Full article reprinted from "The Gray Sheet" - November 9, 2009
The American College of Cardiology will fight reimbursement cuts to cardiology practices imposed by the 2010 Medicare physician fee schedule that CMS finalized Oct. 30. Read more...
Full article reprinted from "The Gray Sheet" - November 9, 2009
The American College of Cardiology will fight reimbursement cuts to cardiology practices imposed by the 2010 Medicare physician fee schedule that CMS finalized Oct. 30.
ACC plans to lobby Congress for a legislative fix, and will also see if it can make a legal case that CMS used poor methodology and inaccurate data in changing the payments, said CEO Jack Lewin.
In an interview with "The Gray Sheet," Lewin called the multiple payment cuts "the most devastating thing that has happened to cardiology in the whole history of the profession."
Under the new fee schedule, on average, Medicare payments for in-office cardiology services will be down 8% in 2010 and 13% by 2013, according to the fee schedule.
According to ACC, payments will decline by 36% over four years for SPECT myocardial perfusion imaging employed for stress-rest tests, by 10% for certain transthoracic echocardiograms, by 5% for electrocardiograms and by 4% for stent placements.
The reduction in service payments is so drastic that "they are no longer going to pay for themselves or even break even," Lewin said. As a result, he predicted, the Medicare ruling will drive cardiologists to abandon their offices in favor of hospital employment.
Tests Could Move To Costly Hospital Setting
In addition, Lewin argued that the payment cuts will lead to higher Medicare costs as services migrate to the more expensive hospital setting.
With drastic cuts to reimbursement for certain office-based diagnostics, for example, cardiologists will "refer the patient to the hospital to get the test that they can no longer afford to do in their office," Lewin said. "That means the test will cost twice as much."
AdvaMed, representing device manufacturers, agrees. "These patients may no longer have access to cardiologists who provide important check-ups, evaluation and testing in an ambulatory setting, and often help to avoid costly inpatient hospital admissions," said Ann-Marie Lynch, AdvaMed's executive VP for payment and health care delivery policy.
"The cuts to cardiologists and the closing of cardiology practices could certainly impact manufacturers," Lynch said. "The magnitude of that impact will depend upon a variety of factors, including the number of practices that close and the response by beneficiaries to the challenge of finding a new provider."
ACC's Lewin insisted that assertions from cardiologists who say they plan to leave their practices are not idle threats; some are already investigating what they must do to lay off their echocardiography and stress test staff and transfer their patients to hospital-based care.
Most of those cardiologists would not give up the practice of medicine altogether, he explained.
"They're just going to be increasingly employees of hospitals, not in community outpatient settings. And it's not a good trend for the patient at all - any more than if your internal medicine doctor has become a hospitalist. You can't see him anymore unless you're in the hospital."
Closing cardiologist offices could limit patient access to cardiac diagnostics and treatments, especially in rural areas, suburbs or inner city neighborhoods not conveniently located near hospitals, he explained.
But primary care physicians are not well suited to taking care of advanced cardiac problems, he stressed. "You want a cardiologist if you are the patient."
CMS Seeks To Improve Primary Care Payments
The CMS policy change behind the payment cuts is intended to give a greater slice of the reimbursement pie to primary care physicians; the hope is to help reverse the growing shortage of primary care physicians in the U.S. It overlaps with efforts in pending health care reform bills that seek to add more incentives for primary care -- efforts that have also received negative feedback from organizations representing specialists (1 'The Gray Sheet' Aug. 3, 2009).
Specialty groups say they don't disagree that primary care doctors should have better reimbursement, but are angered by the idea that it automatically means lower reimbursement for specialists (as a function of budget neutrality rules).
In addition to the overall 13% four-year cut for the cardiology category, radiology will on average see a 16% cut, audiology will see a 23% cut and diagnostic testing facilities will see a 34% cut, the latter of which also includes a contribution from CMS' decision to change the equipment utilization rate for advanced imaging (2 'The Gray Sheet' Nov. 2, 2009).
Meanwhile, family practice payments will increase 7% and geriatrics payments will increase 8%.
CMS is accomplishing this balance shift primarily by switching to a new survey tool to calculate physician practice expenses, which are used to determine Medicare payment rates.
The new tool, the Physician Practice Information Survey, was designed by the American Medical Association to collect cost data across almost all specialties, while the currently used Socioeconomic Monitoring Survey relied on supplemental submissions from specialists for complete data.
ACC Says New Survey Is Flawed
CMS says the new tool is more reflective of relative costs and is the "most comprehensive source of [practice expense] survey information to date." In July, the agency had proposed to implement across-the-board use of the new survey immediately in 2010, but ultimately decided to phase in its use over four years.
Lewin says ACC appreciates the gesture that CMS made with the four-year phase-in, but he charges that the PPIS data is fundamentally flawed.
The cardiology practice survey "apparently was not completed properly by the small number of cardiologists that actually got involved," he said, leading to a "blatantly absurd result" showing that cardiology office costs have gone down by 40% recently, "which is completely ridiculous."
Lewin charges that AMA or CMS should have validated the survey data before using it to implement payment changes.
However, Lewin did not engage in the battle of specialists versus primary care doctors.
"Frankly, I think that primary care should get an immediate boost at the same time that [CMS officials] figure out a way to hold these cuts [to cardiology] up, because I think in both areas, the way the rule is coming out is not going to be effective," Lewin said.
Just as cuts to cardiologists and other specialists will be phased in, primary care physicians also will see their payments go up incrementally over four years.
Primary care doctors "wanted the increase right away," Lewin noted. "They didn't want a phase-in."
Lewin argues the phase-in "sets the tone that they are accepting this faulty data and they are just going to implement the pain over four years. It's not going to work."
Instead, CMS must "use validated data, based on real practice costs, and do the job right," he said.
Responding to stakeholder comments as it finalized its fee schedule, CMS explained that survey responses were adjusted for non-response bias.
CMS also seeks comments on whether the agency should "consider alternatives for collecting specialty-specific cost data or options to decrease the reliance on such data," the rule says.
"I really empathize with CMS," Lewin admitted. "They didn't do this for any political reason. They certainly didn't do it to be mean to cardiology - that's not their thinking."
[Editor's note: More news on the medical device and diagnostics industries is available each week in The Gray Sheet Visit our Web site to sign up for a free trial, or call 1-800-332-2181.]
- Monica Hogan
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