Attendees: Surgeons: Junaid Khan, President; Jeff Milliken, cfo; James MacMillan; Tony Caffarelli; Aidan Raney; Joe Carey, Interim Executive Director

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CASTS Annual Meeting

Caspian Room, St. Regis Monarch Beach Hotel

Dana Point, CA

11:00 AM-3:00 PM June 28, 2014


Surgeons: Junaid Khan, President; Jeff Milliken, CFO; James MacMillan; Tony Caffarelli; Aidan Raney; Joe Carey, Interim Executive Director

Quality Administrators/Data Managers: John Braithwaite; Cathy Major; Vicki Silvius; Michelle Taylor; Laura Perez Aoki; Cathy Hunt; Bruce Bartel; Debbie Sweeney; Debbie Wong; Rhonda Lambert; Thelma Pates; Nancy Satou

Claude Brandeau, CASTS physician Liaison

Holly Hoegh, PhD Manager, Clinical Data Programs, Healthcare Outcomes Center, OSHPD

Justine Norwitz, Washington State Surgical Quality Outcomes Assessment Program and Vice President, Benchmarket Medical, Seattle, WA.

11:00—12:00 AM Welcome and Introductions

CASTS two-year report

Dr. Carey gave a summary of the most recent two years of CASTS events. Presentations at CASTS meetings by Ed Fonner in 2012 and Eddie Fonner jr. in 2013 described the value of collaboration and success achieved in Virginia and other regions. The goal of regional organizations is to “foster collaboration with data sharing, outcomes analysis and process changes and to contain costs by lowering complication rates and improving efficiency”. The benefits of a collaborative group include comparing outcomes, replicating the success of others, reducing isolation, flattening of hierarchy, encouraging innovation, and developing interventions to improve outcomes. Dr. Carey echoed these sentiments, adding that in addition to encouraging a culture of continuous quality improvement, the CASTS mission included education of all stakeholders, including our patients, about our specialty.

The discussion then turned to successes and failures of the CASTS. CASTS has advocated for surgical assistant payments and reform of public reporting laws. Reporting websites were updated to include hospital-specific volume and outcome data on cardiovascular surgery and interventions with long term trends for all California heart hospitals. Following the resignation and subsequent passing of Ed Fonner, the data managers formed a separate group, primarily focused on continuing monthly conference calls. The attempt to form regional associations in LA and Orange counties was abandoned.

While only a small number of surgeons have continued to attend CASTS meetings, clearly the organization has been recognized as the voice of CA cardiac surgeons within the state and nationally. The CASTS has shown that it can influence payers and policy makers. It has been supported by universities and major programs and has attracted grants and institutional funding. Scholarly publications have been produced. The CCSIP website reports have raised the profile of cardiovascular reporting in California.

Given these positive realities, how to overcome the resistance to collaboration and data sharing? There is evidence that some hospitals are in fact disconnecting their quality departments from clinical services. Should quality improvement continue on its own pathway, as suggested by the formation of a separate “data managers” group? Should CASTS continue efforts to form regional groups, for example in Orange County, where a coalition of surgeons is already being formed?

Dr. Milliken commented that Dr. Khan, as president should outline what he hopes to achieve with CASTS over the next 2-3 years. This should be in a very definitive form…with a request for input from membership at the end. Mission statement and goals should be clearly outlined. The value of continued organization and publication of PDD data should be indicated. Two board positions for DBM should be established, possibly nominated by the DBM group. Data managers/quality control administrators should be considered for regular membership (rather than associate) in CASTS.

Dr. Khan reviewed meetings and discussions with Dr. Bernice Hecker, Medical Director for CMS Jurisdiction E (West Coast, HI, Guam). In general, she was agreeable to payment for a second assistant in heart cases, providing documentation was appropriate. A more definitive determination will be forthcoming. He also reviewed recent changes in hospital-surgeon relationships, and indicated that quality control administrators have become disconnected from surgeons in some hospital consortiums.

CCSIP progress (Dr. Joe Carey)

The CCSIP reporting site has been completely revised and updated. Access to procedure volumes for CABG, PCI and valve procedures for all California heart hospitals from 1999 through 2012 is available at Mortality and adverse event rates for 2011-2012 are posted. Outcomes data will require participation fees. A 2013 update will be added this summer. As the only source for information on all CA heart programs, CCSIP reports provide accurate data on volumes, mortality rates and rehospitalizations in CABG, PCI and Valve procedures. This allows heart team members to review trends and see how their colleagues and competitors are doing. Participants will also be encouraged to join collaborative meetings and conferences to pursue QI initiatives.

12:00 Lunch/Status of SB 830 (Dr. James MacMillan)

Dr. Mac Millan reported that while SB 830 sailed through committees without significant opposition, it was tabled by finance because of the proposed budget. This effectively eliminated prospect for passage this legislative session. Budget proposals will be revised and resubmission of the legislation will be considered later this year.

12:30-1:30 PM Achieving Measurable Improvements with Clinical Data

Washington State experience

Justine Norwitz, Benchmark Medical, Seattle WA.

Ms. Norwitz described the improvements in surgical care that had been accomplished in Washington’s Surgical Care Outcomes Assessment Program. SCOAP is clinician-led, using clinical data derived from medical records for defining, tracking, benchmarking and improving quality. It is a learning system focused on process of care: surveillance, process control, process learning, outcome control and evidence-based Interventions. Behavior is impacted through policy, peer to peer networking, checklists, education and public health initiatives.

She described how complications and costs of appendectomy and colorectal surgery have been accomplished through interventions. Recommendations for quality initiatives included:

  • Find the “real” enemy

  • Start small

  • Create wins for everyone

  • Grow leadership from where care happens

  • Know what really motivates

  • Must be physician driven

  • Role of surveillance

  • Meaningful and actionable interventions

Ms. Norwitz emphasized the value of building community, recommended “measuring something that matters and finding something that can be fixed”. She also stressed that we should “remember what motivates”. It is important for hospitals to share to cost of surveillance and quality interventions. In Washington state, hospitals contributed up to $15,000 to support the SCOAP program. Other stakeholders, including payers and provider organizations also provide support.

1:30-2:00 PM Regional Collaboratives and the Legacy of Ed Fonner

Jeff Rich MD, Virginia

Dr. Rich was unable to make the meeting. He sent his apologies and promised to send his comments and recommendations by email.

2:00-3:00 PM CASTS business meeting (open to all) and wrap-up by Dr. Khan

The following items were discussed:

  • Continue efforts to interact with payers regarding title 22 assistant surgeon regulations

  • Resubmit SB 830 with appropriate changes

  • Consider formation of combined committee with CAACC to take an active role with third party payers to insure quality metrics are fair, goals reachable and uniform throughout state

  • Develop membership structure to include data managers, quality administrators and other heart team members

  • Continue to pursue regional collaboration, beginning in Orange County and potentially with Dignity Health, Sutterhealth and other cardiovascular healthcare consortiums

  • Enlist hospital support through participation fees

President Junaid Khan submitted the following report after the meeting:

Title 22 Payments

We had about 60 responses to the initial query about the lack of payment for second assistants from Noridian the Medicare vendor. The problem was nearly universal.

CASTS leadership has had multiple points of contact with Noridian, including a meeting with its director Bernice Heckler MD. We informed them of the unique role of Title 22 in the state of California in requiring a second assistant. Our understanding at this point is that Noridian will be open to paying for the second assistant as long as its role is documented properly. We have heard some feedback from members who are now starting to get paid for a second assistant. Below is a sample composite template on how to document appropriately the role of the first and second assistants, based on some of the responses we have received form members. A follow up meeting was held between CASTS leadership and Noridian at the Medicare Carrier Advisory Committee meeting in San Francisco last month. The following the statement was issued after that meeting. Not completely satisfying, but something we can work with. An alternate proposal for billing the vein harvest as co-surgeon was discussed and though this might lead to slightly higher short term compensation, but I did not think this was a good long term solution, ie if/when the vendor changed again and since it did not resolve the non cabg cases.

Dr. Hecker submitted the following statement:

Esteemed Colleagues, Noridian has received a number of appeals (redeterminations) related to denials for reimbursement of services of a second assistant during open heart surgery. At the redeterminations level, we have been able to make several individual determinations favorable to the appellant based on additional information submitted. This process, however, remains a mutually time-consuming, resource-intensive interim solution. Moreover, a number of claims have remained denied due to the absence of documentation supporting the need or even a role for the second assistant other than fulfillment of a state requirement which is unrelated to medical necessity. We have sought advice from CMS, providers and specialty societies across our states, legal staff, and all on this email but have not yet been able to identify a solution(s) or other resolution to this situation. From our perspective, and that of essentially all with whom we have spoken, Title 22 may need to be re-addressed in light of current national practice and the requirements of Medicare and other payers. In the interim, careful documentation of the specific roles of the assistants is fundamental to payment. We are not allowed to change the Medicare law, but we will do whatever we are allowed to do to assist you.

My regards to each of you,”

Bernice Hecker MD, MHA, FACC, Executive Medical Director, Medicare, Parts A&B, Jurisdiction E (CA, HI, NV, Guam, Samoa, CNMI)

Suggested wording for operative reports:


The 2nd assistant performed saphenous vein harvest and preparation, followed by closure of the incision. Simultaneously, the first assistant assisted with cannulation and placing the patient on cardiopulmonary bypass. The first assistant remained throughout the construction of all proximal and distal anastomoses, and weaning the patient off bypass. When the 2nd assistant finished closing the leg, he/she moved to the chest, to assist with suctioning, retraction, and exposure. Once the patient was off bypass, the 2nd assistant assisted with closure of the wound.

Sternotomy AVR & MVR

The 1st assistant was present from the time of cannulation for cardiopulmonary bypass, to the completion of valve implantation (or repair) until the patient was successfully weaned off cardiopulmonary bypass. The 2nd assistant was present throughout the entire operation, and assisted with retraction, suction, and exposure. The 2nd assistant also held the valve prosthesis during suture placement into the sewing ring to expedite implantation and reduce ischemic time.


SB830, enhancing public reporting to include PCI, continues to make its way through the state legislature committee structure. CASTS was asked to and did provide a letter of support for the legislation.

It was held up due to budgetary concerns, ie cost. We are working with CA-ACC to try to help reduce the cost by importing currently available data from cath labs. More to follow. Dr McMillan is leading the charge for CASTS on this topic.


The CASTS reporting website has been completely revised and updated. The draft version is at The hospital needs to pay a fee to see comparative data. At present this is the only source of comparative data for California heart hospitals. It is rigorously documented and offers a source of information in advance of public reporting, which will take a few years to get off the ground. CASTS would like to enlist hospital participation in QI collaboratives, offering access to the website and regional meetings for an annual fee. We would like your support in the endeavor. Please enlist your data managers’ and hospital administrators’ help in supporting this initiative. The annual fee is really a small amount, so far only a few hospitals have paid. This is the easiest way to secure the financial viability of CASTS.

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