Sanjiv Kaul, MD, FASE

ASE spends considerable time and resources on advocacy. Diane Millman, of Powers, Pyles, Sutter & Verville PC in Washington DC, our legal counsel since 1986 (25 years!), is a very competent, loyal, tenacious, and vocal advocate for our members. Alan Pearlman, MD, was our first chair of the advocacy committee (renamed from Legislative and Regulatory committee in 1993) and did a remarkable job over many years. Committee leaders who continue to contribute enormous time to this effort include Drs. Michael Picard, Thomas Ryan, and Benjamin Byrd, and sonographer leader Elizabeth McIlwain. Our newest addition at ASE Headquarters is Janet Schanzenbach, vice president of health policy, who has extensive experience with advocacy and is supported by senior staffer Cathy Kerr. We have also engaged consultants to offer expertise in building connections with private payers, coding, and preparing code presentations for the American Medical Association (AMA).

Our main advocacy activity over the years has been in making sure that echo-related CPT codes provide fair reimbursement. This is a convoluted process, as codes are valued by the Specialty Society Relative Value Scale Update Committee (RUC) of the AMA. In the past, we have been represented on the RUC by the American College of Cardiology (ACC). The Centers for Medicare and Medicaid Services (CMS) look to the AMA for their recommendations.

Due to our lack of direct representation at the AMA in 2009, ASE did not have access to vital information such as the Physician Practice Information Survey (PPIS) data, which resulted in the steep Medicare Physician Fee Schedule (MPFS) reductions prior to it being sent to CMS. ASE has recently received approval to be on the Specialty and Service Society Caucus for a 3 year period. If we meet their membership requirements during this period, we could ultimately become a member of the House of Delegates and present our case directly to RUC. We hope that by applying for this seat, we will be able to advocate on behalf of our members more proactively and effectively.

We also respond to changes in professional and technical fees for echocardiography. For instance, when in 2009 a cut of nearly 10% a year over 4 years, which we believe was based on faulty data, was proposed by CMS, we sprang into action and hired a firm, Podesta and Associates, to help us lobby Congress against this measure. The 2009 Gonzales Bill was introduced to get a phase-in for the CMS cuts, to request a study demonstrating costs to CMS of imaging services moving into hospitals, and to add sunlight to the conversion/data analysis methodologies. We asked our members to urge Congress to support the Gonzales Bill. As a result, our advocacy expenses for this last year tripled compared to previous years.

Our budget for advocacy, however, dwarfs that of ACC, which is the main advocacy vehicle for cardiovascular specialists. Both the annual dues and physician membership of ASE are a quarter that of ACC. Many ASE physician members are also fellows of ACC. I urge them to actively participate in ACC committees and deliberations to help us have a voice regarding issues concerning echocardiography. We are also actively working with the three other cardiovascular imaging societies: the American Society of Nuclear Cardiology, Society of Cardiac Magnetic Resonance, and Society of Cardiac Computed Tomography, to support the role of imaging in clinical cardiovascular care.

We need to work together with all cardiovascular subspecialty societies toward a common legislative agenda to ensure that the house of cardiovascular medicine is united on legislative issues, particularly in light of the potentially large changes that may occur to our practices because of Health Care Reform. The ACC has an annual “Hill Day” in Washington DC in the fall to reach out to members of Congress, and has now agreed to also hold a legislative summit every winter with all cardiovascular subspecialty societies to develop a unified legislative agenda that has buy-in from all societies.

Historically, we have not had much contact with the US Food and Drug Administration (FDA), but in 2008, when they placed a black box warning on ultrasound contrast agents containing a long list of forbidden indications that would have virtually killed the use of the agents in clinical practice, we initiated a grass roots movement to convince FDA to reverse this action. We held several meetings with FDA to explain the clinical use of the agents and invited their representatives to participate in a session on ultrasound contrast agent safety at our annual scientific meeting in Toronto. As a result, most of the contents of the black box were removed within 6 months, record time for such an action. We now continue to engage with the FDA on a regular basis.

ASE is also very concerned about quality. ASE spun off the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and the National Board of Echocardiography (NBE) as vehicles to improve the quality of echocardiography. The NBE exam is designed to pass individuals with good to excellent training at the COCATS II level. The pass rate of this exam varies from 65 to 75% and, based on a number of benchmarks, we believe that testamurs of this exam are quality echocardiographers. Now the American Board of Internal Medicine (ABIM) is considering providing an echo module with its cardiovascular exam to certify cardiologists with special expertise in echocardiography. They are proposing the same for nuclear cardiology, cardiac MR, and cardiac CT. ASE believes that the standard developed by NBE and the criteria for passing the examination must be maintained in any proposed examination that will test competency in echocardiography. ASE is strongly supportive of standards set forth by ICAEL, which set a quality bar for echocardiography laboratories to achieve accreditation. In the future, quality will be an important measure in maintaining reimbursement levels.