Although newer payment models will continue to evolve over the next few years, interventional cardiology has made small gains recently by becoming a specialty recognized by the Centers for Medicare & Medicaid Services. From MedPage Today.
Although newer payment models will continue to evolve over the next few years, Blankenship noted, interventional cardiology has made small gains recently by becoming a specialty recognized by Centers for Medicare & Medicaid Services (CMS).
This specialty self-designation is "easy to do" and elevates the field as a whole, suggested Blankenship, who is president of the Society for Cardiovascular Angiography and Interventions. Being placed in a new category means an opportunity for interventional cardiologists to be paid for work previously done for free (such as consulting with patients referred by general cardiologists). It also means not having their outcomes compared with those of general cardiologists, who may not see as many risky patients.
So what does a cardiologist have to do to designate his or her sub-specialty?
Blankenship pointed to form 885i provided by the CMS. Because the form has not been updated to reflect the new category, he instructed, interventional cardiologists should check "undefined" and list "P-interventional cardiology" as their sub-specialty designation.
Yet far less clear was the impact of alternative payment models themselves.
Thomas M. Maddox, MD, of Denver VA Medical Center, discussed the Merit-Based Incentive Payment System (MIPS), a value-based program consisting of a score that would determine how much compensation a clinician receives in a year.
The score and its components -- 30% quality of care, 30% resource use, 15% clinical practice improvement activity, and 25% meaningful use of electronic health record technology -- is still open to discussion, he pointed out, as hard definitions for each category have not been provided. That's why "it's up to us to drive that conversation," Maddox emphasized.
Then again, he reminded the room that "MIPS will go away in 2022, eventually giving way to alternative payment models."
Describing one such payment model, William Borden, MD, of George Washington University in Washington, D.C., said that the goal for an accountable care organization (ACO) is to fill in the gaps in care "across settings and across time" with an emphasis on team coordination. The hope is that with more contact with patients, hospitalizations and rehabilitation can be reduced, he said.
In a system where financial gains and losses are shared, these healthcare savings can mean better compliance with the set budget dictating what should be spent for each clinical scenario.
Kirk N. Garratt, MD, of Christiana Care Health System in Wilmington, Del., addressed bundled payment for percutaneous interventions. Inherent in the bundled payment system, a model with a budget akin to that of an ACO, is the incorporation of costs associated with treating the primary problem and giving ancillary services, transitional, and follow-up services.
"It is likely that angioplasty will be targeted [for bundled payment] because it is a common and expensive procedure," he said. "There's no doubt that the old model is failing and new models are needed."
Yet Garratt warned of many obstacles for the bundled payment system, which is being tested in several areas for certain procedures.
He took issue with the fact that compensation is tied to value provided, which in turn is risk stratified: The physician chooses to accept responsibility for a set percentage of outlier expenses (in return for possibly greater financial reward) or to elect protection from risky outcomes.
"This model does not discourage unnecessary episodes of care," he said. Instead, it may encourage inappropriate physician behavior, such as rejecting high-risk patients, up-coding illness severity, limiting access to specialists, delaying additional care until bundled payment end-date, and minimizing services excessively, he suggested.
Thus, bundled payments may "unfairly penalize" academic centers that service economically disadvantaged populations, Garratt noted.
Same-day discharge after percutaneous coronary intervention generally saves healthcare dollars without hurting patient outcomes, a literature review published in JAMA Cardiology found. From MedPage Today.
Same-day discharge after percutaneous coronary intervention (PCI) generally saves healthcare dollars without hurting patient outcomes, a literature review found.
Arguing against the many exclusions for same-day discharge recommended in the 2009 Society for Cardiovascular Angiography and Interventions (SCAI) consensus statement, the totality of "the available evidence supports the safety of same-day discharge in selected patients after PCI," Adhir Shroff, MD, MPH, of the University of Illinois at Chicago, and colleagues wrote online in JAMA Cardiology.
"Greater adoption of same-day discharge programs after PCI has the potential to improve patient satisfaction, increase bed availability, and reduce hospital costs without increasing adverse patient outcomes," they wrote.
And those goals, it seems, may be increasingly within reach for many PCI scenarios.
"Due to advancements in technique, pharmacology, and technology, PCI is much safer and is commonly practiced throughout the world," they wrote. What's more, according to Shroff's group, a prior estimate had predicted that the U.S. health care system would save $200-$500 million per year if half of the patients undergoing PCI were discharged the same day.
Ian C. Gilchrist, MD, of Hershey Medical Center in Hershey, Pa., and a co-author of the review, agreed that "a lot has changed in the way care can be delivered." Unlike bypass surgery, which used to require weeks or months of recovery, "PCI can be done during the daylight hours," he told MedPage Today in a phone interview.
"That pretty much can be done on most routine patients across the spectrum. I think that's something that not all clinicians, especially those outside of the interventional field, understand. They're still thinking back to last decade's approach," Gilchrist said.
One particular barrier to widespread early release is "physician inertia," according to the authors. Given the hazards of staying in the hospital, however -- where infection, accidents, drug errors have been commonly reported -- they suggested that clinicians might overcome this by realizing that "the patient may be safer at home than in the hospital."
Currently, the authors wrote, SCAI's "conservative recommendations would exclude most patients now undergoing PCI regardless of their procedural outcome from same-day discharge. Indeed, the limitations of these exclusion criteria were illustrated in a case series of 100 consecutive patients discharged safely on the same day as their PCI during a period just predating the publication of the 2009 guidelines. Only 15% of these patients actually fit the definitions for appropriate same-day discharge, with most having features considered higher risk by the consensus document."
Shroff's literature review was performed on studies published between 1995 and 2015.
Nowadays, "a priori factors based on age and other preexisting conditions should not necessarily present a barrier to same-day discharge unless those conditions necessitate hospitalization," the authors wrote.
Gilchrist added that "the paper also highlights that just because you can send a patient home earlier doesn't mean that the care of the person is done earlier. All the places that send patients home quickly typically have safety nets set up: patient are contacted the following day, and instructions given on what to do."
Shroff's group suggested that key to every successful same-day discharge are: the accurate assessment of suitability for early release, excellent procedural outcomes, rapid and reliable stabilization of vascular access, reliable provision of dual antiplatelet therapy, and postprocedural patient education (including routine early follow-up and tracking).
Overnight observation can still be appropriate in a situation where the patient has "no social support at home," where no one to take care of them or look in on them, Gilchrist said.
The same goes for patients in whom complications arose during PCI and those who may have heart attacks, he noted.
The authors concluded that "promoting early discharge for stable PCI recipients will benefit patients, caregivers, medical centers, and payers. Same-day discharge after low-risk cases is the next step in the evolution of PCI."
Current Medicare payments are seen as 'adequate,' writes the Medicare Payment Advisory Commission in its latest report. From MedPage Today.
This article was originally published by MedPage Today.
One of the most interesting things about the Medicare Payment Advisory Commission's (MedPAC) most recent report to Congress is what it didn't say -- it didn't suggest increasing physician reimbursement under Medicare.
"The evidence suggests that payments for physicians and other health professionals are adequate," wrote the authors of the report, which was released Tuesday. "Therefore, the commission recommends the [update suggested under] current law for 2017."
What's interesting about that recommendation "is in years past, there has been an assessment by MedPAC that primary care physicians aren't paid properly -- that there are problems with the fee schedule and there's a negative affect on primary care physicians," said Ann Hollenbeck, JD, of the Honigman law firm in Detroit, in a phone interview. "They're not raising that same concern again, which has been a real and perceived concern for many years. That surprises me."
MedPAC did suggest cutting the payments made for drugs purchased by 340B hospitals. "Reducing the price Medicare pays 340B hospitals for separately payable Part B drugs ... would accomplish two things," the report said. "First, it would reduce beneficiary cost sharing. Second, it would reduce program spending for Part B drugs by approximately $300 million -- funds that could be reallocated within the hospital sector to support the Medicare-funded uncompensated care pool."
Under the 340B program, hospitals with high percentages of Medicaid and low-income Medicare patients receive substantial discounts from drug manufacturers for drugs covered by Medicare Part B -- discounts amounting to an aggregate 34% of the drugs' average sales price (ASP), according to the Office of Inspector General at the Department of Health and Human Services.
However, Medicare reimburses the hospitals at 106% of the ASP for the drugs. As a result, "Medicare payment rates are much higher than the acquisition costs of Part B drugs at these hospitals," the report noted. Under MedPAC's proposal, Medicare would cut the reimbursement by 10% and use the savings to reduce beneficiary out-of-pocket costs and to pay for hospitals' uncompensated care.
The 340B program has been under scrutiny for the latest 3-5 years, "the question being one of fairness because there are such substantial savings," said Hollenbeck. MedPAC's proposal "certainly upsets the apple cart as to how it's historically been done, but it upsets the apple cart to the extent of 10%. So they are not suggesting we revamp how 340B works. Instead it's taking a 10% slice of the savings and saying, '10% of it we want to try to distribute more fairly.'"
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The 340B hospitals had a more severe view of the proposal. "What MedPAC proposes is a radical restructuring of the 340B drug pricing program," Randy Barrett, vice president of communications for 340B Health, a coalition of 340B hospitals and health systems, said in a statement.
"It is a solution in search of a problem -- and one that would negatively impact many safety-net hospitals and their communities. Now is not the time to consider fundamental changes to the program, especially as 340B hospitals struggle to meet the needs of their low-income and underserved populations in an era of rapidly increasing drug costs."
MedPAC also recommended that Medicare not take health assessments into account when risk-adjusting payments in the Medicare Advantage program, Edwin Park, JD, vice-president for health policy at the Center on Budget and Policy Priorities, a left-leaning think tank here, noted in an email to MedPage Today.
"Medicare Advantage plans increasingly provide health assessments of their enrollees; for example, a nurse may come to a patient's home to do a physical exam," Park explained in a blog post.
But Medicare has found that "some insurers mainly use these assessments to 'collect' diagnoses in order to raise enrollees' risk scores for purposes of risk adjustment, rather than to improve follow-up care or identify illnesses requiring treatment," he wrote. "In fact, the Centers for Medicare and Medicaid Services had proposed excluding these kinds of assessments but dropped this change in the face of industry opposition."
MedPAC did suggest revising the prospective payment system for skilled nursing facilities, but no changes in the payment system for hospice care.
This article was originally published by MedPage Today.
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