Fall, 2008
From Your Chapter President I think everyone who attended the 80th Annual Scientific Session of The New York Cardiological Society felt that it was a great success.  The format with case presentations by fellows in training, preceding a formal discussion of a related topic and then questions with discussion of the case has made for a better educational experience.  This has allowed an avenue for the fellows to participate at a level at which they can feel comfortable.  Furthermore, the brief presentations by more senior fellows with discussions (and this year we had three such presentations) again gives them an educational and teaching experience while including them in our organization.  I want to thank all the presenters, Drs. Nicholas Hill (pulmonary hypertension), William Boden (COURAGE Trial), Edward Hannan (coronary stenting in New York State) and Janet Wright (quality issues in cardiology) for their participation. The fellows who participated, Drs. Kirsten Healy, Eric Au, Alex Reyentovich, Adam Skolnick and Apoor Patel need special thanks. Also, congratulations to our 2008 young investigator competition winners Brett A. Sealove, MD and M. Rizwan Khalid, MD for their poster presentations. Approximately 90 physicians attended and had a morning of educational and professional interaction that was most satisfying.  While this meeting was the last for Dr. Paul Kligfield and me to organize, I hope that these ideas with case discussion and fellow participation will be continued. In September, I attended the Board of Governors meeting where it was clear that the college wants to strengthen its commitment to the chapters and will see that all states have adequate chapter organizations.  The chapters will be looked at for grass root support on issues promoted by the American College of Cardiology. They will also be asked for their input and ideas.  This commitment is now demonstrated by making chapter dues mandatory for all members of the college. Each chapter will determine its own dues (limited to 50% of national dues) and this will be made part of your total dues payment to the college.  They will also support chapter websites, hopefully, with bidirectional communication. This recognition and dues structure for the chapters has long been supported by Dr. Paul Kligfield and myself. The other hot topic discussed at the Board of Governors meeting was Board Certification.  The fellows in training are swamped with test taking and expense. While the American Board of Internal Medicine offers cardiovascular disease, interventional and now advanced heart failure boards, other subspecialty societies offer nuclear, echo, and now CT and MR boards.  Then, we add recertification in these areas.  The general feeling is that the time and cost are too much. The goal must be education and moving away from punitive test taking.  The college is working on this issue, but there are many independent organizations to bring together and now the insurance companies who want specific subspecialty laboratory certification have entered the certification arena.  Oh, I almost forgot! For the 50% of us who have lifetime cardiovascular certifications and are probably over 55 years of age, there is a movement to revoke these certificates and have you retake the board! It was pointed out that an untoward consequence of this would be early retirement and a reduction in the workforce! Discussions go on. Finally, advocacy. Several of us, again, attended the Legislative conference in September in Washington, DC. Thank you again is in order to Drs. Andrew VanTosh, Linda Gillam, Denis Manor, Sidney Glasofer, Robin Matthews, William Borden and Ms. Tracy Shannon for your attendance, interest and participation at this conference.  The key points were the government interest in comparative effectiveness research where one drug or treatment may be equal to another and utilized to hold down the cost of medical care in that area, and the idea of quality replacing volume in the medical profession with accountability, responsibility and compassion being on the forefront.  As we visited our congressional representatives and senators, we were reminded that health care reform will be important in the next administration, and we must have a voice. Currently, only 10% of the Congress feels that a professional society should help shape health care reform.  We need to change this through support of our American College of Cardiology Political Action Committee.  Please be sure you and your group have participated. Many good ideas came out of our council meeting on October 4, 2008. I was encouraged by the enthusiasm.  While education has always been the main direction of the State Chapter, good ideas for advocacy and quality were brought forward.  Dr. Denis Manor has taken a leadership role in organizing the advocacy committee on both the State and National level.  Thank you. Also, Paul Kligfield has spent many hours and had many meetings in regard to prior approval for nuclear, CT, and now echo.  Again, thank you Dr. Kligfield for your participation in this work. Much is happening and with a strong chapter we can impact on it. We need to stay connected and organized.   I hope to see many of you in December at the 41st Annual Cardiovascular Symposium in New York City. Harry C. Odabashian, Jr., MD, FACC
Judith S. Hochman, MD, FACC 2008 New York Cardiac Center Lecturer   Judith S. Hochman, MD, FACC, has been invited to deliver the Twelfth Annual New York Cardiac Center Lecture.  Dr. Hochman is Co-Director, NYU-HHC Clinical and Translational Science Institute; Clinical Chief, The Leon H. Charney Division of Cardiology; Director, Cardiovascular Clinical Research; and Harold Synder Family Professor of Cardiology at New York University Medical Center.   The title of Dr. Hochman’s lecture is THE ROLE OF REVASCULARIZATION FOR CORONARY ARTERY DISEASE, FROM ACUTE SHOCK TO STABLE OCCLUSION AFTER MYOCARDIAL INFARCTION.  Learning objectives of this lecture include review of the role of early revascularization for cardiogenic shock complicating MI, review of the appropriate role for late revascularization post MI based on the findings, understanding of the experimental and observational evidence for the early and late open artery hypothesis and review of the process of adverse LV remodeling post MI, risk factors and consequences.   The lecture is presented by The New York Cardiological Society of the New York State Chapter, American College of Cardiology, in association with New York Cardiac Center and in co-sponsorship with the American Heart Association.  The lecture will be held on Thursday, December 4, 2008 at the Uris Auditorium New York Presbyterian Hospital-Weill Cornell Medical Center from 7:30 p.m. to 9:30 p.m. Program brochures have been mailed to all members.   There is no registration fee or advanced registration.  For further information, please call the New York State Chapter office at 212.686.0228 or e-mail nweiner@nycms.org     Precertification for Cardiology Testing   Paul Kligfield, MD, FACC Harry C. Odabashian, MD, FACC   None of us like precertification, but unless there is a major revolution in our health care system we need to work with it.  During the past year and a half, a number of us in the New Jersey , New York , and Connecticut ACC State Chapters have met with representatives of national and local insurance carriers and with CareCore Cardiology, a group that provides precertification and appropriate use services to the carriers.  This is meant to be practical.  As ACC CEO Jack Lewin has often said, “if we’re not at the table, we’ll be on the menu.”   What’s not to like about precertification?  Well, first of all, no one likes insurance intermediaries telling us what is and isn’t appropriate use of testing for our patients.  And second, no one likes the slow, increasingly tedious, complex, and often seemingly obstructive process by which precertification is implemented.  Precertification has become a major, time-consuming, unreimbursed, obligatory cost in practice.    On the other hand, tests can be overused and insurance carriers are financially motivated to limit tests that are not “appropriate.”  Who defines what is appropriate?  How can a fair precertification process be organized?  How can a fair process be simplified in terms of time and cost?   In our discussions, we have taken the position that appropriate use of testing in cardiology should be a National issue for definition, not a local State Chapter issue.  Quality of care in cardiology cannot and should not be negotiated on a State by State basis.  ACC already has a series of guidelines on appropriate use of most of our tests that have been put together by National experts in these areas, and the National organization has the resources to keep these timely and to work with insurance carriers to provide safe and cost-effective quality care for our patients.   In contrast, the process of precertification for testing is often implemented at the local level, where at times it seems to be based on a premise that cardiology procedures are being overused by everyone.  For example, in New York we have a situation where CareCore requires faxed copies of ECGs (to support the ACC definition of uninterpretable) and CareCore review of other markers of Framingham risk before approval is granted for myocardial perfusion imaging (MPI) in some patients.  This has involved serial telephone application and faxed supporting documentation that just seems too complicated and too time-consuming. We have spent a fair amount of time discussing the MPI approval process with CareCore, focusing on MPI for several reasons.  MPI is one of the earliest tests to be subjected to precertification around the country and in our States.  MPI appropriate use guidelines are available from National ACC and have been largely adapted (but not exactly) for precertification by CareCore.  The rationale and decision tree process for MPI appropriate use is manageable in scope. Since it has been implemented for some time in our tri-State area, there are some data on MPI approval rates, and perhaps most important, short term data from CareCore demonstrating low rates of major cardiac events in patients denied MPI approval by current appropriate use criteria.  This stands to reason, since low risk patients should have a low rate of endpoint events.   What we have learned is that there are several clinical situations that account for a major number of appropriate use denials for MPI.  Whether we all agree with these or not, routine requests for MPI  are not approved by CareCore for:               1.  Asymptomatic patients after coronary revascularization (CABG, PTCA) within timeframes defined by the ACC.             2.  Asymptomatic patients with low Framingham risk (as calculated by CareCore from risk factor data that we provide).             3.  Symptomatic patients with an interpretable ECG (i.e., no abnormal repolarization at rest, LBBB, WPW, or ventricular pacemaker) as the initial exercise test. It should be noted that in most cases, MPI will be approved by CareCore for further evaluation when the exercise ECG is abnormal.   We think it is fair for our Chapter members to review and reconsider these appropriate use MPI criteria formulated by CareCore—these are largely modeled after current ACC guidelines.  Those of our members wishing to improve their CareCore approval rate to qualify for a greatly simplified approval process (see below) should note that these three clinical situations are the bulk of the problem MPI authorization issues.   In return, CareCore has acknowledged that the authorization process is in need of simplification, and they also agree to reward those of our members with a track record of appropriate use of MPI (and separately, of other tests) with a pilot evaluation of preferential treatment in the authorization process. CareCore has now implemented a fully on-line preauthorization process that in most cases will eliminate any telephone contact and waiting time, although for routine use documentation may still be required to be faxed to support clinical data.  On line teaching modules are available through the CareCore website that list what clinical data is required for several major categories of test indication.  This will allow the person requesting authorization to gather the required data in advance.  The website and modules can be accessed at the following address: http://www.carecorenational.com/ProviderTools.html   It is also acknowledged by CareCore that it may not be efficient or necessary to burden all of us with documentation to prove that everything we submit is true.  Accordingly, CareCore has also agreed to implement a “Preferred Provider Access System” (PPAS) for those ACC members who have demonstrated appropriate test utilization.  PPAS will allow preferred members to receive immediate on-line authorization for MPI if entered patient data supports appropriate use—members who enter this program will no longer need to fax supporting documentation to CareCore for requests meeting criteria for approval. Participants in the program may be periodically audited for supporting documentation, but this seems to be a time and cost saving step in the right direction for many of us. Information about participation in the CareCore PPAS is also available at the website above.   Again, none of us may like preauthorization, but until it’s gone we can continue to try to simplify it.  This may be one small step.   Practice Administrator New Membership Category   The American College of Cardiology has instituted a new category of membership --Practice Administrator.  Any individual who is responsible for managing a private practice or the business of cardiovascular care delivery is eligible to join.  The membership category was established in order to address the business aspects of practice management.  Additional information may be found at:   http://www.acc.org/about/join/practice_admin-app.pdf. http://www.acc.org/practicemgt/practice_management.htm.   Please encourage your practice administrators to join.      CARDIOLOGY 2008: THE SCIENCE OF QUALITY CARE   The 80th Annual Scientific Session of The New York Cardiological Society and the 18th Annual Meeting of the New York State Chapter of the American College of Cardiology, CARDIOLOGY 2008: THE SCIENCE OF QUALITY CARE, was held at the New York Athletic Club on Saturday, October 4, 2008.  Paul Kligfield, MD, FACC, downstate governor and president of The New York Cardiological Society; and Harry C. Odabashian, Jr., MD, FACC, upstate governor and president of the New York State Chapter welcomed the attendees.   The program began with the presentation of the 2008 Young Investigators= awards followed by a presentation by Janet Wright, MD, FACC entitled, ACC Perspective: Quality Issues for Cardiology.  A brief case presentation, A Patient with Pulmonary Hypertension, preceded a lecture by Nicholas S. Hill, MD, Evaluation and Management of Pulmonary Artery Hypertension.  The next lecturer was William E. Boden, MD, FACC, Lessons Learned from the COURAGE Trial , preceded by a brief case presentation, A Patient with Stable Angina Pectoris.   Included in the program, again this year, was a section entitled, Emerging Insights in Cardiology: Short Presentations by New York State Fellows in Cardiology, which included three presentations: A 49 year old Woman with Palpitations and Syncope, A 53 Year Old Woman with Chest Discomfort and ST-Segment Elevation during Doobutamine Stress Testing and A 49 Year Old Woman with Syncope and a Positive Exercise ECG.  Time for discussion and questions followed each of the lectures.  The meeting concluded with a lecture, An Update on Recent Studies of Coronary Stenting in New York, presented by Edward L. Hannan, PhD, FACC.   2008 Young Investigators= Awards Presented   The winners of the 2008 Young Investigators= Competition sponsored by the New York State Chapter are M. Rizwan Khalid, MD, from New York Hospital and Medical Center of Queens and Brett A. Sealove, MD, from Mount Sinai Medical Center.  Poster presentations of their research appeared at the October 4th Annual Scientific Session of The New York Cardiological Society/ New York State Chapter, Cardiology 2008: The Science of Quality Care.   The New York State Chapter gratefully acknowledges CV Therapeutics for graciously underwriting the 2008 Young Investigators= Competition.     Notice of Elections    A slate of candidates for the 2009 New York State Chapter Council election will be presented to the membership in late December, 2008.  All New York State Chapter members are eligible to vote.  Councilors are elected to a two-year term of office and may be elected to two consecutive terms. Councilors will be elected in the following districts:      $ District 1- Bronx, Kings, New York, Queens and Richmond counties $ District 2- Nassau and Suffolk counties $ District 3- Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester counties $ District 4- Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery , Otsego, Rensselaer , Saratoga , Schenectady , Schoharie, Warren and Washington counties $ District 5- Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison,  Oneida, Onondaga, Oswego, St. Lawrence and Tompkins counties $ District 6- Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Tioga, Wayne and Yates counties $ District 7- Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming counties   Councilor responsibilities include: C  developing Chapter policy and direction by attending at least one Chapter Council meeting annually C  monitoring the needs of cardiologists within his or her district and communicating these needs to the Chapter President and the Council C  assisting the President in membership development including contacting ACC members who have not paid Chapter dues C  helping to locate interested volunteers for Chapter committees when vacancies occur C  assuming the role of leader/promoter for the Chapter by relaying accomplishments and activities to colleagues C  assisting the President in activating a network pyramid when deemed appropriate for urgent communication    If you would like to receive additional information regarding the election process, please contact the New York State Chapter at 212.686.0228.   Strong Chapters Equal Strong ACC   While the American College of Cardiology (ACC) works hard and effectively to provide education, quality initiatives and advocacy for all its members, to paraphrase a famous line from former Speaker of the House “Tip” O’Neill Jr. — “All health care is local.”   The New York State Chapter Chapter, along with the ACC’s other 48 Chapters, is a critical link to other cardiovascular specialists in New York State.  We provide critical local education, quality and advocacy opportunities and play a key role when it comes to networking, leadership building and mentoring.  Given the invaluable roles all Chapters play, the ACC Board of Trustees recently approved the implementation of mandatory Chapter dues for active physician members. The goal is to provide Chapters with the resources necessary to develop innovative education and advocacy programs and enhance the benefits of Chapter membership.   One of the major challenges for the New York State Chapter today is to remain fiscally viable despite a political and economic climate that is making health care funding increasingly difficult to secure and/or narrowly limited in scope.  Other similarly situated medical associations, such as the American College of Physicians, implemented mandatory dues and have seen an increase in Chapter membership and a greater sense of involvement from their members as a result. Enabling a baseline membership experience is extremely important to energizing grassroots Chapter work. It is our hope that mandatory dues will lead to greater involvement and ownership in the great work that the New York State Chapter is already doing.  The practice of cardiovascular medicine is increasingly affected by legislators and regulators at the state and national levels.  Member involvement at every level is crucial for success, and Chapters are key to involvement at the local level. Without mandatory Chapter dues, we run the risk of limiting the education, advocacy and quality improvement programs that are necessary to ensuring the highest quality care for patients.  We also run the risk of disengagement by members. The ACC’s annual dues statements will be arriving in mailboxes this month and will reflect the mandatory Chapter dues decision.  In the coming months, you’ll see a new look for the national Chapters Web site www.acc.org/chapters.  You’ll also see an increased effort to keep you informed about Chapter opportunities and more information about how every member of the cardiovascular care team can benefit from Chapter involvement.  Strong Chapters mean an even stronger ACC, and we are excited about the opportunities to make the ACC as strong as it can be. Jane Schauer, MD, FACC Chair, Board of Governors   Upcoming Meetings   9th ANNUAL                                 CURRENT CONCEPTS IN CARDIOVASCULAR MANAGEMENT ‘08 (co-sponsor)  Millennium Airport Hotel Buffalo Friday-Saturday, November 14-15, 2008     The Twelfth Annual New York Cardiac Center Lecture THE ROLE OF REVASCULARIZATION FOR CORONARY ARTERY DISEASE, FROM ACUTE SHOCK TO STABLE OCCLUSION AFTER MYOCARDIAL INFARCTION   Judith Hochman, MD, FACC Uris Auditorium New York City Thursday, December 4, 2008   41ST ANNUAL NEW YORK CARDIOVASCULAR SYMPOSIUM (co-sponsor) Hilton New York Friday, December 12- Sunday, 14, 2008 New York City   ADVANCED REIMBURSEMENT & CODING SEMINAR FOR CARDIOLOGY Tuesday, February 24, 2009 Syracuse Wednesday, February 25, 2009 LaGuardia Airport East Elmhurst     Up-to-date meeting information appears on the New York State Chapter website www.ny-acc.org