• Changing New York's State of Mind

    July 28, 2014

    This content is from the Summer 2014 issue of SCAI News & Highlights.

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    SCAI Advocates for Medicaid Patients’ Access to Cardiovascular Care

    As healthcare costs continue to rise, policymakers and payers are searching for new ways to curb costs. Cardiovascular interventions, like many other procedures, are facing increasing scrutiny. However, when policymakers inappropriately apply cost-cutting measures, SCAI mobilizes its advocacy team to watch for potentially negative impacts on patients’ access to quality care.

    That’s what happened in New York when the state’s Department of Health announced that its Medicaid Program would recoup payments for percutaneous coronary interventions (PCIs) deemed inappropriate according to its interpretation of the 2012 appropriate use criteria (AUC) for coronary revascularization. The interventional cardiovascular community went to work, bringing together the expertise of several SCAI members and the reputation of SCAI, ACC and the State ACC Chapter. Working together, they succeeded in educating the Department of Health and convincing policymakers to rethink a policy that ultimately could have reduced access to medically necessary procedures for vulnerable Medicaid patients.

    “To our knowledge, the New York case represents the first time a state attempted to apply the AUC to reimbursement, but it may not be the last,” said SCAI 2014–15 Secretary and Advocacy Committee Chair Peter L. Duffy, MD, MMM, FSCAI. “We would not be surprised if policymakers and payers across the United States will seek creative ways to cut costs. New York interventionalists’ advocacy experience in partnership with SCAI provides important lessons for cardiologists everywhere.”

    Lesson 1: Building Understanding

    New York’s Medicaid policymakers misunderstood the purpose of the AUC, said SCAI Past President Gregory J. Dehmer, MD, MSCAI, who has served on multiple AUC-writing committees. “The 2012 Update states AUC are not to be used as a method to determine payment. The AUC are intended as a quality improvement tool.” Unfortunately, the AUC that are currently in place for revascularization still use the term inappropriate to describe a minority of procedures and will be replaced in future versions by the term rarely appropriate, said Dr. Dehmer. Nonclinicians and those unfamiliar with the AUC process have misunderstood what the term inappropriate means within the context of the AUC process. For that reason the new term, rarely appropriate, is a better characterization of the clinical situation. Most policymakers don’t understand that six clinical domains guide the AUC; that these six domains couldn’t possibly take into account all of the clinical factors, including age, comorbidities and patient preference; and that physicians examine each patient’s entire clinical situation.

    “A procedure that appears inappropriate according to the AUC can be appropriate when the entire clinical picture is considered,” said Dr. Duffy. “Similarly, a case that appears to be appropriate by the AUC may be inappropriate for a given patient. The challenge, in New York and elsewhere, is conveying that information to policymakers and payers"

    Lesson 2: Communicate and Coordinate

    “If proposed policies in your state appear detrimental, share your concerns with SCAI,” said Srihari S. Naidu, MD, FSCAI, who was among a group of SCAI members and staff who traveled to Albany to meet in person with the state’s Medicaid team. “National associations may not hear about proposals in every state, so members need to share the information to garner support.”

    When SCAI requested a face-to-face meeting between New York officials and SCAI and ACC representatives, the State’s policymakers recognized that the organizations represent thousands of cardiologists.

    “National organizations have the clout to schedule a meeting with state officials,” said Dr. Naidu. “The State realized that SCAI and ACC are at the forefront of developing quality improvement tools, which makes the associations powerful allies.”

    When it comes to advocacy issues, especially situations like the one in New York, where the policy was already being enacted, mobilizing swiftly is key.

    “The sooner you contact SCAI, the better,” said Dr. Duffy. “Knowing the whole story and being able to promptly notify state and local policymakers about concerns gives SCAI time to understand the situation.”

    Lesson 3: Stay Educated and Alert

    In SCAI, members have a partner to work with, but local physicians are the Society’s eyes and ears, added Dr. Duffy. “Educate yourself about what’s going on nationally and at the state level. We need the on-the ground experience and insights of local members and their input on how to approach the situation at the local level.”

    Members are the Society’s legs, too, added Dr. Naidu. “There’s more powerful than a busy physician who represents a large number of other physicians traveling to meet policymakers on theirown turf to discuss their concerns,” he stressed.

    Lesson 4: Detail Cardiologists’ Concerns and Strive for A Positive Message

    “Advocacy is a balancing act,” said Wayne Powell, SCAI’s senior director for Advocacy and Government Relations. “Recognizing that policymakers and cardiologists both want to deliver appropriate care for all patients is key to an effective relationship.”

    The New York proposal was frustrating, said Dmitriy N. Feldman, MD, FSCAI. “When we traveled to Albany, we focused on educating, rather than battling, policymakers and started by outlining several concerns about the state’s proposal:

    • Patients could be denied medically necessary care and ultimately harmed by implementation of the policy. While the committee’s goal was to curtail overuse, they hadn’t thought through how their policy could lead to underuse of PCI among underserved patients.
    • The state had not developed a collaborative process to help physicians understand the proposal prior to its planned implementation.
    • The state had not developed an appeals process, and it appeared that they planned to take back money before any appeal could be considered, let alone a process that would draw on the expertise of practicing interventional cardiologists.

    “We identified the main concerns relevant to this issue in a constructive, respectful way that represented the wish of the state to practice value-driven medicine,” recalled Ajay Kirtane, MD, FSCAI, who initially brought the issue to SCAI’s attention.

    In other words, advocacy is best approached as a bi-partisan effort, where everyone is focused on a shared goal of improving patient care. In New York, the advocacy group focused on common ground with the state Medicaid program, namely that neither physicians nor policymakers want inappropriate procedures being performed.

    “It’s incumbent on us to be the trusted organization – by being strong advocates for our patients and our members, always in support of our colleagues’ efforts to provide exemplary care in cardiovascular medicine,” added Dr. Duffy.

    Lesson 5: Think Broadly and Engage

    “We aren’t sure how widespread the desire is to create regulations like these,” said Dr. Duffy. Although the New York proposal was limited to Medicaid patients, SCAI is concerned that implementation of such a policy could lead to similar proposals affecting Medicare patients and those covered by third-party payers.

    “There could be a domino effect,” Dr. Duffy continued, as he urged cardiologists to become involved.

    For more information about this issue and how to get involved with SCAI’s advocacy program, visit www.SCAI.org/Advocacy or email Wayne Powell at wpowell@SCAI.org.