E-Journal of the Society of Chest Pain Centers
Spring 2002, Volume I, Number I
PERSPECTIVE
Government Correct
OBSERVATIONAL SERVICES
Chest Pain Observational Services in Emergency Departments as a Quality Improvement Initiative and their Proper CMS (HCFA) Reimbursement
Raymond D. Bahr, MD, FACP, FACC
St. Agnes Hospital
Baltimore, Maryland
A STUDY IN GOVERNMENT CORRECT (as in politically correct)
Who says you cannot fight the Government? ... that the Government represents big bureaucracy ... and snarls you in the web of its red tape ... with a foreign language explanation for its actions ... that Government frequently places you in a "no win" situation with patients ... pressing you to either commit errors or abuse the system and face fraud charges.
Nonsense ... The Government is only as big as the monster that you make it. Give it a chance ... challenge it ... see if it can be made to engage the proper people who will listen to your case. It is not so important that they initially take a different stance ... but that they understand enough to respect your efforts to sort out the facts before reaching a conclusion.
Whether you realize it or not, Government employees are "people" as well who experience the same type of medical problems as providers and they are "people" who want the very best in medicine for themselves when they become ill.
This was the premise under which we called to make an appointment in May 2000 to see this HCFA giant. It turned out to be easier than we thought. Once we were able to relate to them that a fair number of medical organizations were concerned that HCFA with their APC policy would be interfering with the Clinton Administration's objective of reducing errors in hospitals (proposed $50 million New Center), we were able to get an appointment with them. Much to our own ignorance, HCFA was located just 10 minutes away from our hospital, St. Agnes HealthCare in Baltimore, Maryland.
The next step was to bring together other medical organizations with similar concerns. We were able to do this with the assistance of the American College of Cardiology, the American Heart Association, the American Society of Nuclear Cardiology, the American College of Emergency Physicians, the American Medical Association, the American Society of Internal Medicine and the American College of Physicians.
Even the Quality Improvement Division of Medicare was supportive in our efforts. We wondered why the two divisions of HCFA had not discussed this before our meeting. We also wondered why the HCFA inpatient side could not be brought into the equation since the savings here reflected an improved outpatient effort as a result of Chest Pain Observational Services.
We clearly saw these as problems and stated this as such. We relied on this discovery to enlighten the decision makers who viewed observation medicine in a different light than we did.
In November 2000, we found out that we did not win the first time around because we were not able to stop the train due to a timetable for APC completion and implementation that had been set in motion by this bureaucracy. However, we did win in getting HCFA's attention and commitment to review in depth the evidence based data on observational services with changes in the APC to be made later. Unfortunately, the reimbursement aspect had to wait another year, but as they stated, this was the best they could do.
We graciously accepted this as progress, both in our own development as well as in HCFA's. Deep down however, we were anxious because there was to be a new administrationÉand then there might be a change in players and perhaps in policy. Good intentions could not be counted upon. Promises could not be made. We were left only with Trust ... trust in the HCFA administrators ... trust in a government that our country was founded upon, but we had done the best we could. We had made our points. We were left with the chips to fall into place and hopefully in our favor.
We were confident with what we believed to be the best possible cost effective service for heart attack evaluation and hoped that ... the HCFA Committee would come to the same conclusions based on scientific studies in peer reviewed journals.
We were happy with developing events with the change in the presidency. We had had a change in HCFA leadership that was more intent on being user friendly ... and even changed their name for this reason (HCFA to CMS). The New CMS was committed to reducing government manipulation in medical care that was tearing down the very fabric of medicine.
We began to breathe easier. We were able to come up for air as we were waiting for CMS to iron out these differences in approach to observational services.
Finally, the regulation came through on the Federal Registry reflecting proper reimbursement for chest pain observational services (August 20, 2001).
We were relieved ... we had won ... we had beaten big government ... but really had we? Our success was due to our ability to energize fellow Americans who shared the bigger picture of improving heart attack care as much as we did. The final outcome was thus a victory for all of us. No longer was "government correct" to be considered an oxymoron, but a desired middle ground of communication achievable with an understanding of the finish line or ... the bottom line that represented cost effective improved heart attack care.
In summary, The Real Victory belongs to the American Public which will benefit from better heart attack care through a shifting paradigm that places more emphasis on early care where more benefits can now take place ... namely the strategy of Chest Pain Centers to provide prepared heart attack care at the community hospital level in the more than 5,000 hospitals in the United States.
With the proper reimbursement now available for observational services, we expect to see a renewed interest in chest pain centers that will result in exponential growth in these centers throughout the United States. The current number of 1,300 chest pain centers is expected to double in the next 1-2 years. It comes at a time when guidelines for the care of patients with Acute Coronary Syndrome are being promoted by the American College of Cardiology and the American Heart Association in an effort to close the gap that exists between the science-based evidence and current practice in heart attack care. The Guidelines (1) are similar to the ACEP Clinical Policy (2) on this subject. Together they have made chest pain centers a Class I recommendation by incorporating needed observational services for patients with low to moderate risk of having ischemic heart disease (see figure 2 - algorithm in the ACC/AHA Guidelines, page 1498).
Similar chest pain center discussions have been reported from the 31st Bethesda Conference on Emergency Cardiac Care (1999) (3) as well as included in the National Heart Alert Program Position Paper on Chest Pain Centers (4).
The Marriage of a Quality Improvement Initiative with a Chest Pain Center Delivery System now having Proper Reimbursement through CMS (HCFA) is a major step forward in our efforts to make a significant impact on the mortality and morbidity in the heart attack problem at the grass roots community hospital level.
Furthermore, this creative packaging may further redefine hospital care in the future provided by changing the landscape to a more efficient, cost effective outpatient type care that improves patient outcomes by placing emphasis on early evaluation and treatment available at the community hospital level.
For further information visit : www.scpcp.org for a time table of the HCFA events and the evidence based data that support the case for chest pain observational services in the Emergency Department provided by Michael Ross, MD, and Louis Graff, MD, et. al.
- ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Executive Summary and Recommendations - Volume 102, No. 10 September 2000
- Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting With Suspected Acute Myocardial Infarction or Unstable Angina - Annals of Emergency Medicine May 2000 p521-538
- Journal of the American College of Cardiology - 31st Bethesda Conference Emergency Cardiac Care (1999) September 13-14, 1999 Volume 35, No. 4, 2000
- National Heart Attack Alert Program Position Paper: Chest Pain Centers and Programs for the Evaluation of Acute Cardiac Ischemia - Annals of Emergency Medicine May 2000, p462-471
