November 28, 2000

Recent ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction have been published in the latest issues of JACC and Circulation. Enclosed please find the algorithm for evaluation and management of patients suspected of having acute coronary syndrome. In this outline patients that are not crashing with acute events are observed for a period of time while EKG's and cardiac markers are obtained allowing a proper decision to be made as to disposition.

Chest Pain Observational Services (approximately 1200) within the Emergency Department are now recognized as a way to deal with such patients. Recent articles in peer reviewed journals have been published showing the benefit of a reduction in missed MI's being sent home as well as a reduction in appropriate admissions in such patients to the hospital resulting in reduction in overall health costs.

Chest Pain Centers have had observation services as part of an overall strategy to reduce heart attack deaths within the community. Growth of Chest Pain Centers throughout the United States is a reflection of this approach. This exponential growth was recently challenged when HealthCare Finance Administration put into practice Medicare's Outpatient Prospective Payment System (PPS) but did not take into account this developing observational strategy for community heart attack care.

The Society of Chest Pain Centers and other groups responded to this through an exchange of meetings and teleconference to correct the problem.

The plan to correct this was recently outlined in a letter from HCFA in an effort to stem the tide to prevent hospitals interested in developing Chest Pain Centers and Observational Services from putting them on the back burner. The full content of the letter is available on the website www.scpcp.org To quote from it Tom Gustafson, Director of Purchasing Policy Group Center for Health Plans and Providers stated "You and your colleagues have raised with us concerns about lack of explicit payment for observation for chest pain under the Outpatient PPS. The issue, as we understand it, is that although hospitals are being paid for these services as part of the APC payments the lack of a payment visibly associated with observation for chest pain may lead hospitals to cut back on providing such observation. Chest Pain Centers have been put forth as an important focus for addressing chest pain symptoms, and your concern that lack of explicit payment may interfere with diffusion of this innovation among hospitals. We believe that your concerns are important and would like to attempt to address them. In the case of chest pain, we are prepared to revise our policy (through notice and comment rule making) to provide separate identification of payment for a well defined set of observation services if the concerns about potential abuse can be addressed. You and your colleagues have generously shared with us some suggestion about how this might be accomplished and we believe these suggestions are promising. We expect to advance a formal proposal under which we would specify particular circumstances where separate payment would be made for observation associated with chest pain and would set rules and design to prevent abuse. Such a proposal would be designed to permit separate payment under the outpatient PPS for observation of chest pain and well defined circumstances; any new APC for this purpose would have to be funded by making non-trivial reductions in the payment for existing APC's. This proposal would appear in the Spring of 2001 in the upcoming notice of proposed rule - making for the outpatient PPS. As with other such changes in the system, it would be open to public comment, and we would finalize the proposal in response to those comments later in the year. The change would take effect on January 1, 2002. We are sorry we are not in a position to move more quickly to address your concerns.

We very much appreciate the thoughtful input you and your colleagues have provided us, and we look forward to bringing this matter to a satisfactory outcome."

In the teleconference it was announced that a specific address on their HCFA website will be made available for questions and answers Q & A concerning this issue. Once this is supplied, it will be found on the Society's website www.scpcp.org for all to view. Feel free to e-mail your comments here.

In summary then, many of you have corresponded to the Society of Chest Pain Centers for input as to how HCFA was reviewing Chest Pain Observational Services. This then is the latest information. We will continue to work closely with HCFA in the implementation of this joint effort.

Sincerely and Respectfully,

Raymond D. Bahr, MD, FACC, FACP
President

www.scpcp.org
www.ehac.org
www.chestpaincenters.org
www.deputyheartattack.org