ACC NEWS
President’s page: cardiologists under stress: the response of the American College of Cardiology
George A. Beller, MD, FACC1
Reprint requests and correspondence: George Beller, MD, FACC, Cardiovascular Division, Department of Internal Medicine, Health System, University of Virginia, P.O. Box 800158, Health Sciences Center, Charlottesville, Virginia 22908-0158
Over the course of the past year, I have used these pages to expand on new programs and initiatives sponsored by the American College of Cardiology (ACC) as well as to convey the ACC’s positions regarding national political issues. I also attempted to explore issues that I believe will have an impact on the profession of cardiovascular medicine and the ACC. For example, I have examined the causes and potential solutions for the shortage of nurses and analyzed the financial crises that plague academic health centers. Likewise, I have considered the enormous potential of advances in molecular genetics and technology that will enhance diagnostic cardiology. I have touched on the emerging epidemics of obesity and diabetes, which are contributing to the increased prevalence of coronary heart disease in this country and around the globe. In the process of researching and writing these "President’s Pages," I have learned a great deal about the issues facing cardiology and medicine in general.
It has also been an honor and privilege to serve as President of the ACC, to work closely with so many of the College’s members and staff, and to participate in a year in the College’s history that is certain to be viewed as a year of change. I was fortunate to begin my presidency with an especially clear agenda, one based on the hard work of my predecessors and the many ACC volunteers who participated in task forces dedicated to steering the College into the new millennium.
I have had the opportunity to visit chapters during their annual meetings and to talk with numerous ACC members in various venues throughout the year. I have sensed the frustration and uneasiness that is so prevalent today among many of our members engaged in the practice of cardiovascular medicine. They are constantly bombarded by policies created by nonphysicians regarding medical decisions that adversely affect the practice of high-quality care. Our members want the right to care optimally for their patients and retain decision-making authority, which is not easy these days, when managed care organizations often place emphasis on cost rather than quality care.
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Stresses on cardiovascular specialists
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Cardiologists throughout the country are assuming greater workloads but see decreased reimbursement for their energies. They are caring for a more elderly and sick population of patients with heart disease and applying new and exciting findings to improving patient outcomes and enhanced quality of life. Unfortunately, cardiovascular specialists spend an inordinate amount of time writing in charts for the purpose of documentation and dealing with nonmedical bureaucratic matters. More time is now spent getting involved in practice management. There is a fear of being audited and even being prosecuted as a result of improper documentation. Our members feel helpless with respect to Health Care Financing Administration policies that have created a climate of confusion and a presumption of fraud and abuse regarding Medicare compliance. It is overwhelming and very difficult to understand what constitutes proper coding and how to comply with constantly changing government rules. All of this bureaucratic activity means that physicians are having to devote more time to day-to-day management of their practices, yielding less time for delivering care and engaging in other important tasks (e.g., education, family time, community service, thinking time).
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Advocacy
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Over the past year, I have learned that our members want the ACC to be more active in and more vocal about these health care system changes, particularly with the College’s advocacy role in influencing legislation and regulatory policies. In response to member needs, the ACC is promoting the value of the cardiovascular specialist, lobbying to ensure high-quality patient care, working to oppose unrealistic managed care constraints, protecting patients and preserving appropriate physician autonomy, fighting to ensure fair reimbursement, and fighting arduous billing documentation requirements.
The ACC has been reaching out to the public and making other outside organizations cognizant of the issues that affect quality health care. The ACC has certainly become more visible in the governmental advocacy arena and has assumed a leadership role in several coalitions representing the needs of patients and specialty care. As I previously wrote in these "President’s Pages," the College is creating a 501(c)(6) organization to allow the ACC to protect, preserve and strengthen its educational mission and, at the same time, increase its flexibility with respect to advocacy. The tax code has limited current advocacy efforts, and the 501(c)(6) is required if the ACC is to do more in advocacy on behalf of our members. Enhanced advocacy activities could jeopardize the College’s 501(c)(3) nonprofit charitable status, so a separate, affiliated organization that is classified as a 501(c)(6) will permit the College to increase its advocacy activities and even form a political action committee if it so chooses. The new organization is a vehicle for fulfilling the College’s strategic initiatives in advocating for high-quality cardiovascular care.
In the meantime, our efforts in advocacy have proceeded. It was especially gratifying for me to participate in the College’s Annual Legislative Conference and to see firsthand how enthusiastically U.S. congressional representatives received ACC members. Members know how hard the ACC worked this year on a number of legislative and regulatory issues, including supporting a significant budgetary increase for the National Institutes of Health and becoming one of the first medical societies to develop formal principles for health care reform that will make provisions for the nation’s 44 million uninsured.
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Quality of care
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This year was also focused on quality of care. The ACC drafted a document, under the leadership of Past President Dr. Arthur Garson, Jr., outlining principles for health care reform. This document sets down a blueprint for health care coverage for all Americans. It emphasizes that physicians, health care professionals and other providers have a responsibility for ensuring quality of care. It states: "We support continued work toward quality improvement through the encouragement and practice of evidence-based medicine; the establishment of ‘best practice documents’—practice guidelines; reduction in practice variation where appropriate; and consistent quality assurance monitoring." The ACC must play a role in defining quality and assist physicians in the implementation of practice guidelines. If we do not want payers to develop guidelines and physician performance measures on their own, then we have to be a leader in the quality area. We must educate payers and members regarding appropriate clinical indicators. The ACC must seek to define outcomes and performance measures that indicate high-quality and appropriate care.
We are already focusing efforts by way of the Guidelines Applied in Practice, or GAP, Project, which is piloting strategies to increase adherence to ACC/American Heart Association (AHA) clinical practice guidelines. The GAP Project involves the creation of educational tools for physicians to use in applying guidelines to practice, creates patient guides to enhance patients’ understanding of their illnesses and outlines responsibilities that patients must assume for their own health care. Also in the quality area, the ACC-National Cardiovascular Data Registry (NCDR) has been given a boost for increasing its data collection, and the NCDR is achieving its enrollment goals and objectives. The ACC is partnering with the AHA in the development of physician performance measures and the role that these measures can play in improving quality of care. Practice guidelines are now continually being updated by writing groups to remain current.
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Education
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There is no better way to sustain high-quality patient care than through continuing medical education. The ACC continues to be a leader in providing educational products and programs to cardiovascular specialists. Members have benefited from the Journal of the American College of Cardiology, ACCEL, the Annual Scientific Session, clinical practice guidelines and expert consensus documents, self-assessment programs, board review courses, programs at the Heart House Learning Center, and other extramural programs given throughout the nation each year.
Working with the AHA, the ACC made great strides this past year in the plans for an online cardiovascular knowledge database (currently known as KDE—Knowledge Delivery Enterprise—a joint learning initiative of the ACC and the AHA). Knowledge Delivery Enterprise will become "a preeminent source of highest quality, credible and objective cardiovascular knowledge for health professionals and their patients, available when and where that knowledge is needed." This internet-based learning initiative will feature a comprehensive, online database that users can access at the point of care or in a more leisurely manner. Using a Web browser or a handheld device, one will be able to get "just-in-time" responses to clinical questions that will be extracted from a rich database containing a multitude of knowledge elements. Sophisticated search capabilities should permit users to obtain specific information in response to clinical questions. With respect to the more leisurely learning aspect of KDE, members will be able to "browse and learn," and learning will come from a variety of resources. These will include online board review preparation, recertification review, clinical trials reports, original journal articles, diagnostic images, expert commentaries, cybersessions from the Annual Scientific Session and other venues, practice guidelines, case studies, and self-paced tutorials. Continuing medical education will be personalized and related to the needs of members. We expect an editor-in-chief of KDE and an editorial board with associate editors will be selected in 2001. Partnership with subspecialty societies is being discussed, and cardiology links to other partners are being proposed. At the time of this writing, the ACC is working closely with the AHA in developing a business plan for KDE.
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Final comments
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For all of the opportunities and experiences granted to me by my ACC fellowship and during my presidency, I thank the members of the College, its extraordinary volunteers, and its superb staff. Despite the stresses on our profession, I am pleased to assure ACC members that the College is thriving and remains committed to advocating for and educating the membership. The College is committed to welcoming into its ranks new members of the ACC who are embarking on their careers in this new century. Personally, I would like to see more of our young members participate in the College’s activities. Many can start by volunteering in their chapters and as members of the national committees and task forces. The chapters are extremely important to the ACC, and effective grassroots advocacy with third-party payers and state legislatures can make an amazing difference. The College will be there for new members, just as it has been for cardiovascular specialists since its inception more than a halfcentury ago. Thanks to the unfailing dedication of its volunteers and its staff, the future of the ACC is shining brightly.
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Acknowledgments
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I am, indeed, grateful to Ms. Kathy Boyd for her immense contributions to these "President’s Pages." I would also like to thank Mr. Jerry Curtis for his superb editorial assistance.
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Footnotes
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1 President, American College of Cardiology 
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Stresses on cardiovascular...
Advocacy