried) proposes to reduce the time limit (from two years to one year) in which a health plan can demand a refund from a health care provider except where there has been reasonable evidence of fraud or intentional misconduct. It would also eliminate the ability of a health insurer to demand a refund by using the grossly unfair practice of extrapolation of a relatively few claims. A.9720, Bing/S.7474,Breslin would require a health insurer to reimburse a physician for legal and expert expenses when a health plan inappropriately alleges abusive billing in an audit.
• Work closely with the Agency for Healthcare Research and Quality (AHRQ) to establish value based purchasing metrics as it pertains to electrophysiology, most specifically the Physicians Quality Reporting Initiative (PQRI). Recent engagement has yielded favorable results, including the ability for medical service providers to appeal decisions.

The future of healthcare reform will be shaped over the next several years. It would be an injustice for each of us to sit idly and not participate in its putative transformation. Our clinical autonomy remains at stake. Inaction is not an option. Similar to tennis, we have the choice to either play to win, or play not to lose.