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Uncertainty in the era of health care reform
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An air of apprehension, even melancholy, has settled over the cardiology community as health care reform is slowly implemented. Despite continued gradual improvement in the economy, a soaring stock market, avoidance of the “fiscal cliff” and minimal impact thus far from implementation of the Affordable Care Act, many cardiologists are skeptical that the future holds good tidings for them.
Issues in funding, payment, cost savings
Mildly bad news has become good news. The budget sequester “only” cuts physician Medicare payments by 2%, sparing physicians from much larger cuts mandated for the military and other discretionary spending programs such as NIH research. There is talk of permanently dismantling the sustainable growth rate (SGR) legislation, which could have reduced Medicare physician payments by 26.5% this year had there not been a last-minute reprieve from Congress. But, encouraging news about the SGR was precipitated mostly by the recession and flattening of the rate of rise of health care spending during the past 5 years, reducing estimates of the budgetary costs of eliminating the SGR. Cardiologists have already felt the impact of declining procedure volume, in effect already paying for the anticipated cost of eliminating the SGR.
L. Samuel Wann
There is bipartisan support in Washington, D.C., to eliminate the SGR, but negotiations for repeal include wider reforms in physician payment, with a shift away from fee-for-service toward a performance-based payment, with a general outline favoring increasing payment for primary care and reducing payment for procedural specialists. Another solution for eliminating the SGR accumulated deficit is to freeze physician payments to current levels for the next 10 years. Neither approach is particularly attractive to cardiologists who intend to practice for another 10 years, but less painful than an immediate 26.5% cut in Medicare physician payment in 2014 if the SGR stands.
Besides hotly contested provisions to increase revenue, President Obama’s proposed 2014 budget targets Medicare for reduced spending, particularly at the expense of hospitals, largely sparing physicians. However, as nearly 70% of cardiologists are now employed by hospitals, many with contracts coming due for renegotiation, hospitals are likely to be less generous in sharing their declining profits from technical services with their physician employees. CMS will continue pressure to eliminate self-referral for imaging and has announced it will require preauthorization for selected inpatient imaging services. Hospitals are likely to share their pain with employees, including physicians, as employee costs account for 70% of the budget in most hospitals. Similar to physicians, hospitals are consolidating, acquiring one another and closing unprofitable locations.
The proposed shift to performance-based physician payment models depends heavily on information technology, which promises unparalleled capacity to analyze health care practices, eliminate duplication, prevent errors, and improve quality by comparing effectiveness of alternative treatment strategies and comparing individual physicians and hospitals to each other and to benchmarks. Although the move to electronic records is inevitable and will eventually deliver on its promises, implementation of IT has proved more expensive and disruptive than expected and has already vastly increased the complexity and expense of medical practice, reduced professional autonomy, and lessened personal satisfaction for physicians and patients alike.
As cardiologists continue to integrate their practices with hospitals and other large institutions, including insurance companies, discussions are under way in Washington, D.C., to consolidate Medicare Part A hospital care with Medicare Part B physician care, further consolidating hospitals and physicians. Medicare Part A and Part B have distinct legislative histories, with different deductibles and co-payments to be paid by the patient or supplemental insurance. Combining the programs could reduce administrative burden and encourage integration of care, but likely will also result in higher costs to patients, a larger proportion to be paid by higher income Medicare recipients (means testing) — a negotiating point not too dissimilar from Rep. Paul Ryan’s voucher system.
Rep. Tom Price, a former orthopedic surgeon, has reintroduced legislation to allow physicians to bill patients directly for the balance of any charges not paid by Medicare Part B, rather than the current requirement that a physician accept the Medicare fee schedule as full payment for services, with Medicare paying 80% of the approved charge and the patient or his/her insurance company paying 20%, with no payment for charges in excess of the Medicare fee schedule. This proposal appeals particularly to independent physicians, but has an uphill battle in Congress, as there is little support for increasing payments for health care by either the government or individual patients.
As the Affordable Care Act takes full effect, even more rigid cost-saving measures can be expected. Thirty million additional patients will have health insurance, but politicians, both Democratic and Republican, are still promising to reduce total spending for health care. CMS recently increased payment for outpatient physician services to levels paid by Medicare, an increase mainly benefiting primary care physicians. As a compromise with states that do not plan to expand Medicaid as suggested by the Affordable Care Act, CMS is also considering various state plans to use federal Medicaid allocations to provide private health insurance, rather than expand Medicaid itself.
Impact on modern cardiologists
Efforts to re-engineer the entire health care enterprise and provide health insurance to every American are occurring at the same time that our general population and physician workforce are both rapidly aging. We are facing an age bubble as baby boomer cardiologists eventually retire. Although much is said about the coming shortage of physicians, many cardiologists are, at present, seeing continued reduction in the number of procedures they perform. Whereas electrophysiology and peripheral vascular specialists are in demand, most other areas of cardiology are stagnant.
An American Heart Association panel recently recommended additional training for cardiologists to specialize in ICU management of cardiac patients, dealing with new technical advances such as left ventricular assist devices. Just as PCPs are staying in their offices, turning over management of their hospitalized patients to specialized hospitalists, cardiologists are spending more of their time in the catheterization laboratory or in highly specialized cardiac imaging suites or seeing patients in their offices and may not be able to concentrate on minute-to-minute care of critically ill ICU patients in a timely fashion, or possess the highly specialized skills needed to optimally manage these patients.
Core Cardiology Training Symposium (COCATS) guidelines are becoming increasing detailed, as the technology and knowledge base of contemporary cardiology continues to expand. To provide optimal care, modern cardiologists need highly specialized training in interventions for coronary and structural heart disease, arrhythmias, multiple imaging modalities and specific diseases such as complex congenital heart disease, pulmonary hypertension and HF. The Affordable Care Act provides some limited funding for training PCPs, but the prospect for funding training for subspecialty cardiologists is dismal, even as we continue to migrate toward ever more sub-sub-specialization.
Expanded use of semi-independent mid-level providers and physician extenders may provide some relief from continuing budget cuts and looming personnel shortages. In this environment, cardiologists will need to develop their skills as team leaders. Fair and credible metrics are needed to assess the quality of care, assign accountability and determine the compensation of individuals as part of that team. There are no easy solutions to our health care crisis. Cardiologists are correct in their perception that the future of the practice of cardiology may be more uncertain now than ever before.
Disclosure: Wann reports no relevant financial disclosures.