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Congressional Health Care Reform: What To Expect for CV imaging activities
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CV imaging has seamlessly revolutionized the care of the CV patient during my 27 years as a physician. There is absolutely no doubt in the minds of the quaternary care medical school hospitals of Philadelphia regarding the key role that CV imaging has played in the 30% reduction in CV mortality nationally within the past 10 years.
Interestingly, this outstanding success has been aided not only by the evidence-based scientific proof of the clinical therapies and outcomes CV imaging changes in sick patients (not to mention the objective reassurance to many patients triaged to medical/lifestyle management), but also to the ability of the system to have found a financial model that created access to quality CV imaging services throughout the nation in a large variety of diverse venues. Although the science and quality outcomes remain clear, the current era presents a variety of challenges for CV imaging care delivery. Some of these challenges are health care reform-based, but many are not.
Reimbursement reductions
First, there have been some sudden drops in CMS reimbursements for CV imaging physician work and office practice expense for study acquisition in the past 3 years. Unrelated to legislative health care reform, CMS’ work to bundle CPT codes performed at the same time has led to reductions in echo and nuclear cardiology physician work in image interpretation. These reductions did not take cost out of the system but rather were redistributed among the other CPT codes.
Also unrelated to health care reform, the American Medical Association delivered to CMS in 2008 the results of the Physician Practice Information Survey, a multispecialty solicited survey across all of the specialties in the house of medicine, and the basis for calculating the “in-office” practice expenses for procedures. The cardiology portion of the survey was extremely poor data with incredibly low response rate and suggested a significant decrease in cardiology practice expense from a 2005 survey, whereas all other specialty practice expense survey costs went up. This survey data placed into the mathematical practice expense equation caused a marked reduction for all four CV imaging modalities in the office setting in the 2009 Medicare physician fee schedule.
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In a zero-sum game, these reductions did not take cost out of the system, but instead redistributed it to the other specialties for their office practice expense, resulting in what many believe was the largest transfer of funding ever in the Medicare program. Common sense advocacy by the CV imaging societies and the American College of Cardiology have so far been unable to reverse this situation. Unfortunately, this lack of financial access stability has led to a large trend of cardiology private practices selling to hospitals and become “hospital employees.” Although a short-term solution (for a variety of reasons) was attractive to those more advanced in their careers, this is a concerning trend with fears for physician leadership of patient care and physician/patient relationships, especially for physicians early in their career.
SGR cuts
Second, both unrelated and related to congressional health care reform, is the threatened cuts to all physicians by the congressionally mandated CMS operationalized sustainable growth rate (SGR). Enacted in 2001, the SGR is a component of the conversion factor used to calculate every physician payment in the CPT fee schedule and was targeted to help “control health care costs” by decreasing physician reimbursement per service as utilization of services increased. This extremely flawed formula uses many economic parameters, most notably gross domestic product, which clearly varies independently of the real cost of medicine. Based on a 2000 benchmark, it has led to a proposed cut in physician payments every year.
Each year, Congress has stepped in to abate the cut to near neutral, adding the threatened cut to the next year and yielding a possible cut of more than 20% in 2010. Ongoing abatements by Congress have delayed this year’s cuts out to Dec. 1 (after the election process in November). The threatened additive cut to all physician services in January 2011 would likely be more than 28% for that year and 40% by 2015. Less amusingly, hospitals, nursing homes and Medicare Advantage insurance plans have been guaranteed positive “cost-of-living updates” every year. Hospitals have averaged just less than 4% every year for the past 6 years, whereas physicians have needed congressional intervention to avert marked decreases in December of every year and have been lucky (sans imaging) to average 0.5% each year.
These yearly threatened cuts create financial access instability and frustrate long-term health care planning. The AMA has a top priority of repealing the SGR, and many in Congress believe this yearly accelerating crisis cannot continue either; the question of what the trade-off in the legislative health care reform process will be remains.
Congressional health care reform
Finally, what of congressional health care reform and its effects on CV imaging? As recognized by many, the current bill is a broad brush outline and a timeline for portions of the outline to be enacted each of the next 5 years. In such a fluid situation, the angel or devil will clearly be in the evolving details. Five provisions may affect CV imaging delivery. First, all imaging labs need to be “lab accredited” (ACR, ICAL or JCAHO) by 2012 to receive Medicare payments. Second, a comparative effectiveness research program has been mandated to help clinicians make informed evidence-based choices. Some CV imaging projects have been suggested in its second and third tiers. Third, solicitations have been requested for pilot programs in appropriate use criteria clinical algorithms for efficient patient care (the ACC has submitted a proposal to this).
In addition, requests for proposals have gone out for two categories for pilots using new payment systems beyond fee for service. One category is looking for suggestions in “Episode of Care,” and the other in the nebulous grouping of “Accountable Care Organizations,” possibly linking multiple care providers in a bundled payment. The delivery of CV imaging may be affected by any of these, depending on how the requests are answered and how the pilots progress.
Some things are sure about the field of CV imaging for more than 40 years: It is innovative and flexible, has been entirely patient-centered, and has attracted passionate providers dedicated to clinical quality, diverse access venues, and improvement of the field through research. It has a variety of organizations and people dedicated to meeting the aforementioned challenges (and others that could not fit). Interesting times are likely to reinforce the downstream cost-savings of CV imaging, as we all look forward to continuing declines in national CV mortality and morbidity, which remains our No. 1 disease process.
William Van Decker, MD, is a member of the cardiovascular imaging faculty at the Temple University School of Medicine, a participant in government relation committees of several medical professional organizations, and is the immediate past president of the Philadelphia County Medical Society.