Taken from the Providence Journal

Michael F. Gilson: R.I.’s looming cardiology crisis

WHILE ANGST about the high cost of medical care and the debate over health-care reform dominates the headlines, the Centers for Medicare and Medicaid Services (CMS) has quietly proposed payment cuts that, if introduced, would reduce reimbursement for cardiovascular services by 30 to 40 percent across the board. For reasons specific to Rhode Island — reasons that have received scant attention in the national or local dialogue — Rhode Islanders are uniquely threatened by the contemplated cuts. 

Rhode Island has one of the highest rates of cardiac disease and one of the lowest reimbursement rates for cardiovascular care in the nation. The rates are low because Rhode Island has a disproportionately large Medicare population and, because of its small size, lacks a competitive private insurance market. As such, all third-party reimbursement rates are closely tied to Medicare reimbursement schedules. It is therefore not hard to understand that, while the extraordinary new round of CMS cuts scheduled to become effective on Jan. 1, 2010, threatens the viability of health-care organizations across America, the impact of these changes on the delivery of cardiovascular services in Rhode Island may well be catastrophic. 

It is reasonable to predict that the immediate effect of these cuts will be the contraction of several cardiology practices, and the closure of others. As a result, many cardiac services will be curtailed across the state and in some cases will not be available at all. Travel distances to a reduced number of testing sites will increase. Waiting times for diagnostic testing will increase. As physician availability drops, schedule delays for follow-up and new appointments will increase. Coverage for 24-hour acute-care services will be stretched to the limit, potentially jeopardizing Rhode Island’s stellar record of prompt response to true cardiac emergencies. (Heart attacks do not generally keep banker’s hours.) 

The damage from shrinking and failing practices will not be restricted to deterioration of patient care. Non-physician workers, many highly trained, who support cardiology practices (secretaries, nursing assistants, nurses, nurse practitioners, physicians assistants, imaging technicians and exercise physiologists) will lose their jobs and add to the growing number of unemployed in Rhode Island. 

The long-term view of the effect of reimbursement cuts is no less disconcerting. Over the next decade, as the population ages, the number of people in the state who will require acute lifesaving care for heart attacks and chronic care for coronary disease and heart failure is projected to increase. During that same period, close to 40 percent of cardiologists currently in practice will have retired or reached retirement age. Providing first-class cardiac care to Rhode Island residents into the future requires that we attract and retain talented young physicians who want to make their lives in this state. Currently, competing for talent with surrounding states (with more favorable reimbursement environments) to keep pace with retirement and attrition is already a difficult task. If the proposed cuts are applied as contemplated, the task probably will prove impossible. 

All care givers in Rhode Island embrace the principles driving health-care reform. Affordable, high-quality health care for every American is a goal we must all strive to achieve. Physicians are ready to play their part in this transformation. We applaud the application of evolving technology and systems to ensure appropriate testing, prevent duplication and reward good clinical outcomes. 

(The American College of Cardiology is heavily invested in developing practice guidelines, appropriateness criteria for testing and algorithms for measuring clinical outcomes.) 

Thoughtful use of these powerful new tools will result in significant and ongoing cost savings without sacrificing overall quality of care. In contrast, the proposed Medicare cuts represent a short-term and short-sighted response to the cost dilemma. Health-care “reform” that achieves cost savings through compromised patient care is an outcome unworthy of the imperative we face: to achieve cost savings while preserving the high quality of care that all patients deserve.