The sustainable growth rate (SGR) formula has drawn seemingly limitless criticism from cardiologists and other physicians, but it may have a silver lining of sorts. It has served as a persistent reminder that physicians or their representatives need to be involved in the shaping of legislation that affects reimbursement and patient care. To be effective, cardiology’s advocates must choreograph and execute a delicate dance between persuasion, politics and what could be seen as self-interest.
Turn the calendar back several years, to the time when the Centers for Medicare & Medicaid Services (CMS) unveiled what cardiologist M. Eugene Sherman, MD, likened to “ripping the guts out” of the specialty. Rule changes ranged from 10 percent to 40 percent phased-in reductions in reimbursement for cardiovascular services, with imaging taking an especially hard hit. The cuts precipitated the movement from private to employed practice and altered the way patients received care.
Sherman, chair or the American College of Cardiology’s (ACC) Advocacy Steering Committee and a physician at the Aurora Medical Association in Colorado, had before then been involved in other committee activities. “But at that point I became clearly dedicated to that professional organizations should advocate on behalf of their members and equally on behalf of their patients,” he says. “In terms of cardiac imaging, this is critical [for] patient access to timely care.”
Physicians have served as advocates for the profession for decades, but their participation may have gained urgency in recent years as the practice and payment of medical care are in transition. Cardiologists who have been insulated from the vagaries of Washington in the past now wrestle with the consequences of policy decisions. Those pain points may vary from time-consuming preauthorization for tests to shrinking payments tied to readmissions or performance measures.
“This has a lot more traction and will get a lot more attention as we see declining revenue and increasing expenses and a smaller operating margin for healthcare facilities and for practices,” says Peter Duffy, MD, co-chair for the Advocacy Committee for the Society for Angiography and Interventions (SCAI) and director of quality for the cardiovascular service line at FirstHealth of the Carolinas Reid Heart Institute at Moore Regional Hospital in Pinehurst, N.C.
High-profile issues like calling for the repeal of the SGR also helped raise awareness but may have blunted cardiologists’ impulse to act because few believed the perennial threat of draconian pay cuts would be enforced. “There was a lot of disbelief when we said you have to write letters to Congress,” Duffy says. “They said, ‘Why bother? They will change it anyway. It doesn’t matter if I write letters or not.’ To some degree, while it was positive because it got attention, their feeling was that what is going to happen will happen regardless. Our job is to make sure they don’t feel that way.”
Communication & messaging
Society-affiliated advocates’ responsibility to their members is to educate key decision makers about cardiology practices and explain issues from the cardiologist’s perspective, according to those at the front lines. That requires advocates first understand the fine points of legislation, agency proposals and regulatory processes such as approvals and reimbursement for new devices or therapeutics. For instance, it is important that facilities are adequately remunerated for services or patients won’t reap the benefits, Duffy says, and advocates can help make sure CMS staffers and policy makers realize that potential barrier.
“No one who has the responsibility for policy making or coverage decisions wants to make the wrong decision,” Duffy reasons. “They just want to have the right facts in front of them.”
Members also have a responsibility to inform societies of concerns, listen and provide feedback. “Physicians have to realize they need to speak up and tell their professional organizations,” Sherman says. “In the other direction, [organizations] need to keep their members informed as to what is going on so they can all work together.”
Advocates speak with members to bounce off ideas in a back-and-forth process that refines dialog into clear talking points. The goal is to distill often complex concepts into a cohesive and unified message that can be presented to lawmakers, congressional aides, FDA officials, staffers at federal funding agencies and others in Washington.
“If too many people are involved, then is it is a mixed message and not a repetitive message,” Duffy says. “What we have learned in Washington is, it has to be simple, it has to be understandable and it has to be repeated.”
Degrees of involvement
It is unrealistic and impractical to expect every cardiologist to travel to Washington to meet with legislators, points out Osvaldo Steven Gigliotti, MD, co-chair of SCAI’s Advocacy Committee and co-director of the Seton Heart Institute’s research program in Austin, Texas. Their involvement may be passive, such as contributing to political action committees or paying fees.
Sherman adds that cardiologists who participate in the ACC’s National Cardiovascular Data Registry and other registries indirectly engage in a form of advocacy. “Being armed with data puts us in an advantageous position when we talk to Congress and to regulatory agencies, particularly CMS, because we have millions upon millions of procedures and outpatient records to show how care is delivered, trends in care and quality outcomes in care,” he says. “Our physicians have bought into this and it has become a big part of the messaging.”
Younger physicians may be more inclined to be involved in advocacy activities, in part because they still face long careers whose quality will be affected by policy decisions. As a fellow at the University of Florida in Jacksonville, Gigliotti attended advocacy presentations organized by local chapters of societies but the experience was informal. “As a fellow, we are very well trained at taking care of our patients, but when it comes to issues like business and advocacy, which are very important in the care of our patients, we are left to our own devices,” he observes. “It is learn on the fly.”
That may be changing. Mark A. Earnest, MD, PhD, co-director of the Leadership Education Advocacy Development Scholarship (LEADS) Program at the University of Colorado Denver School of Medicine in Aurora, argues that advocacy should be part of medical training, with schools offering educational tracks and opportunities for practicing physicians. Training should encompass competencies in communication, policy and processes and relationships. Relationships focus on defining those who need to be engaged, including supporters and opponents.
LEADS participants practice communication skills with media training and practice interviews as well as exercises in writing editorials and persuasive messaging. They also attend state legislative events to understand the processes and join in community service projects.
“I view this as a developmental process,” Earnest says. “Most medical students don’t envision themselves lobbying Congress or testifying in front of the state legislature. They may even have a hard time imagining themselves taking a leadership role in their home institution because they are so far down on the totem pole.”
He defines advocacy in the framework of justice. “Advocacy addresses the underlying problems that result in injustice,” he says. “I can treat somebody in need today. If I advocate effectively, then I may prevent that need tomorrow.”
Service or self-serving?
Pursuing change under the banner of justice can be construed as simply protecting self-interests, warns Thomas S. Huddle, MD, PhD, of the University of Alabama Birmingham School of Medicine. Many of the issues raised by physicians to lawmakers boil down to reimbursement, and while patients benefit because they gain access to services and treatments, hospitals and physicians also gain because they get paid.
“There is an obvious suspicion that the altruistic kind of advocacy may in fact be a kind of smokescreen for more a self-interested kind of advocacy,” Huddle says. Advocating for the repeal of the SGR, for instance, “is a classic instance of something that is clearly a matter of self-interest on the part of the medical profession. Physicians will take one position because they want to be paid by Medicare. That is not a bad or unexpected thing, but it is hard for me to pitch that to myself or anybody else as anything other than physicians working for their own self-interest.”
Professional societies and their advocates provide legitimate benefits to lawmakers by educating them about medical and healthcare issues for the public good, Huddle proposes. He sees their value in addressing circumstances that might undermine the profession such as threats to an academic mission or to the professional norm for practicing medicine.
The issue of being able to practice medicine within standards of care drives much of the work they do, according to advocates. “People may think that this is about money, and it is about money, but it is not necessarily about physician income,” Gigliotti says. “Most of the people get involved because they see how it affects how they deliver care.”
Duffy adds that their goal is not to lasso resources for interventional cardiologists but to ensure that resources are available for their members to properly care for their patients. But cardiologists may be challenged when trying to reconcile their duty as physicians with the need to be responsible stewards of finite resources. Failing to do so contributes to the unsustainable growth in healthcare costs.
The code of ethics behind the doctor-patient relationship requires physicians to provide competent and compassionate care, do no harm and respect patients as individuals. The distribution of resources falls under justice, according to Earnest, and that may be in conflict with the doctor-patient relationship. For instance, treating an octogenarian with heart failure with a medically appropriate implantable cardioverter-defibrillator might mean that in the future the pot is empty for an infant in need.
The patient in front of the practitioner often wins out against the hypothetical patient, Earnest acknowledges. Physicians naturally want to help their patients, although sometimes that means initiating a conversation about end-of-life care. Both doctors and patients often see treatment, with its promise of delaying death, in a positive light, “and that difficult conversation may never happen. There are so many incentives that line up from preventing it from happening.”
Earnest adds that the challenge is even greater when reimbursement aligns with patient benefit. “If we are going to have a rational, sustainable healthcare system, then we will need to have some mechanism of weighing the cost-benefit of that across society,” he argues. “Yet we don’t trust the government or private insurance to do it and we’ve deemed it not fair for individuals to do it in terms of saying if you want it you have to pay for it yourself. We are sort of stuck.”
Physicians should not distance themselves from the political arena, Huddle insists, especially because the practice of medicine affects the public good. But he cautions against advocacy that pits health against other public needs. “One of the key moves that leads us to error is to say we are about health rather than about treating the sick,” he says. Health may then be presented as a good preferred over other goods. “Basically you are saying this vision of the good is right and some other vision of the good that puts health on a lower level is not to be preferred. That is not something physicians have any authority to do.”
Cardiologists arguably may be seen as a public resource, according to Earnest, in keeping with the view that political advocacy is a professional responsibility. They offer specialized knowledge and expertise and are committed to public health. “We have done very little historically to help physicians think through that,” he says. “That is at the core of what we are trying to do, is broaden the sense of what it means to be a doctor and the purview of what your practice is.”
Whether at the local, state or national level, cardiology advocates need to exercise care to ensure they aren’t viewed as partisan. Institutions and their boards are sensitive to activities deemed political that might raise a public relations ruckus or rub their membership or donors the wrong way. “If you are thoughtful, professional and evidence-based in your approach, then you avoid the really partisan politics and you can pursue this just as you would anything else,” Earnest says.
That may make initiatives such as the ACC’s registries all the more valuable for advocates’ decision-making contacts. The evidence emerging from analyses of the data may help policy makers refine rollout of the Affordable Care Act, Sherman says, by showing what improves or worsens outcomes and efficiencies. “For example, we’re not beta testing exchanges and ACOs [Accountable Care Organizations]. We are alpha testing; we are charting new waters. We are being asked to do things that have never been done before.”
“We have to come up with a better system,” Duffy agrees, referring to soaring healthcare costs. “That is why we are in advocacy. It is not to say, ‘Here is how you have to do it.’ It is to work with people to find solutions to a common goal.”