Having read your several parapgraph statement on the outcome of the CMS efforts to reduce medicare payments to private practice cardiology outside of the so-called "integrated system" of care and after seeing the actual numbers on simple procedures such as stress echo in the office setting vs. hospital setting its dumbfounding that CMS would support such a differing amount of reimbursement. My organization in Memphis includes 15 Cardiologists all boarded and most of whom eligible for or are boarded in several subspecialties in Cardiology. We provide care to over 35,000 patients a year and have rural clinics in Ark, Tn, and Ms. outside of our two main offices. We employ close to 100 individuals some for over 25 years. We obviously provide nuclear, echo and all of the appropriate ancillaries any full service small or large cardiololgy practice would provide and perform state of the art interventional coronary, carotid, abdominal aortice and peripheral procedures along with EP studies no other group in our community can provide. In other words, Cardiologists in our community refer some of their patients to us for management. We also have an out-patient HF clinic and an active research program. We see many "self-pay" patients. Our practice will be devastated by this change in reimbursement. We will not be able to support our present level of staffing, manage things such as  PQRI, handle our patient call backs, and in general provide the level of support to our patients, and in particular medicare patients, they expect and are accustomed to receiving. Our group is NCQA certified and I have pesonally passed this certification on a second go round. Most likely this type of accountalbility will be much more difficult to maintain without appropriate staffing. We have a Cardiology specific EMR that requires a significant amount of infrastructure to keep up and running and the expense involved is enormous. The concept that we should not make a good living for what we do is wrong. We all work over 50 hours a week. Continue to take call on top of this work schedule and are responsible for STEMI patients as you are. All in all, it doesn't seem to rosy for us in the near future for the level of expertise, responsibility and work requirements we all have. Appreciate your efforts.