The Changing Cardiovascular Market When knowing is not

The Changing Cardiovascular Market: When knowing is not enough and Action is Required Chris Nelson RN, RCIS, FSICP Director, Cardiac Education & Technology Sentara College of Health Sciences President, Cardiovascular Credentialing International

DISCLOSURES Christopher M. Nelson, RN I have no real or apparent conflicts of interest to report.

I see you. . Regina

• Occasionally, executing a maneuver such as a left turn would cause your car to shut down and refuse to restart, in which case you would have to reinstall the engine. • For no reason whatsoever, your car would crash. . . . 
Twice a day. • Every time they repainted the lines in the road, you would have to buy a new car. • Occasionally your car would die on the freeway for no reason. You would have to pull to the side of the road, close all of the windows, shut off the car, restart it, and reopen the windows before you could continue.

US Healthcare Economy • 2009 cost = 2. 5 Trillion. . 17. 6% of GDP (expenditures expected to increase 6. 2% / year – 2018 Projected cost = 4. 4 Trillion. . 20% of GDP (50 % subsidized by the US government) • 78 million US Citizens will be over age 64 by 2017 (25% of US population & 50% of the workforce) • 2008: 55 -60 million (est. ) unisured in the US (up more than 20% from previous estimates) – 2013: 28% (projected) of the workforce will be uninsured The National Coalition on Health Care, Health Insurance Cost, www. nchc. org - Government Pays Growing Share of Health Costs, WSJ, Feb 2007 US Bureau of Labor Statistics, 2009

Health Care Costs are rising faster than the economy Percentage of GDP All Federal Spending In Fiscal Year 2007 All Federal Revenues In Fiscal Year 2007 Assumes that health care cost growth will not exceed GDP growth. Assumes that health care cost growth continues at the average rate for the past 40 years (2. 5 percentage points greater than GDP growth. ) Assumes that health care cost growth rate declines to 1. 0 percentage point greater than GDP growth— consistent with the assumption used by the Medicare Trustees.

Estimated direct and indirect costs for coronary heart disease is $479. 3 billion American Heart Association: 2009 Heart and Stroke Statistical Update

Workplace Health Premiums Continue to Rise 2009 Health Premiums: Single Coverage = $4, 824 Family Coverage = $13, 375 Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999 -2008.

The Landscape: How Do We Compare? Total Spending: $7, 600/person in 2007 Source: United Nations Population Division, United Nations Population Fund Organization for Economic Co-operation and Development. OECD Health Data 2004

Houston – We have a another problem. . • Since the beginning of Medicare, the program’s cost has steadily risen as a percentage of US economic activity. • Medicare Part–A is financed primarily through payroll taxes, yet the worker to Medicare beneficiary ratio is declining. . 1970: 4. 5 workers to 1 Enrollee 2005: 3. 9 Workers to 1 Enrollee 2020: 2. 9 Workers to 1 Enrollee • Medicare Board of trustees “intermediate” estimate is that Part-A trust fund will exceed income in 2010. . . And that trust fund reserves will be exhausted, under current expectations, in 2018

Houston. . . umm, can you hear me now? ! Some estimates suggest that by 2030, Medicare would draw nearly 20% of all federal tax revenues. . . Options for cost savings are limited. . . 1. Reduce benefits and increase the age of eligibility 2. Increase taxes and premiums 3. Borrow, borrow

Congress faces a political problem with Medicare reform because it is a zero-sum game. . Someone will get hurt

Markets ice hospital plans Chicago Business News e work 0 ff 20 ncer yo to la -Intellige ish wed ttle Post S Sea rs Budget cuts may affect thousands of health care jobs Industry officials embrace the governor’s proposal to increase the cigarette tax to offset the reduction in Medicaid funding. Roanoke Times The Universi ty of Chicago Med ical Center Broad pause in hiring staff; practic al solution is to pause in h iring until th e length and d epth of the current natio nal economi c realities bec omes better known -

Modern Healthcare Reports Executives at UPMC face 25% pay reduction ue l reven ita w hosp es in lo at clin Citing ere de ns, officials ev ur and s e ent ret and Scienc investm Health SU n Orego y and its OH tween sit be Univer are cutting iscal f al Hospit 1, 000 job in d 500 an 2009. Henn ip 431 -b en Coun ty Me e is cut d publicly d ting 1 owne ical Cent d 0 e layoff s and 0 jobs thro hospital, s r, a a u f not b ound reezing all gh attritio id it n by co ntrac capital pro and ts. jects Crozer-Keystone Health System in Springfield PA will eliminate 400 positions though it’s unclear how many employees will be laid off, said Crozer-Keystone spokeswoman Kathy Scullin. Westchester Medical Center said it would cut 400 positions including 190 jobs that will be eliminated by closing its skilled-nursing home.

Action is required. . . Deficit Reduction Act of 2005 • Congress stands to gain 2. 8 billion in savings over 5 years from the imaging provision President Bush signs Deficit Reduction Act of 2005 in February 2006 • “All in all, the DRA will have a concentrated impact on a subset of imaging procedures and results in a fairly substantial cut – not across-the -board cut – of 30 percent to 70 percent in a variety of individual procedures. ” (Health Imaging News, Spetember 19, 2005 – Report on DRA, Phone interview with Don Moran, The Moran Group)

Access to Medicare Imaging Act of 2006 (S 3795)

2010 Medicare Physician fee Schedule • 36% reduction in fees for SPECT Imaging • 10% reduction in physician payment for transthoracic echo w/spectral & color doppler • 5% reduction for ECGs & 14% cut for the combined echo codes

Is action required? ! ! ! t u o n w ro h T

It’s not just about economics. . . Regulatory initiatives in pursuit of assuring quality

Look what’s going on in Oregon Is licensure in your future? • HB 2245 creates licensure requirement for Medical Imaging Professionals (all specialties) • This bill also allows the Oregon Board of Radiologic Technology to modernize into the Oregon Board of Medical Imaging. • Changing the name of the Limited Permit Holder to the nationally recognized title of Limited X-Ray Machine Operator (LXMO).

Current OBRT Composition Nine Members • • • 1 Radiologist 1 Public Member 1 Limited Permit Holder 1 Radiation Therapist 4 Radiologic Technologists • 1 Professional Imaging or Public Member

Medical Imaging Board Composition Add Specialties (Eleven Members) • • • One Radiologist Two Public Members One Limited X-ray Machine Operator One Radiation Therapist Two Radiologic Technologists One MRI Technologist One Nuclear Medicine Technologist One Diagnostic Medical Sonographer One licensed physician, other than a radiologist, in a specialty that routinely supervises the use of multiple diagnostic imaging modalities

Knowing is definitely not enough Action is Required. . Sonography Licensure Coalition: Influence Through Cooperation • The American Registry for Diagnostic Medical Sonography (ARDMS) • The American Society of Echocardiography (ASE) • Cardiovascular Credentialing International (CCI) • Society for Vascular Surgery (SVS) • Society for Vascular Ultrasound (SVU) • Society of Diagnostic Medical Sonography (SDMS) • Society of Invasive Cardiovascular Professionals (SICP)

Update • House Health Care Committee gave HB 2245 a “Do Pass” recommendation from the committee. The bill now goes to the joint House/Senate Ways and Means Committee.

Meanwhile back at the outhouse. . . On April 6 New Mexico Governor Bill Richardson SIGNED HB 498 "Medical Imaging and Radiation Therapy Health and Safety Act” into law! “The purpose of the Medical Imaging and Radiation Therapy Health and Safety Act is to maximize the protection practicable for the citizens of New Mexico from ionizing and non-ionizing radiation in the practice of medical imaging. This purpose is effectuated by establishing requirements for appropriate education and training of persons operating medical equipment emitting ionizing and nonionizing radiation, establishing standards of education and training for the persons who administer medical imaging and radiation therapy procedures and providing for the appropriate examination and licensure of those persons. ” NM HB 498 4/09

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West Virginia • West Virginia is planning to propose amending their RT licensure statute in their 2011 legislative session to include sonographers under their licensure laws. . .

Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 • Imaging provision of 2008 MIPPA and facility accreditation standards. . . – Services include x-ray, ultrasound and fluoroscopy – Outlines considerations for designating accreditation organizations – Directs secretary to designate organizations to “accredit suppliers furnishing the technical component of Advanced Diagnostic Imaging Services”

Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 Secretary to develop criteria that includes: Standards for qualifications of medical personnel who are not physicians and who furnish the technical component of advanced diagnostic imaging services.

So what does this mean for you? • Certification and Accreditation are on Congresses' Radar • Sets requirements for OP labs - no requirements for accreditation of in-patient / in-hospital labs. . . yet Where does this leave the CARE act? • • Stalled in 2008 due to MIPPA New version focusing on certification, dropped education Needs new sponsors Senate “not excited” about the same bill returning. . .

US Healthcare: The Patient • Preventable Medical Errors = 6 th Leading Cause of Death in the US (between 44, 000 - 98, 000 Americans are effected) • Effective prevention of disease and chronic illness management occurs only 50% of time • Today, nearly seven of every 10 U. S. adults are overweight, and about three of every 10 are obese. • The relative risk of CAD associated with physical inactivity ranges from 1. 5 to 2. 4, which is comparable to high blood cholesterol, high blood pressure or cigarette smoking. Institute of Medicine -- E. A Mc. Glynn et al, “The Quality of Health Care Delivered to Adults in the US, NEJM, 348, No 26, 2003 US Bureau of Labor Statistics, April 2009

Obesity Trends* Among U. S. Adults BRFSS, 1990, 1999, 2008 (*BMI 30, or about 30 lbs. overweight for 5’ 4” person) 1999 1990 2008 No Data <10% 10%– 14% ≥ 30% 15%– 19% 20%– 24% 25%– 29% Source: CDC Behavioral Risk Factor Surveillance System.

The Current Cardiovascular Market • CVD effects 25% of the population and is the leading cause of death in the U. S. • In 2003, the # of people with CVD = 71 million……this is expected to double by 2030.

Where’s the Volume?

Invasive CV Procedures September ‘ 06 – September ‘ 07 PCI ESC Dx Only ACC – Courage Release FDA Panel Normalized to 100 110 105 >10% decline 100 95 100 90 85 86 80 89 75 Sep Oct 2006 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep 2007 Source: BSC Bellwether Franchises

Impact of Preventive Therapy on PTCA and CABG 2006 2008 2010 2012 2014 2016 2018 *Assumes constant 2006 population. Sources: Impact of Change® v 8. 0; NIS; Sg 2 Analysis, 2009. 2020

The Changing Cardiovascular Market • Prediction: 4% increase overall 2007 -2018, with declining ALOS due to endovascular approaches • Cardiac Surgery +6% – Cardiac surgery will be flat due to interventional and medical therapies – Valve surgeries will increase due to age, demographics with a shift toward endovascular methods – VADs expected to grow over 55% • Interventional -8% – Heightened prevalence of obesity and diabetes will drive growth but will be tempered by medical therapy – Outpatient shift will slow I/P growth – Stenting will continue to be an alternative to CABG but will decline due in part to the discovery of late stent complications. Source data: Sg 2 Impact of Change Online, Advisory Board Cardiovascular Roundtable

The Changing Cardiovascular Market EPS + 33% • Use of ICD’s and AF Ablations will drive much of the expected growth – 8% increase in pacemakers 2007 -2012 – 28% increase in ICDs – 40% increase in CRT-Ds – 96% increase in AF catheter ablation Source data: Sg 2 Impact of Change Online, Advisory Board Cardiovascular Roundtable

US Healthcare: Workforce • 2006: Healthcare provided 14 million US jobs • 7 of the 20 fastest growing occupations are health related • Healthcare will generate 3 million new jobs between 2006 – 2016 • 544, 000 new healthcare jobs have been added since the start of the recession • Healthcare workforce among the most highly educated US Bureau of Labor Statistics, 2009

Action is Required • Pressure to Reduce Costs – maintain a positive bottom line – Develop an efficient system • Measure and Influence Quality • Accountability for Quality and Cost