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November 2009 - CMS Cuts Update
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Oregon Chapter of the ACC
CMS Cuts Update - November 2009
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The Governor's Message...
Dear Oregon ACC Chapter Members,
As I am sure you all know, CMS issued the finale rule for the 2010 Physician Fee Schedule last Friday. Okay, everyone take a deep breath.
The outcome was not what we had hoped and we still have work to do, but we averted disaster. Up until two weeks ago, according to inside sources, CMS was prepared to let the rule go through without revision and containing all the cuts to cardiology services. Instead, CMS attempted to mitigate the impact of the cuts to cardiology by phasing in the cuts over a four year period.
While we may have failed in our attempt to prevent the final rule from including the cuts to cardiology, I think it is important to realize that we were successful in one very important and perhaps most critical aspect. We were able to exert significant political pressure on CMS. Virtually every other physician specialty organization supported full implementation of the rule. Despite this overwhelming support for the rule, we were able to force this concession to cardiology from CMS. (This concession came at the expense of primary care which will now only see a 1% increase in reimbursement this coming year.)
Some may consider this is a hollow victory since cardiology can not absorb the cuts whether implemented over one year or over four, but it is not. This is a true victory because it shows the political power the ACC is able to wield. This is a true victory since we will be able to continue to use our power to further influence the political process. We currently have the support of a third of Congress. In the coming months the ACC plans to leverage this support to further influence the final outcome of the "final" rule.
The ACC is currently working on a four pronged strategy that is outlined below following a detailed summary of the phased in final rule provisions. Part of this strategy is mobilizing the membership to get involved and to give money to the PAC. As I have mentioned many times over the past year, this is critical to our success. Winning requires political power. Political power comes from the ability to influence politicians. Influence comes from access to those politicians and access comes from campaign contributions. We will not win this battle to preserve our practices and protect our patients unless we all get involved and we all put some skin in the game. We know what is ahead for us and our patients in January if we don't.
Let's all take a deep breath, write a check to the PAC and get to work.
Mike |
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CMS Cuts Update
I participated Monday morning and again Monday evening in conference calls with the BOG, the Presidential team, Jack Lewin, Jim Fasules and the advocacy and regulatory affairs staff. We discussed the implications of the rule and the ACC's strategy going forward.
The Final rule provisions summarized and then explained in detail below:
· Overall Cardiology Impact: Policy changes finalized in the Rule reduce Medicare payments to cardiology by 8 % in 2010 and by 13 % over the next four years, not including the 21.2 % conversion factor cut required by current law.
· AMA Physician Practice Information Survey (PPIS): A 4 year phase in of data from the PPIS cuts aggregate cardiology payments by 10%. Although CMS did not withdraw the proposal to use PPIS, as ACC had recommended, the decision to implement a transition period is a response to the concerns cardiology raised.
· Equipment Utilization Rate: A 4 year phase-in of a 90 % equipment use rate assumption for diagnostic equipment priced over $1 million limits CT and MR payments.
· Malpractice RVUs: Implementation of updated malpractice premium data will increase malpractice RVUs slightly for EP procedures, while a new resource based formula for technical component services cuts RVUs for imaging services.
· Bundled Codes for SPECT MPI: Interim RVUs published for the new bundled code for nuclear perfusion imaging studies show a 36% payment cut for this core cardiology service, mainly because CMS has not applied the 4-year phase in of the PPIS data to this newly numbered code and cut work RVUs even more than the AMA/Specialty Society RVS Update Committee (RUC) recommended. This is a priority for ACC action.
· Consultations: Medicare will no longer pay for the consultation codes. Physicians will now code these services for Medicare patients with the office or hospital visit codes. RVUs for office and hospital visits have been increased.
· MPFS Update and SGR for 2010: CMS will finalize its proposal to remove Part B drugs from the Sustainable Growth Rate calculation. As required by current law, the Final Rule implements a 21.2% cut to the Medicare conversion factor. The SGR for 2010 is estimated at -8.8%.
· PQRI: New measures groups, which require physicians to report on only 30 patients instead of 80% of eligible patients to qualify for a 2 % bonus, have been added for CAD and heart failure. Most cardiology measures, along with the new measures groups, can only be reported through a registry, effectively eliminating the claims submission option for most cardiologists.
· E-prescribing: CMS finalized its proposal to require reporting of e-prescribing for only 25 eligible patient encounters to qualify for the e-prescribing bonus.
· New codes for cardiac CT, MR: In positive news, CMS accepted the RUC recommendations for new cardiac CT and MR codes.
· Revised RVUs for Cardiac Device Monitoring Services: ACC and HRS successfully challenged interim RVUs assigned to several cardiac device monitoring services. New, higher RVUs will be implemented for 2010.
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PRACTICE EXPENSE RELATIVE VALUE UNITS (RVUs)
1. Implementation of AMA Physician Practice Information Survey (PPIS)
CMS had proposed to implement a new practice expense survey that was coordinated by AMA with financial contributions by medical specialties. The survey showed significant decreases in cardiology practice expense per hour and significant increases for most other specialties. The result of these numbers was a proposal to cut payments to cardiology services by between 10 and 40 percent. In the final rule, CMS finalized its decision to implement this new practice expense survey, but in a significant concession to the specialties that objected, agreed to phase-in the changes over a four year period.
CMS noted the objections of commenters which primarily focused on the transparency of the process. CMS indicates that the AMA has been responsive to requests regarding the data and indicates that further analysis of the data has been performed that indicates that it is correct. While the rule indicates that this analysis is available on the CMS website, the only document currently available appears to be a discussion of why response rate was so low. CMS does seek comments on how it can adjust PE RVUs in the future.
CMS notes that commenters expressed concern that only 51 percent of direct costs are paid based on scaling factors, but believes people misunderstand how that works. However, their own calculation seems to clearly show that the first step in the direct PE scales back based on the total dollars available. This will be an important point to clarify with CMS.
It was clear that the vast majority of the comments received were strongly in favor of implementing this survey data immediately and it took considerable political pressure to change that.
2. Equipment Utilization Rate
Current practice expense RVUs account for the procedure-specific cost of equipment using a formula that calculates a per-minute equipment cost based on an assumption that all equipment is in use for 50% of the time a physician office is open. MedPAC has recommended on multiple occasions that this utilization rate was too low, asserting that payments for equipment-dependent services like diagnostic imaging were, as a result, too high. In the Proposed Rule for the 2010 MPFS CMS proposed to change the equipment utilization rate assumption to 90% for equipment priced at $1 million or more. Within cardiology, this proposed change affected cardiac MR and CT equipment, along with the angiography room equipment used for non-hospital cardiac catheterization services. Among other specialties, radiation oncology was particularly hard hit by this proposal. The ACC opposed the proposal.
CMS will finalize the proposed equipment utilization rate change, but only for diagnostic equipment with prices higher than $1 million. Data from the PPIS that showed utilization rate for angiography rooms at about 50% persuaded CMS to drop this element of proposal. The impact of the 90% utilization rate on cardiology Medicare payments is difficult to assess. Although current practice expense RVUs for cardiac MR services reflect the lower utilization rate (and higher cost per use), current technical component payments are capped by the DRA at a level substantially lower than the RVU-based rate. Consequently, the 2009-2010 change in actual cardiac MR payments that can be directly attributed to the change in equipment utilization rate alone is probably small. Cardiac CT payments are also capped by the DRA, but the existing category III codes (replaced in 2010 with new Category I codes) had no national RVUs assigned, so isolating the 2010 payment impact of the change is difficult. The more significant impact for both modalities is probably on future potential for expansion into the physician office setting.
It's important to note that health reform legislation in both the House and the Senate addresses this issue also. Although neither the House nor Senate bills increase the utilization assumptions to the 90 % level CMS finalized, both versions go beyond CT and MR to include nuclear medicine services.
MALPRACTICE RELATIVE VALUE UNITS
CMS will finalize the major elements of its proposals to update the malpractice RVUs with new professional liability insurance premium data and establish new resource based RVUs for technical component services. The changes to the malpractice RVUs result in an estimated 1% reduction in total Medicare payments to cardiology. This aggregate figure is somewhat misleading, encompassing both increases and decreases in malpractice RVUs for specific cardiology procedures. In particular, malpractice RVUs for imaging services decline significantly under the proposal. Malpractice RVUs account for a small part of total RVUs for any procedure, so the overall impact on payment is much less significant than the impact of the changes in practice expense RVUs. Nevertheless, ACC addressed two important issues in our comments.
1. Updated malpractice premium data
The malpractice premium data underlying the malpractice RVUs was last updated in 2005. CMS collected malpractice premium data at the specialty level for three risk categories - non-surgical, minor surgical, and major surgical. The premium data used now does not distinguish between minor and major surgery. Sufficient data were available to calculate a national average premium and risk factor for cardiology in each of the three categories. The new data resulted in higher cardiology risk factors in each category. In other words, cardiology malpractice premium increased in both absolute and relative terms.
ACC supported CMS's proposal to use the newly collected data, and the proposal to make the minor/major surgery distinction. The higher premiums are consistent with anecdotal information from members. The addition of the major surgery category gives greater weight to the higher premiums paid by cardiologists who perform complex invasive procedures. We commended CMS on the very thorough description of the data collection methodology and data analysis process (a sharp contrast to the discussion of the survey process and data analysis for the PPIS).
Although our comments supported CMS's proposal to make distinctions among non-surgical services, minor surgery, and major surgery, we disagreed with the manner in which CMS proposed to make that distinction because a number of electrophysiology, diagnostic cardiac catheterization and interventional procedures were not properly classified. CMS decided not to finalize that aspect of the proposal and instead will maintain its current classification of procedures as surgical and non-surgical. The current classification assigns EP, cardiac cath, and interventional procedures to the higher valued surgical classification. For example, MP RVUs for 33208 (Insertion of pacemaker) will increase from a 2009 level of 0.56 to 1.39. However, the RVUs published in the Final Rule do not appear to accurately reflect the surgical classification for the cardiac catheterization and interventional procedures. ACC will investigate this apparent error with CMS.
2. Resource based methodology for technical component services
Current MP RVUs for global, professional, and technical components of services such as imaging procedures are based not on specialty level malpractice premiums and work RVUs, but on historic charges. CMS proposed a methodology to calculate resource based MP RVUs for these services. Our comments identified apparent errors in the proposed malpractice RVUs for some cardiology services. ACC also recommended that CMS implement this change in methodology over a multi-year transition period. While it appears that CMS corrected the errors we pointed out, the agency decided to proceed with implementation of the resource based method for TC services in a single year. Under the new method, MP RVUs for 93306 (Transthoracic echocardiography with spectral and color flow Doppler) decrease from 0.37 in 2009 to 0.04 in 2010.
BUNDLED MYOCARDIAL PERFUSION/SPECT CODES
CMS's continued pressure to bundled together imaging services reported with multiple codes has now hit myocardial perfusion imaging. In 2010 myocardial perfusion imaging/SPECT studies including wall motion and ejection fraction (78465, 78478, and 78480) will now be reported with a single code, 78452. ACC worked with ASNC, ACR, and the Society of Nuclear Medicine to recommend to recommend work RVUs and practice expense inputs to the AMA/Specialty Society RVS Update Committee. The RUC's work RVU and practice expense recommendations for the new bundled code were lower than the combined values for the existing three codes. However, CMS rejected the RUC's work RVU recommendation and assigned an even lower value, in addition to reducing the practice expense value. To make matters worse, because there is a new code for the service, CMS apparently is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value. The result is a 36% cut in payment for 2010. This change alone accounts for more than one-third of the projected payment cut to cardiology. ACC will begin immediately to pursue strategies to mitigate these cuts.
CONSULTATIONS
Despite objections from a number of specialty societies, CMS finalized its proposal to eliminate consultations and instructed physicians to report office and hospital visits in place of services that had been considered consultations. The work RVUs that had been assigned to consultations have been distributed to these visit codes so that the payment for visits has increased, but in most cases not to the level that was previously paid for the similar consultation service. CMS has instructed physicians to use the E/M standards for a particular family rather than crosswalk the codes. CMS reviews the long history of these codes in detail, but restates its belief that the services are identical to a visit with the exception of the requirement that a report be sent. Some commenters argued that consultations required more work and expertise because they involved issues that other physicians could not address. CMS indicates that it believes that complexity is not that simple and that an issue that might be difficult for a general internist to address might be easy for a specialist to address so there is no relevant difference.
Physicians will be instructed to report the appropriate hospital or office visit code based on the documentation requirements for that category of service. There will not be a crosswalk between the codes. CMS indicates that it will create a modifier that physicians will be required to use to indicate that he or she is the admitting physician for a hospital or nursing facility. It is unclear what the consequences of not using this modifier might be.
In a surprise, CMS accepted the recommendation of surgical specialty societies to pass through increased work values for hospital and office visits through to global surgical packages.
ACC staff will be providing education to members on these changes as well as discussing the changes with private payers.
MPFS UPDATE AND SGR FOR 2010
CMS will finalize its proposal to remove Part B drugs from the Sustainable Growth Rate calculation. The physician community has advocated for this administrative change for years. Removing drugs from the formula has no immediate impact on the conversion factor, but does lower the legislative price tag for a permanent replacement of the SGR system. In the event that the SGR system remains in place, removing the cost of drugs from the formula decreases the chances for large negative updates in future years. As required by current law, the Final Rule implements a 21.2% cut to the Medicare conversion factor. Unless Congress intervenes, the 2010 Medicare conversion factor will be 28.4061. The SGR for 2010 is estimated at -8.8%.
PQRI
CMS finalized a number of changes to the PQRI program for 2010 related to registries, measure groups, and reporting standards. The most important change finalized by CMS in the rule was the decision to remove most cardiovascular measures (those that were developed by ACC/AHA) from claims-based reporting and move them to registry-based reporting only. While there are still enough general codes and CV-related codes that would allow most general cardiologists to participate, CMS is clearly moving the program to one that focuses on registry and electronic health record reporting.
CMS is still testing a process that would allow for the direct reporting of PQRI data through an electronic health record. There are a limited number of reportable measures as well as a limited number of vendors that are participating in these tests. It is unclear if physicians will be able to participate in PQRI through direct PQRI reporting in 2010.
CMS did create two "measures group" for cardiovascular disease (coronary artery disease and heart failure) but limited their use to registry reporting. These measures groups allow a physician to report related measures on 30 patients in order to qualify for a 2% Medicare bonus. In 2009, physicians had been required to report on 30 consecutive patients in order to qualify, but CMS removed this requirement with that rule. This significantly reduces the burden for reporting if a registry is available for reporting.
CMS also finalized the creation of a group-based participation in PQRI but this participation is limited to multi-specialty groups with more than 200 physicians.
E-PRESCRIBING
The agency has finalized a number of its proposals pertaining to the 2010 E-Prescribing Incentive Program. There are two changes that will have a significant effect on cardiology providers, one that affects the initial determination for qualified professionals and one that influences a qualified professional's successful participation. ACC generally supported the changes proposed by CMS as a way of decreasing the burden of the program on participating providers.
In order for providers to qualify for the E-Prescribing Incentive Program, 10 percent of their charges must be associated with one of the codes set forth by CMS. This list of codes originally consisted mainly of codes for professional services furnished in the office or outpatient setting. For 2010, CMS has expanded this list to include codes for services furnished in skilled nursing facilities and the home care setting.
More importantly, providers will no longer need to submit one of three codes on 50 percent of applicable claims in order to be eligible for the incentive program. Instead, as CMS proposed, providers will be required to report one code on 25 e-prescribing events over the course of the year in order to be eligible for the incentive program. The measure, G8443, will be modified to reflect that at least one prescription was electronically generated and transmitted. This means, for example, that visits where only prescriptions for controlled substances are generated will not apply towards the 25 required e-prescribing events. Nor will visits where the prescription is generated electronically, but is not transmitted electronically, such as those where the provider prints out the prescription at the behest of the patient. As part of the 2009 program, providers could qualify for the incentive program if they reported that they generated and transmitted prescriptions electronically, nothing was prescribed during the encounter, or were unable to generate prescriptions electronically because of patient or system reasons. Because the change means the program will be based on encounters during which e-prescribing occurs CMS will be eliminating the other two codes.
The final measure specifications, like those for the PQRI, will be posted on the CMS website by Dec. 31.
For 2010, CMS will also require that qualified e-prescribing systems must comply with new standards on electronic messaging for Part D prescriptions that were adopted earlier this year.
The agency notes that to qualify for this program, the numerator code, that is, the G-code must be listed on the same claim as the applicable numerator code.
CMS also finalized its group practice participation proposal for the 2010 E-Prescribing Incentive Program. Most importantly, groups of 200 physicians or more can only participate using the group option for the e-prescribing program if they are participating in the 2010 PQRI program also using the group practice option. The opposite does not hold true, so groups can participate in the 2010 PQRI program without participating in the e-prescribing program.
Providers will have the same three reporting options for the e-prescribing program as they do for the PQRI program: claims-based; qualified registry; or qualified EHR. Only registries and EHRs deemed qualified to submit quality data for the PQRI program will be qualified to submit data for the e-prescribing program. However, PQRI-qualified registries and EHRs are not automatically qualified for the e-prescribing program. The e-prescribing program registry selection process will mimic the PQRI registry selection process.
The ACC Response
· Because of efforts by you, many members of Congress, and patients, CMS did attempt to mitigate the impact of practice expense portion of the rule by phasing in the changes over a four-year period. This means, not only are cuts phased in, but payment increases to other specialties are phased as well. Many specialties are not happy with the ACC for having engineered this partial solution.
· The bottom line is that the data used to determine the practice expense portion of the cuts was not reviewed or validated. Cuts of this magnitude-whether enacted this year or spread over four-cannot be absorbed and the ACC will continue to fight the implementation of this data until a rigorous review is conducted.
· These cuts are very bad public policy. Taken together with the payment cuts cardiology has already experienced, CMS' final rule is a grave threat to cardiology practices and to patient access. By shifting services from out-patient to in-patient, this new Medicare rule will more than double the costs of services, and therefore, increase the Part B Medicare premiums patients will have to pay. This is a double whammy; an unprecedented threat to access at twice to three times the cost.
· The ACC understands the very real impacts these cuts will have on practices and patients. We also have a keen eye to any issues related to health care reform. Our primary message is to strongly advocate for patient access to quality cardiovascular care.
To this end, the College has developed a four-pronged strategy to support this message.
1. We will submit legislation to prevent implementation of the rule and ensure practice viability and access are part of health care reform;
2. We are planning both legal and regulatory action with the goal of protecting access to care and practice viability;
3. We are organizing an unprecedented public awareness campaign; and
4. We are going to mobilize members like you to help us fund and succeed in this most important challenge we and our patients and their families have ever faced.
· This fight has just begun and we will prevail. But we need your involvement now more than ever. While the outcome is not what we hoped, we are being heard, and we will not let up.
We will continue to provide updates as the ACC's strategy unfolds.
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Support the ACC PAC
Again, I cannot overstate how important your PAC contributions are. 100% of your personal PAC contributions go to Legislators who are supportive of the ACC (on both sides of the aisle). Please donate to the PAC today. I would encourage every chapter member to consider an individual contribution of $1000. Be part of the "$1000 from 1000" Campaign. Go to https://www.accpacweb.org/ssl/
Finally, I would encourage every Chapter member to Support the OR ACC PAC.
Of the three House members from Oregon who signed the Gonzalez-Rogers
letter, the ACC PAC donated to two: Walden and Schrader. I cannot
overstate how important these PAC contributions are. Did the PAC
contributions buy their support? No. The PAC contributions provided us
critical access and with that access we had the opportunity to develop
relationships that translated into support for the OR ACC. Consider
this: the trial lawyers outspend physicians 10 to 1 when it comes to
campaign contributions. Is it any wonder that tort reform is not even a
topic in the health care reform debate? Please consider donating to the
PAC today. I would encourage every chapter member to consider an
individual contribution of $1000 or a group contribution of $2500. If
every OR ACC member made at least a $100 donation, we will be well
positioned to ensure that your voice is heard. |
Save the Date for the
2010 Oregon Cardiovascular Symposium
June 5 - 6, 2010 |
Continue to Involve Your Patients
The ACC has patient materials and a letter that your patients can send to Capitol Hill on our CardioAdvocacy website - http://www.acc.org/advocacy/CAN_Network/can.htm
Feel free to pass this link along to your colleagues and print it out
for your offices. Congressional offices pay attention to upset Medicare
constituents. |
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| Michael Widmer, MD, FACC
ACC Oregon Chapter Governor
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Oregon Chapter of the ACC
PO Box
55424
Portland, OR
97238
503-345-9294
www.cardiologyinoregon.org
Alan Morasch, CAE,
Chapter Administrator
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Our ACC Mission Statement
The mission of the Oregon Chapter of the
American College of Cardiology is to build a cohesive cardiovascular community
throughout the State of Oregon in order to locally promote cardiovascular
education, research, quality care and influence healthcare
policy.
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