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In the last months the cardiologist have been exposed to certain threats which has made us aware of the importance of been united. Usually we lack this union which is extremely important to make significant changes in our practice. This is the moment in time to achieve this goal.
 
As all of you probably know the SSS company sent us letters announcing a significant reduction in cardiac catheterization procedures reimbursement. This decision was made in view of a revision of the company “definitions and standards in the claims coding and management, in the line with what was established by the AMA in the CPT and CCI”. (Letter from SSS June 24, 2009) They identified “that the interpretation of the cardiac catheterizations procedures (93501-93533) should be billed with Modifier 26”.
 
The company, in a letter to one of our cardiologists, stated that the problem was that:
“The fee change responds to the fact that SSS noticed that it was duplicating its payments for the cardiac catheterizations. The paid fee to the cardiologists included the technical component for the cardiac catheterizations, which at the same time was been paid to the facility. Therefore, the policy established the correct action of only paying the professional component (Modifier 26) to the cardiologists.”
 
Also they stated that the way to be billed the cardiac catheterization was as follows:
 
“Billing a cardiac catheterization requires three groups of codes:

1. Code for positioning the catheter (series 93501-93529)
2. Code for supervision and interpretation (93555 and /or 93556)
3. One or more codes of injection (series 93539-93545)

The codes for positioning of the catheter and the codes for supervision and interpretation require the Modifier 26 to bill the medical component.”
 
Finally they sent the way the corrections were to be made and in approximately 8 months the new reimbursement fees would be in effect to its maximum reduction. Please refer below for an example of a common left heart cardiac catheterization (LHC) of the impact these changes will be since July 2010.
 

 
After discussing case with other cardiologists billing department they informed me that the catheterization code SSS allowed was only 93510 and when it was tried to bill as above they failed to reimburse. It must be clear that the fees for a R & L catheterization will change (increase) the reimbursement. The cases for congenital catheterization are not expressed in my letter either.
 
With this threat presented by SSS since September 2009 a group of cardiologists decided to react. Under the direction of Dr. Norma Devarie (President of the cardiology chapter of the “Colegio de médicos y Cirujanos de PR” {CMCPR}) meetings have been made in the PRMC. Meetings with SSS were made but no changes were obtained. Lawyers were hired to assess us in the best way legally to deal with this. The recommendations from these meetings let us issue a press release in a local newspaper. In this way we notified the pertinent authorities (government) that the SSS action could bring a reduction in the cardiovascular invasive procedure services. The television press conference was made and many other associations assisted in view the changes which are been presented to cardiologists are not the only ones. SSS is attempting also to make reimbursement changes which will affect almost all the sections of medicine. (Anesthesiology, orthopedics, etc.) In a last meeting between all the parts with the secretary of health it was decided to hold the changes until more conversations take place between the company and us. He explained this was not the time to traumatize more the Puerto Rican people in view of the recent social events.
 
Since then the ACC decided to be part of the group. Even direct contact from ACC central was made to SSS trying to clarify the stated problem. It is must certain that also the “Sociedad de Cardiología de PR” will join our forces in the next meeting scheduled for October 8, 2009 in the auditorium B in the PRMC.
 
The PR chapter of the ACC in union with the cardiology chapter of the CMCPR request your assistance to these meetings. It’s markedly important your presence. You should contact your billing officer, discuss the realities of the present status and the proposed changes, understand completely the aspects related to this changes just to be ready for the open discussion in the meeting allowing fast movement for decisions as how to react with SSS.
 
As part of our efforts we have spent money for the legal representation, press conference and other actions taken which will need your cooperation. We have estimated that $200.00 from every cardiologist will suffice for now. You must understand that economical resources from the cardiology chapter of the CMCPR and the ACC are limited and this extra cooperation is definitively needed. The checks should be made to the CMCPR cardiology chapter. It could be brought to the next meeting also.
 
This is a very important time in history. You must understand this and be with us. This unilateral action taken by the SSS company opened a door through which has made us more united and also realize the weakness we have when dealing alone against these companies.  

This is the time to be act. As a song by Chicago expressed years ago; “We can make it happen, yeah”. But; we must be united!

José R. Rivera Del Río, MD, F.A.C.P., F.A.C.C.
President and Governor

The War on Specialists
ObamaCare punishes cardiology and oncology to finance GPs.

In President Obama's Washington, medical specialists are slightly more popular than the H1N1 virus. Compared to bread-and-butter primary care doctors, specialists cost more to train and make more use of expensive procedures and technology—and therefore cost the government more money. Even so, the quiet war Democrats are waging on specialists is astonishing.

From Senate Finance Chairman Max Baucus's health-care bill to changes the Administration is pushing in Medicare, Democrats are systematically attacking specific medical fields like cardiology and oncology. With almost no scrutiny, they're trying to engineer a "cheaper" system so that government can afford to buy health care for all—even if the price is fewer and less innovative ways of extending and improving lives.

***

Take a provision in the Baucus bill that would punish any physician whose "resource use" is considered too high. Beginning in 2015, Medicare would rank doctors against their peers based on how much they cost the program—and then automatically cut all payments by 5% to anyone who falls into the 90th percentile or above. In practice, this rule will only apply to specialists.

Since there will always be a missing chair when the music stops, every year one of 10 physicians will be punished if he orders too many tests, performs too many procedures or prescribes too many drugs—whether or not the treatments result in better patient outcomes. The 5% fine is substantial given that Medicare's price controls already pay only 83 cents on the private dollar.

In Medicare, meanwhile, the Administration is using regulation to change how doctors are paid to benefit general practitioners, internists and family physicians. In next year's fee schedule, they'll see higher payments on the order of 6% to 8%. The loose consensus is that the U.S. does have too few primary care doctors—less than 5% of medical students are entering the field—in part because they're underpaid.

Fair enough. But this boost for GPs comes at the expense of certain specialties. The 2010 rules, which will be finalized next month, visit an 11% overall cut on cardiology and 19% on radiation oncology. They're targets only because of cost: Two-thirds of morbidity or mortality among Medicare patients owes to cancer or heart disease.

The way Medicare works is that Congress decides each year how much it wants to spend on doctors, period. If one area of medicine receives a larger slice of this pie, another must accept a smaller one. The portion sizes are determined using a formula known as Relative Value Units, or RVUs. Medicare assigns an RVU to each of 7,500 billable services—in 2008, a colonoscopy earned 5.64 of these units, a hip replacement 37.66. Then it multiplies a doctor's total RVUs by some dollar factor, currently about $36, and cuts a check.

The chunks Team Obama took out of cardiology RVUs are especially drastic. The basic tools of heart specialists—echocardiograms (stress tests) and catheterizations—are slashed by 42% and 24%, respectively. Jack Lewin, who heads the American College of Cardiology, said in an interview that the crackdown will cause "a horrible disruption" that will force many community and independent practices to close their doors, lay off staff or make senior patients wait days or weeks for tests and services.

Cancer doctors get hit because the Administration believes specialists order too many MRIs and CT scans. Certain kinds of diagnostic imaging lose 24% under new assumptions that machines are in use 90% of the time, up from 50%. There isn't a radiologist in America running an MRI 10.8 hours out of 12, unless he's lining up patients on a conveyor belt. But claiming scanners are used far more often than they really are lets the Administration "score" spending cuts.

And this change is applied to all expensive equipment, not just MRIs and CTs, so payments for antitumor radiation therapy will fall by up to 44%. The American Society for Radiation Oncology says it "will have a devastating effect on cancer patients' access to care."

One priority of the Baucus bill is to require the executive branch to wreak this kind of devastation every year, not just when a Democrat is President. It directs the Secretary of Health and Human Services to search out "potentially misvalued" RVUs, meaning those "for which there has been the fastest growth" or "that have experienced substantial changes in practice expenses." In other words, any specialty that grows too much must be targeted.

It's important to understand that these are "cuts" that don't actually cut any spending; the RVUs merely redistribute it from one medical bucket to another. In this case, Team Obama is sending a message to the medical community about its political priorities. The fee schedule is designed to avoid wild year-over-year payment swings, but HHS justified its decision with a flimsy survey whose data it won't release and whose results can't be replicated. Dr. Lewin told us that both HHS Secretary Kathleen Sebelius and budget director Peter Orszag refuse to meet with him to discuss the topic.

We have nothing against primary care physicians, and clearly the country could use more of them. But then, it could probably use a lot more doctors, including specialists, as the boomers age and the prevalence of obesity, diabetes and other chronic diseases rises. The increase in specialists has tracked advances over 50 years in medical science and technology. Democrats look at these advancements and see only the costs, not the benefits.

***

Markets are supposed to determine the composition of the workforce, not a command medical economy run out of Washington. It is perfectly insane to support one type of doctor by punishing others on a flawed theory about cost-control. The press passes all this off as routine when it bothers to notice, but we suspect our media colleagues would show more interest if Messrs. Obama and Baucus were deciding how much journalists should be paid and what they should cover.

If Democrats are going to stomp on specialists, they should at least be open about it. Then again, all Americans might take a different view of health-care "reform" if they understood that it means snuffing out the best medicine.

ACCPR letter to Governor Fortuño

Dear ACC members:
 
In view of the CMS threatening actions made in July 2009  to make a significant reduction in reimbursement next 2010, the ACC  has develop an onslaught attack trying to withdraw this menacing change. All the states have engaged in direct contact, letters, meetings and reunions with senators and legislators and soon even personally in Capitol Hill now in september. In view of our limited voting access in Capitol Hill we decided to make this letter informing our Governor of the present status and the reasons why this changes should be avoided. We urgently request his help in this matter. The impact to our island will be worst than in any other state of the nation in view our already reduced reimbursement condition. Please read this letter carefully which is short and self explanatory. Any doubts or comments please contact us.
 
Jose R. Rivera Del Rio MD, F.A.C.P., F.A.C.C.
President and Governor
ACC PR Chapter

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PUERTO RICO DOES IT AGAIN!!

SMALL CHAPTERS HERO AWARD On January 30, 2009 Puerto Rico ACC Chapter obtain for the first time the HERO (Heroic Efforts to create Results and Opportunities) Award for the “Small Chapter” category. The Chapter Awards Program is a recognition and celebration of the good work done last year (2008) by the American College of Cardiology Chapters.

Puerto Rico Chapter was recognized for its consecutive well attended (>60% ACC members) and well received meetings not only for the members of the ACC but also for the patients. The communitarian symposium has covered for the last 10 years the needs of the patients to obtain information related to cardiovascular conditions and their management. Also our chapter has reached the private schools and the Boys Scouts with cardiovascular teaching topics. The annual conventions has always brought the best lecturers been the latest example the January meeting where ten renowned Masters of the ACC (MACC) assisted and lectured about the past, present and future of cardiology.

Phothograph: Left to right: John Harold, MD (Elected President of the Board of Governors) Andy Baldwin, MD (US Navy Lieutenant, Undersea Medical Officer0 José R. Rivera del Río MD (President and Governor PR ACC Chapter) Eurencia G. Olmo (Chief Executive Administrator PR ACC Chapter) Jane Schauer (President Board of Governors)

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Puerto Rico 20th ACC Convention

The 20th annual convention of ACC PR chapter celebrated in January 23-25, 2009 was an outstanding event. The presence of 10 Masters of the American College of Cardiology (MACC) at the same time together in a chapter was an event that we will share the rest of our lives. The MACC were directed by our own and first MACC, Dr. Mario Garcia Palmieri. The topics discussed, the friendly atmosphere, and the local Puerto Rican amenities made the convention a great success.

The convention had 253 attendees of which 155 were physicians and of the ACC members 53% assisted. The invited guests displayed their knowledge in a way only a MACC can do. Timely topics, review of the past history and glimpse of the near future was heard throughout the lectures. Review of cholesterol management, epidemiological cardiovascular history of PR, management of chronic angina pectoris, PTCA/STENT present status, antiplatelet therapy, quality in cardiovascular medicine, surgical repair of the MV assisted by echocardiography, etiologies of SAM, health reform, wide pulse pressure predictive value, EKG clues, RV dysplasia and acute dissection of the LM were among some of the topics presented.

During the amenities the MACC show us that age was not an important factor. Dr. Leonard Dreifus (85 y/o) and his lovely wife danced with us “Plena” , “Merengue”  and even Limbo! Their energy might explain why the thirst for knowledge doesn’t wane with age. One of his topics was “The next 50 years” and he said he would be there to see it!
As always the Fellows in Training (FIT) presented very interesting clinical cases and discussed the related cardiovascular information related to it. Also four satellites symposia were presented related to cardiovascular and diabetic topics.

Concomitant with the ACC Convention the Cardiac Care Associates (CCA) had their 3rd Annual Convention with two invited guests and our local lecturers. The assistance was also impressive (89% of the OSCAR registered island CCA’s) and the attendees reported excellent lectures and interesting and very productive workshops.
The Puerto Rico Chapter already started the coordination of its 21st Annual Convention which will be  as always, another  event to plan in your annual agenda.  This time will be again in May as before in the Ritz Carlton Hotel.

Until then,
 
José R. Rivera Del Río, MD, F.A.C.P., F.A.C.C.
President and Governor
ACC Puerto Rico Chapter

FIRST CARDIOVASCULAR CARE ASSISTANCE (CCA) SYMPOSIUM IN PUERTO RICO

Last 5th of April 2008 we had the opportunity to start our CCA educational symposium for the first time in the island of Puerto Rico. It was celebrated in Mayaguez, PR with an assistance of 108 participants. Of these 92% were females. There were 9 invited speakers among them PhD nurses, cardiologists, our first PR MACC (Dr. Mario Garc’a Palmieri) and even the University of Puerto Rico Mayaguez (CAAM) campus dean. The topics ranged from nursing management, PR medical history, pharmacology to psychological and religious assistance. The event took place from 8:00 AM to 4:00 PM. People from 10 different institutions came to the symposium and many of the participants came from other 4 nearby towns.

The symposium was evaluated as excellent by 95% of the participants and 5% as a good activity. They considered that this type of activity is greatly needed in these areas, should be done more frequently and include a wider variety of topics. Significant recommendations obtained from this meeting included: distribute the conference in writing mode, more promotion, and increase the duration.

The PR ACC chapter has engaged in an active sponsorship effort to improve the education and training of its CCA, general nursing and pharmacologistÕs assistant in the island. After this first symposium the plans are to develop a yearly organized program which will cover the island from west to east. In the next months the full program will be announced.

Dr. Marcos Velazquez, FACC, Mrs. Ana Santana, RN, MSN (CCA President), and Mrs. Miriam Nieto, RN, PhD (CCA Secretary) should be congratulated for the excellent symposium they coordinated.

JosŽ R. Rivera Del R’o, MD, F.A.C.P., F.A.C.C.
President and Governor
Puerto Rico ACC Chapter

The first Puerto Rican MACC!!

Born in the town of Adjuntas, Puerto Rico (PR) Dr. Mario Ruben García Palmieri obtained his bachelor in science (Magna Cum Laude) in the University of Puerto Rico and his MD in the University of Maryland. At present, Dr. García is Distinguished and Emeritus Professor and Head of the Section of Cardiology of the University of Puerto Rico School of Medicine. He has trained more than 100 cardiologists in Puerto Rico. He is board certified in Internal Medicine and Cardiology.

Dr. García is a member of more than 20 professional societies including many with restricted admission such as the Alpha Omega Alpha, Association of University Cardiologists, and the Association of American Physicians. He has been a major lecturer in scientific programs in 33 countries, has been designated Honorary Member in 14 national cardiological societies, and has been decorated by the governments of the Dominican Republic, Venezuela and Spain.

Locally in Puerto Rico, Dr. García has presided many Societies such as: the Puerto Rican Society of Cardiology, the PR Medical Association, and the PR ACC chapter in 1957. He served as the Secretary of Health in 1966, and in many commissions and committees with the PR government. Actively he still participates in the ACC chapter executive committee. He has also contributed to the US government as member in NIH committees and United States Presidential commissions. Internationally he has presided over the International Society and Federation of Cardiology and on two occasions the Interamerican Society of Cardiology.

Dr. Garcia has published 178 medicine articles, 6 books, and more than 80 newspapers columns geared to orient the people concerning medical problems. He holds Fellowships in the Royal Society of Health, the American College of Chest Physicians, the European Society of Cardiology, and the American Heart Association. He was granted many honors which include the title of Master of the College of Physicians and the Honor and Gold Key Award for most distinguished alumnus in the University of Maryland. The University of Puerto Rico has established the Mario Garcia Palmieri endowed chair since 1996 and the main lecture of the Interamerican Congress of Cardiology held every two years bears his name. In 1989 the ACC bestowed him with the Distinguished Service Award.

Besides his professional endeavors Dr. García Palmieri has been an avid sponsor of master craftsmen in Puerto Rico. He assembles bonsais and has one of the most complete collections of photographs of cardiologists all over the world.

Dr. Garcia Palmieri is a man of many interests and talents: a gifted clinician, an articulated teacher, a productive clinical investigator, a supporter of educational activities for residents in cardiology, a supporter of Puerto Rican culture, an example of excellence in public service and above all a teacher of teachers. All these contributions in a life dedicated to serve his country, physicians, fellow workers and students are so outstanding that he constitutes a role model to us in our College.

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