Primary care physicians are cheering—and radiologists are jeering—a new CMS proposed change to the Medicare Physician Fee Schedule that will cut reimbursements for imaging services by as much as 30% and use the savings to raise reimbursements for primary care by as much as 8%.
"I am surprised. We all kind of knew this sort of thing was coming, but until you see it in writing you don't believe it," says Ted Epperly, MD, president of the American Academy of Family Physicians. "We've been there before and never saw it. Putting it out now in the heat of the debate is a big deal. It sends a strong message."
"I'm impressed that CMS is actually doing stuff to reformulate the system toward primary care. Of course, the devil is in the details and we will see what the final product looks like, and it's not a total fix, but it's a step in the right direction," he says.
However, the cheers among primary care physicians may be short-lived if CMS actually goes through with the long-delayed reimbursement cuts–projected to be reduced by 21.5% in 2010–that are part of the sustainable growth rate formula in the Balanced Budget Act of 1997. This formula has called for reimbursement reductions beginning in 2002. However, after physicians howled, CMS took administrative steps to avert a reduction in 2003, and Congress has found ways to avoid the reductions over the past five years.
It's not clear if Congress will finally allow these very deep cuts to occur in 2010, an election year. "I will predict confidently that you will have tens of thousands of physicians who will either drop out of Medicare or stop taking Medicare patients, just when the Baby Boomers start to hit Medicare," says Douglas S. Arnold, executive director of the Middlesex (CT) Professional Services, Inc., a network of more than 300 physicians.
"You are going to have millions of Medicare patients who won't have access to physicians. They are going to be [angry] and they vote and they are going to take it out on the incumbents," he says.
This year may be different, however, because the move toward healthcare reform may actually force CMS and Congress to impose the deep reimbursement cuts. "The big difference this year is all the health reform legislation and all the big price tags. This becomes one little component in the greater scheme of things," Arnold says.
"All the projections that have come out of CBO are taking into account this 21.5% rate cut. If they pay Medicare rates at 21.5% lower than they do now, I don't think anybody has thought out what that is going to mean. You are going to have doctors who say take this job and shove it. Who can take a 21.5% fee cut for the majority of their business?" he adds.
CMS says the change is needed to address concerns from the Medicare Payment Advisory Commission and the Government Accountability Office about the rapid growth and high cost of imaging services.
“Those things have been overvalued and overpriced,” Epperly says. “We are the only part of the economic sector where new technology doesn’t lower cost. It actually raises cost. What is missing from the system that needs more attention is the basic coordinated integrated care not this fragmented specialty care that we get now.”
The GAO says spending on imaging, such as CTs, MRIs, and PETs, is growing almost twice as fast as spending on other types of imaging services, and is a significant contributor to the rapid growth in healthcare spending in recent years.
Shawn Farley, public relations director for the American College of Radiology, disputes that assertion. He says MedPAC figures show that imaging growth per beneficiary in 2006 and 2007 was 2%. “They’re talking about imaging growth has skyrocketed, but the numbers don't bear that out for the past two years,” he says. “That is very much in line with other physician services out there.”
To address imaging costs, CMS proposes adjusting the payment rates, which now assume that imaging equipment will use it about 50% of the time during regular office hours. CMS survey data suggest imaging equipment is being used as much as 90% of the time. “As the use of this type of equipment increases, the per-treatment costs for purchasing, maintaining and operating the expensive equipment declines, making a reduction in payment appropriate,” CMS says.
Farley says the notion that imaging equipment is in use 90% of the time is "insane." He says the CMS recommendation is based on a 2006 survey of imaging use at six large urban hospitals.
"At the time, when they did it, even the head of MedPAC said these numbers aren't reflective of what is going on nationwide and shouldn't be used for calculating imaging reimbursement. CMS agreed, but nonetheless here it is," he says.
Farley says a more comprehensive survey by the Radiology Business Management Association determined that the average national usage for imaging equipment is about 58%, and drops to 48% in rural areas.
The RBMA also estimates that a 90% utilization rate for CT and MRI scans alone would translate into an additional 30% reimbursement cut, on top of a 23% hit that imaging services took from the Deficit Reduction Act of 2005.
"You are talking about a cut that will literally affect whether or not a provider can keep the doors open and the lights on. You are talking about a severe impact, not an inconvenience," Farley says.
He says imaging has become the flogging post for healthcare reform. "Certainly we feel like there are a lot of eyes on radiologists these days," he says. "We feel like, particularly with the cuts that have already been enacted, the volume and dollars spent in our area of medicine are very much in line with the physicians services overall, and shouldn't be singled out to this effect."
The proposed changes would affect payments beginning calendar year 2010, and could impact more than 1 million physicians and non-physician practitioners who are paid under the MPFS, which sets payment rates for more than 7,000 procedures in physicians' offices, hospitals, and other healthcare settings.
CMS is also proposing to:
Remove physician-administered drugs from the definition of "physician services" in anticipation of enactment of legislation to provide fundamental reforms to Medicare physician payments. While the proposal will not change the projected update for services during 2010, CMS projects that it would reduce the number of years in which physicians are projected to experience a negative update. AMA President J. James Rohack. MD, called the proposal "a major victory for America's seniors and their physicians."
Implement a mandate in the Medicare Improvements for Patients and Providers Act of 2008 that suppliers of the technical component of advanced imaging services be accredited beginning Jan. 1, 2012 by designated accrediting organizations. The accreditation requirement would apply to mobile units, physicians' offices, and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them.
Implement provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program and the Physician Quality Reporting Initiative. Professionals or group practices that meet the requirements of each program in 2010 will be eligible for incentive payments for each program equal to 2% of their total estimated allowed charges for the reporting periods. CMS is proposing to simplify the reporting requirements and is also proposing a new process for group practices to be considered successful electronic prescribers.
Refine Medicare payments to physicians, which are expected to increase payment rates for primary care services. The proposals include an update to the practice expense component of physician fees. For 2010, CMS is proposing to include data about physicians' practice costs from a new survey, the Physician Practice Information Survey, designed and conducted by the AMA.
Stop making payments for consultation codes typically billed by specialists at a higher rate than evaluation and management services. Physicians will instead use existing E/M service codes when providing these services. The resulting savings would be redistributed to increase payments for the existing E/M services.
Increase the payment rates for the so-called "Welcome to Medicare" visit to be more in line with payment rates for higher-complexity services.
Refine how Medicare recognizes the cost of professional liability insurance in its payments. These changes would have a modest impact, but they will promote payment equity by redirecting the portion of Medicare's payment for professional liability insurance to those physicians that have the highest malpractice costs.
Taken together, CMS says refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6% and 8%.
"Primary care pay needs to go up and specialty care pay needs to come down," Epperly says. "When that gap narrows, the students coming out of medical school will redirect their choices for workforce much more into primary care than away from it."
CMS will accept comments on the proposed rule until Aug. 31, and will respond to all comments in a final rule to be issued by Nov. 1.
Cost-effective medical practices deployed in developing countries are delivering good results. With healthcare costs soaring in the United States, many experts are starting to ask whether the same healthcare solutions used in poor nations can be done here. But the obstacles range from the complexities of insurance reimbursement to regulations designed to protect patients. Another hurdle is cultural because of a deep-seated reluctance to accept that simpler and less expensive treatments like those used abroad might be good enough.
Nurses all too often see the brutal aftermath of gun shootings, sexual assault, child abuse, and other violent acts when caring for patients, but since undergoing unique forensic training some can also see clues that trace back to the victimizers.
William S. Smock, MS, MD, professor of emergency medicine at University Hospital and Louisville Metro Police surgeon in Louisville, KY, created the voluntary program that teaches nurses how to collect forensic evidence in medical situations. The program requires nurses undergo 400 hours of training, including ride-alongs with police officers, visits to crime scenes, forensic photography training, and shifts with the state's medical examiners office. Nurses must also complete examinations and a research project, and attend weekly lectures.
"The goals of the program are to provide the highest level of medical care and also the highest level of forensic care for victims of violent crime," says Smock. "And these two are not mutually exclusive."
Four out of the eight nurses that began training in September 2008 received their official certification last week. In obtaining this new knowledge, nurses can gather crucial evidence when encountering wounded and abused patients that helps the Louisville Police Department (LPD) determine what really happened during incidents. For example, a forensic nurse can look at a wound and identify the weapon that was used, or determine when and where a bullet exited.
"I have always seen the need to have a forensic evaluation performed in the emergency department on victims of violence and crimes," says Smock, who has 25 years of living forensic evaluation experience. "It is the ideal place to provide a high level of care, but make sure evidence is preserved, injuries are recognized, and evidence is documented."
The forensic nurses are involved in a wide range of cases, such as domestic assault, elder abuse and neglect, traffic incidents, and gun shootings. It is because of this that they must complete Sexual Assault Nurse Examiners (i.e., SANE) training to be eligible for forensic training. Other qualifications include five years of nursing experience and "a commitment and sincere interest in forensic nursing," according to Smock.
The extensive training has given Rena Lopez, RN, BSN, in the coronary care unit at the hospital, a different perspective on patient care.
"Before I was just used to the procedures—trying to take care of the patient, looking at the dressing changes, and the 'now' portion," says Lopez. "Now, the history tends to make a little more sense; instead of just packing a gunshot wound, I can explain what the wound is and why it is the way it is."
The hospital's ED is currently funded to perform the forensic evaluations by the LPD and forensically-certified nurses cannot perform the evaluations at other facilities.
"The University of Louisville, the LPD, and the medical examiners office have been completely supportive of the project and all of the nurses who are going through it," says Lopez. "It has been a wonderful experience."
Smock is currently seeking grant money to fund full-time forensic nurse positions in the hospital's ED. He says his dream is to create a three-pronged approach to forensic nurse training: providing clinical service; conducting research in forensic nursing; and educating nurses about forensic medicine.
"In the long-term, I would like to establish the University of Louisville as a national training center, so that we can bring nurses in from across the country and provide this unique and much-needed training," Smock says.
For those who see private health insurance as a major problem in the healthcare system, reform is a chance to get insurers in line. But insurers and their supporters say added industry regulations will simply increase healthcare costs.
The health insurance industry has already come forward to say that it will accept certain regulations if the federal government requires all Americans to have health insurance. America's Health Insurance Plans said health plans will accept everyone regardless of preexisting conditions and not charge women more for individual insurance if an individual mandate is part of healthcare reform.
Health insurers will allow these two changes without a fight because an individual mandate would flood the system with an influx of millions of newly insured (including young people with low health costs).
"Guaranteed issue can only work if everyone–the young and healthy, as well as higher-risk individuals–purchases coverage. This would help keep premiums affordable," says Justine Handelman, executive director of legislative and regulatory policy at the Blue Cross and Blue Shield Association.
As long as everyone is required to have health insurance coverage, Handelman says, the BCBSA supports new rating rules, including phasing out the practice of varying premiums based on health status. She added the change must be phased in gradually state by state "to avoid major disruptions and large premium increases for current enrollees. It would still be critical for insurers to adjust premiums based on age [and] wellness factors, such as non-smoking and geography."
But there are other regulations being discussed in Congress that health insurers are not ready to accept, such as benefit design requirements that include removing lifetime benefit limits and limiting premiums based on differences in age, community, and family size; guaranteed issue without the individual mandate; and coverage mandates. Private insurers say these kinds of requirements would increase premiums and have the biggest effect on the less-regulated states.
Rather than finding ways to regulate insurers, Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy at American Enterprise Institute for Public Policy Research, says lawmakers should look to reduce healthcare costs. Focusing on insurance regulation does not improve "a very inefficient healthcare system" or address the "fundamental cost drivers," says Antos.
"The question is how onerous do we want those regulations to be and do we want regulations that will substantially increase costs of insurance?" says Antos.
"If you tell insurers that they have to take on all comers regardless of their cancer diagnosis they just got and now they want to buy insurance, that means the average premiums will have to go up to account for the fact that they are taking on people they were not taking on before," says Antos. "That means average cost of insurance goes up. That means young healthy people will buy insurance less and it will have less value to them."
Robert E. Moffit, PhD, director of the Center for Health Policy Studies at The Heritage Foundation, says lawmakers should not place limits on health insurers' underwriting policies, especially if new regulations supersede state law. Local conditions should drive health policy and regulations—not the federal government, he says.
Moffit says regulations to the health insurance market, such as mandates and benefit design requirements, limit innovation. "The danger I see is the federal government creating a straitjacket that will prevent any kind of serious creativity and insurance market reform at the state level, and we can basically say good bye to innovation," says Moffit.
Coverage mandates
The Council for Affordable Health Insurance, an insurance carrier research and advocacy association, reported in its "Health Insurance Mandates in the States 2009" that there are 2,133 mandated healthcare benefits and providers throughout the country. Those mandates are increasing health plan costs (in some states by about 50%), according to the study.
In response, some states now let insurers offer mandate-lite plans, which allow lower cost options to under-covered groups, such as recent college graduates. Fewer mandates allow young adults to purchase basic health insurance without being required to pay for mandated coverage that won't likely affect them, such as chronic disease and coverage for grandchildren.
Antos says adding regulations will price people out of health insurance, especially young people, and require the federal government to offer subsidies or make exceptions for people who can't afford it. "If you put enough regulation on it, then you better start making exceptions because you will have a fairly large population that can't live by your rules," says Antos.
Individual mandate
Health insurers are not against all new regulations. They stand behind the individual mandate, which would require most or all Americans to have health insurance.
Requiring coverage would serve as a shot of adrenaline to the health insurance industry that is struggling with dropping enrollment in the employer-based insurance market because of layoffs and businesses dropping coverage.
President Barack Obama opposed the individual mandate during his presidential campaign and it seemed like the idea was dead, but the president and many Congressional leaders are now open to the idea. Bruce McPherson, president and CEO at Alliance for Advancing Nonprofit Health Care, says the employer mandate is now a lightning rod for controversy.
"I'm pretty surprised that there's been such a consensus on that one already," says McPherson about the individual mandate. "I have to believe that labor and some other groups will be pushing back pretty hard, but it doesn't seem like they have a lot of allies on that."
Public insurance and insurance exchanges
If a public insurance option and/or insurance exchanges are part of healthcare reform, insurers will likely face additional new regulations. The federal government could impose minimum federal requirements for insurers to operate within an exchange.
The public insurance option would have a much larger effect on private insurers. McPherson says insurers in his group are most concerned about the public plan because they think a public plan will lead to an unlevel playing field and the federal government will ultimately create Medicare and Medicaid for all in a few years.
Richard Cogley, MD, chief medical officer for Saint Vincent Health System in Erie, PA, speaks about the generational differences and the implications for practice priorities, recruitment, and loyalty.
Miami physician Roberto Rodriguez was sentenced this week to 97 months in prison for his role in a fraudulent Medicare scheme involving HIV infusion services. Rodriguez was also ordered to pay more than $9 million in restitution to the Medicare program during his sentencing hearing.
Rodriguez, 54, had pleaded guilty before a federal judge in March to conspiracy to commit healthcare fraud. In his guilty plea, Rodriguez admitted that he was a co owner of and practicing physician at Midway Medical Center, a Miami clinic that said it specialized in the treatment of HIV patients.
Rodriguez admitted that while working at Midway, he and his co conspirators—including other physicians—billed the Medicare program for services that were medically unnecessary and in many instances were never provided. Rodriguez also admitted that he purchased only a small portion of the drugs that were allegedly administered to the clinic's patients.
Many of the services reportedly provided to Midway patients were billed to Medicare as treatments for thrombocytopenia, a disorder involving a low count of platelets in the blood. According to the plea documents, none of Midway's patients actually had low blood platelet counts.
Rodriguez said that to make it appear that the patients actually had low platelet levels, he and his co conspirators used chemists to manipulate the blood samples drawn from patients before their blood was sent to a laboratory for analysis. In his plea, Rodriguez admitted that he did order that patients at Midway receive medications designed to treat thrombocytopenia—even though the laboratory results had been reportedly falsified and the patients did not have the condition. Rodriguez also admitted that he caused more than $20 million in false claims that were submitted to Medicare at all of his clinics, including Midway.
Rodriguez's co defendants, who have already been sentenced for their roles at Midway and related clinics, are physician Carlos Garrido, 69, who was sentenced to 37 months in prison; medical assistant Gonzalo Nodarse, 38, who was sentenced to 78 months in prison; medical assistant Alexis Carrazana, 41, who was sentenced to 72 months in prison; and chemist Alexis Dagnesses, 44, who was sentenced to 90 months in prison. Rodriguez's co defendant Carmen del Cueto, a physician, is scheduled to be sentenced in September.
The case was investigated by the Department of Health and Human Services' Office of the Inspector General and the Federal Bureau of Investigation. The case was brought as part of the Medicare Fraud Strike Force, which has increased its activities in Miami.
Slightly more than half of the doctors who responded to a physician survey in Massachusetts last fall said they kept patients in the hospital longer than necessary because of a lack of access to home health services, according to a new report.
But most of the doctors said they were aware that use of such agencies can safely reduce days of hospitalization and their cost as well as emergency room utilization, an increasing priority in the health reform agenda.
"As physicians see it, greater use of home services can ease costs without compromising quality of care. In today's healthcare environment, that's a winning formula," said Mario Motta, MD, president of the Massachusetts Medical Society.
The society collaborated with the Home Care Alliance of Massachusetts, a nonprofit trade group, to produce the report.
Patricia Kelleher, executive director of the alliance, said there are enough home health agencies around, but "certain kinds of specialized services are in short supply."
"The biggest delay is in getting physical therapists, who in general have been in short supply," she said. "When the patient is ready to be discharged on Monday, but the agency can't get someone to the home until Thursday or Friday, doctors must face a choice between sending patients home with no therapy for two or three days until the service can be found, or keeping them for an extra two or three days in the hospital."
The survey was launched because, according to the society, there is "a dearth of research on physicians' utilization of, and satisfaction with" home health services. Nevertheless, home healthcare can provide an increasing amount of skilled nursing, physical, occupational, and speech-language therapy, and medical social services to people in their homes.
Kelleher added that the survey has implications for the creation of accountable care organizations, in which the silos of hospital care, physician care, and home healthcare are torn apart and the three entities work together to reduce costs and produce better outcomes for patients.
"This report says that at least for Massachusetts, there are very good relationships between physicians and home health agencies that can form a building block for any sort of accountable care organization that we may be envisioning in the future," she said.
The survey found four other significant trends in the use of home healthcare for patients discharged from the hospital, a resource that promises to become much more important as the population ages and new federal limits on paying hospitals for readmissions take effect:
Although reimbursement issues are a barrier to the use of home health agency services, 71% of physicians said they do not submit "care plan oversight" charges to Medicare for reimbursement, which they are entitled to receive for managing patients' home care programs. Thirty-five percent of primary care physicians and only 19% of specialists said they had submitted this charge to Medicare.
The survey found that 64% of the doctors said they were unaware they could be reimbursed, which amounts to about one office visit charge. Other reasons for failure to submit include the perception among physicians that the rules for documenting how much time was spent are too cumbersome or some physicians may think it's not worth the effort for what they would be paid, Kelleher said.
45% of physicians selected the home health agency based in part on a patient's request or patient's reference while 79% said they took into consideration the agency's affiliation with a hospital or network.
Specialists were far less likely than primary care physicians to recommend their patients for home healthcare, either for terminal care or for chronic disease management, the survey found.
More than half of physicians called out paperwork as the biggest barrier to their use of home healthcare services for their patients, while 40% said it was reimbursement issues.
"One of the impediments is that while a physician may feel that a patient may benefit from home health services, they sometimes are not covered by insurance because their needs don't meet the level of acuity of care deemed necessary for the insurance company to pay for it," said Dennis Dimitri, MD, a Worcester physician, who is president of the Massachusetts Academy of Family Physicians.
He added that another obstacle is the "bureaucratic paperwork, which can be a nightmare of filling out forms and signing requests," not to mention the amount of time it takes to set up referrals, communicate with nurses, and maintain oversight of the medical status reports that come back.
The survey has an important limitation, however. It sent the surveys to 3,000 of the 22,000 physician and medical student members for a sampling of 12 specialty areas of practice, but received responses from only 8.3% or 248.
The survey report concluded that "educating physicians on reimbursable home healthcare services and providing them with less burdensome administrative processes" could improve access for physicians and their patients.
According to a May report funded by the Alliance for Home Health Quality and Innovation, early use of home health services following discharge from a hospital saved Medicare $1.71 billion between 2005 and 2006, and another $1.77 billion would be saved if all Medicare beneficiaries with similar chronic diseases had access to such programs.
Dimitri said that one important finding from the survey is that "physicians utilize home health services a lot, and find them helpful in transitioning patients from hospital to home when they aren't quite able to take care of themselves at home.
He said that home health services are especially important for terminal patients, who would rather be at home during their last days.
"This is not only good thing from a fiscal point of view, but also it's much better for patients," said Dimitri.
After years of strenuous opposition, Wal-Mart, the nation's largest private employer, announced that it supports a controversial proposal requiring businesses to contribute to the cost of employee health insurance. Wal-Mart's endorsement comes as the health reform debate intensifies, and it could have broad economic and political consequences. Many business groups, displeased with the shape of the legislation that has emerged so far, have begun to mobilize against President Obama's reform efforts.
While the federal government has been involved in many high-profile fraudulent Medicare and Medicaid cases this year, some of the more striking examples of fraud are occurring within the private insurance industry, according to a new report from The George Washington University School of Public Health and Health Services in Washington, DC.
For instance, in 2007, when the U.S. spent nearly $2.3 trillion on healthcare and both public and private insurers processed more than 4 billion health insurance claims, fraud was estimated to reach as much as 10% of annual healthcare spending. With this rate, the losses in 2007 would have been more than $220 billion—or enough to cover the uninsured—if estimates from government and law enforcement are used.
The researchers found that no segment of the healthcare industry or geographical area was immune from fraud. Eighty percent of fraud was committed by medical providers, followed by consumers (10%). The rest was by others, which included insurers themselves and their employees. The examples have been drawn from a search of reported actions using legal search engines, legal journals, and news articles.
Among individuals, fraudulent billing, kickbacks, upcoding services, and bundling were common examples of fraud. In the private insurance industry, avoidance of sick and high-need members, plus systematic misrepresentation of the cost of care to group plan sponsors were examples.
"Vulnerable populations"—which include the elderly, women, minorities, or less educated—are the "most likely victims of fraud," regardless of whether the fraud is public or private, the report noted.
Therefore, researchers noted, as work continues on healthcare reform, attention should be directed at anti-fraud actions. This means in part considering steps to "strengthen the reach and scope" of HIPAA insurance fraud provisions regarding marketing, enrollment, consumer protections, healthcare access, and claims payment.
"The evidence presented in this analysis should put to rest the notion that the problem of fraud is limited to public programs. Because fraud can arise in any sector of the health industry, comprehensive efforts to both detect and deter fraud systemwide are essential to national health reform," said Sara Rosenbaum, professor and chair of the school's Department of Health Policy, in a statement.
Lawmakers working on a major overhaul of the healthcare system have reached a familiar juncture in their effort. Committee chairmen in both chambers are crafting bills they hope will attract the support of moderate Democrats and possibly some Republicans. The situation in many ways follows the path of then-President Bill Clinton's failed bid to extend health insurance to all Americans in 1993 and 1994. Yet the dynamic is different this time, with congressional Democrats appearing more inclined to act decisively on the issue, according to this Wall Street Journal article.
