How Healthcare Reform Is Affecting Radiology, Pam Kassing


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How Healthcare Reform Is Affecting Radiology - Presented by: - speaker: Pam Kassing, MS, Senior Director of Health Policy, American College of Radiology. Presented at the GE Virtual Conference, September 14, 2011.

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  • Partial capitation may be applied to highly functioning ACOs in future
  • Partial capitation may be applied to highly functioning ACOs in future
  • How Healthcare Reform Is Affecting Radiology, Pam Kassing

    1. 1. Pam Kassing, MPA, RCC Senior Economic Advisor Economics and Health Policy American College of Radiology How Healthcare Reform is Affecting Radiology September 14, 2011
    2. 2. Objectives <ul><li>Health Care Reform: </li></ul><ul><li>Starts with legislation </li></ul><ul><li>Mandates dictate the transformation </li></ul><ul><li>Medicare implements transformation </li></ul><ul><li>through regulations </li></ul><ul><li>Potential future changes </li></ul>
    3. 3. 112 th Congress Overview: Where are We Now? <ul><li>Power Shifting Mid-Term Election </li></ul><ul><ul><li>House Republicans gain 63 seats to win majority </li></ul></ul><ul><ul><li>Senate Republicans win six seats to reduce Democratic majority </li></ul></ul><ul><li>Split Congress will make it difficult to pass any legislation deemed controversial over the next two years </li></ul><ul><li>Last year for Congress to get work done before entering the election cycle </li></ul>
    4. 4. 112 th Congress - Health Care Agenda <ul><li>SGR Fix/Repeal– Will it ever end? </li></ul><ul><ul><li>House Republican leadership pledging to “tackle the big issues” and have stated that fixing SGR is one of those issues </li></ul></ul><ul><li>Much activity in the House driven by Republican Leadership </li></ul><ul><li>Repeal and Replace of Accountable Care Act (ACA), oversight committees </li></ul><ul><li>There will most likely be only one Medicare-related legislative bill to amend with any radiology-related issues (end of the year) </li></ul><ul><li>Now the issue of lowering the debt ceiling as mandated by the President </li></ul><ul><li>Mandated cuts in the budget place all possibilities on the table </li></ul>
    5. 5. ACR Issues During the 112 th Congress <ul><ul><li>Potential Cuts for Radiology </li></ul></ul><ul><ul><li>Avoiding arbitrary cuts to the PC </li></ul></ul><ul><ul><li>GAO report recommends cuts to the PC for imaging of 50% </li></ul></ul><ul><ul><li>MedPAC proposal also to apply the multiple procedure discount to the professional component similar </li></ul></ul><ul><ul><li>Medicare proposes this for the 2012 Medicare Physician Fee Schedule </li></ul></ul><ul><ul><li>2) Raising the Equipment Utilization Rate as suggested in the most recent Trade Bill </li></ul></ul><ul><ul><li>3) Suggestion of the use of RBMs to manage utilization of imaging for Medicare gets a positive CBO score. </li></ul></ul>
    6. 6. ACR Issues During the 112 th Congress <ul><li>ACR’s Response to Potential Cuts: </li></ul><ul><li>Publication in JACR on the true efficiencies when multiple procedures and interpreted by a radiologist. Letters to Congress. </li></ul><ul><li>Offer computerized order entry (CPOE) system as an alternative to Radiology Benefit Managers (RBMs). Pilot study due for completion and report to Congress in 2012. </li></ul><ul><li>Continual monitoring of all legislation for potential cuts in imaging as “pay-fors.” </li></ul><ul><li>General message that enough is enough. </li></ul>
    7. 7. Impacts for 2013 for Technical Component <ul><li>Code Description 2006 Pay 2013 Pay 2008 Total % Change in Total Change in </li></ul><ul><li>Allowed Pay 2006-2013 Total Pay </li></ul><ul><li>Services ($ million) 2009-2013 </li></ul><ul><li>70553 MRI brain w/o & w/dye $1,118 $439.51 255,700 -$173 -60.7% </li></ul><ul><li>78452 Ht muscle image spect, mult $548 $379.97 1,710,760 -$288 -30.7% </li></ul><ul><li>77080 DXA bone density, axial $139 $44.74 1,560,947 -$148 -67.9% </li></ul><ul><li>75978 Repair venous blockage $658 $132.79 109,871 -$58 -79.8% </li></ul><ul><li>71020 Chest x-ray $36 $27.42 3,098,389 -$28 -24.6% </li></ul><ul><li>70549 MRI angiograph neck w/o&w/dye $968 $622.74 21,228 -$7 -35.6% </li></ul><ul><li>75710 Artery x-rays, arm/leg $564 $164.91 28,428 -$11 -70.8% </li></ul><ul><li>75635 CT angio abdominal arteries $745 $457.02 22,393 -$6 -38.6% </li></ul><ul><li>73720 MRI lwr extremity w/o&w/dye $1,089 $446.37 10,489 -$7 -59.0% </li></ul><ul><li>77057 Mammogram, screening $86 $72.17 733,406 -$10 -15.7% </li></ul><ul><li>Note: Includes previous policies of Deficit Reduction Act, changes in practice expense and equipment utilization rate using 2010 CF </li></ul>
    8. 9. ACR Issues During the 112 th Congress <ul><ul><li>Other Issues of importance to radiology: </li></ul></ul><ul><ul><li>4) SGR/Imaging Reimbursement Issues – NO MORE CUTS! </li></ul></ul><ul><ul><ul><li>- Could be a deal for a permanent fix if the coalition of physicians offers solid payment model recommendations </li></ul></ul></ul><ul><ul><ul><li>6) U.S. Preventative Services Task Force Reform </li></ul></ul></ul><ul><ul><ul><li>7) Radiation Safety – Mandatory accreditation for hospitals </li></ul></ul></ul><ul><ul><ul><li>8) Primary Care Physicians want more money – from where will they get? </li></ul></ul></ul>
    9. 10. 112 Congress (Health Care Issues) Where Are We Heading? <ul><li>In Summary </li></ul><ul><ul><li>2010: A big year in health care reform for Congress with passage of ACA </li></ul></ul><ul><ul><ul><li>Only the beginning </li></ul></ul></ul><ul><ul><li>Agency rules and the implementation of those rules over the next several years will be a larger task, than passage of HCR itself </li></ul></ul><ul><ul><li>Although House has passed bill to repeal ACA, will House Republicans attempt to “tweak” ACA? Will the courts deem it illegal? </li></ul></ul><ul><ul><li>Working to keep RBMs out of Medicare and offer alternatives </li></ul></ul><ul><ul><li>Mandate that hospitals be accredited </li></ul></ul><ul><ul><li>Working to deter any additional cuts to radiology payments </li></ul></ul><ul><ul><li>Working with the physician coalition to try to make a SGR permanent fix a reality </li></ul></ul>
    10. 11. <ul><li>Independent Physician Advisory Board </li></ul><ul><li>Misvalued Codes </li></ul><ul><li>Multiple Procedural Reduction Rule </li></ul><ul><li>(TC of Imaging by 50%) </li></ul><ul><li>Accountable Care Organizations and Payment Models </li></ul>What Happened in Regulation as a Result of the Affordable Care Act?
    11. 12. Independent Physician Advisory Board <ul><li>Developed to make all health care policy decisions related to slowed growth and savings to the Medicare Program </li></ul><ul><li>Its major role is to find ways to reduce payments, not coverage or quality issues. </li></ul><ul><li>Final decisions are immediately implemented starting in 2015 unless Congress acts </li></ul><ul><li>The Board members are selected by the President </li></ul><ul><li>Ideally, this Board would be repealed. </li></ul>
    12. 13. Misvalued Codes Mandated in the PPACA <ul><li>Misvalued Codes Under the Physician Fee Schedule (Sec. 3134 of H.R. 3590) </li></ul><ul><ul><li>The Secretary of Health and Human Services (HHS) is required to periodically identify physician services under the MPFS that are potentially misvalued and make appropriate adjustments </li></ul></ul><ul><ul><li>The Secretary would focus on codes with the following criteria: </li></ul></ul><ul><ul><ul><li>fastest growth </li></ul></ul></ul><ul><ul><ul><li>substantial changes in practice expenses </li></ul></ul></ul><ul><ul><ul><li>new technologies or services </li></ul></ul></ul><ul><ul><ul><li>frequently billed in conjunction with furnishing a single service </li></ul></ul></ul><ul><ul><ul><li>low relative values </li></ul></ul></ul><ul><ul><ul><li>billed multiple times </li></ul></ul></ul><ul><ul><ul><li>not been subject to review since implementation of RBRVS (Harvard-valued codes) </li></ul></ul></ul><ul><ul><ul><li>other codes Secretary determined to be appropriate </li></ul></ul></ul><ul><li>Note: Criteria listed make it likely that imaging codes will be subject to the Secretary’ review . </li></ul>
    13. 14. Misvalued Codes <ul><li>The ACR is concerned about the volume of radiology codes and the time frame for accomplishing this work. </li></ul><ul><li>In the final rule, 21 out of 57 codes in just two of the categories related to radiology and were listed for RUC review. </li></ul><ul><li>Radiology codes that fall out on other screening categories to be resurveyed often generate numerous code proposals (e.g. new bundled codes) </li></ul><ul><li>If your physicians get RUC surveys, please encourage them to fill them out with care!! </li></ul>
    14. 15. Misvalued Codes <ul><li>Other screens already in play: </li></ul><ul><li>Codes billed together on Medicare claims: </li></ul><ul><li>95% of the time: CT of the abdomen and pelvis </li></ul><ul><li>90% of the time: Myocardial perfusion </li></ul><ul><li>75% of the time: Interventional radiology </li></ul><ul><li>Fastest growing codes: CT spine </li></ul>
    15. 16. Upcoming Codes on the 75% Screen List <ul><li>New codes for 2012: </li></ul><ul><li>While the ACR cannot provide detailed information on the codes, descriptors and values developed for 2012 at this time, we can inform our members of the codes identified as being performed together greater than 75 percent of the time and being considered for possible bundling. </li></ul><ul><li>Computed tomographic angiography (CTA) of the abdomen and CTA of the pelvis (74175 and 72191) </li></ul><ul><li>renal angiography (36245-35248 in conjunction with 75722 or 75724), </li></ul><ul><li>Inferior vena cava filter (37620 and 75940), </li></ul><ul><li>Abdominal paracentesis (49080, 49081 in conjunction with 76942 or 77012) and, </li></ul><ul><li>Sacroiliac joint injection (27096 and 73542). </li></ul><ul><li>Nuclear medicine lung ventilation/perfusion and hepatobiliary code families to be revised and revalued in 2012 as well. These codes were identified to be re-surveyed by the Five-Year Review Identification Workgroup (now known as the Relativity Assessment Workgroup). </li></ul>
    16. 17. Multiple Procedural Payment Reduction Rule <ul><li>Radiology was the only physician “pay for” in PPACA to the tune of $3 billion (equipment utilization and MPPR). </li></ul><ul><li>CMS suggests where cuts can be made. </li></ul><ul><li>The money comes out of the Medicare budget and back to the federal fund. </li></ul><ul><li>Bad for Medicare and all of medicine, bad for radiology. </li></ul><ul><li>Significant payment reductions are not limited to a handful of codes. More than 200 codes are subject to the multiple imaging payment reduction. </li></ul>
    17. 18. Multiple Procedural Reduction Rule <ul><li>CMS expands this policy to non-contiguous body areas and across modalities on the same patient, same session performed by the same physician (An additional estimated impact of $200 million over 10 years) </li></ul><ul><li>Their rationale is that this policy would be consistent with the mis-valued codes efforts and suggestions by the GAO </li></ul><ul><li>MedPAC recommended in their March meeting that the MPPR be applied to the PC </li></ul><ul><li>Medicare proposes to implement this for 2012 </li></ul><ul><ul><li>ACR to comment extensively and meet with CMS </li></ul></ul><ul><ul><li>All member mailing </li></ul></ul><ul><ul><li>Paper in July JACR </li></ul></ul>
    18. 19. Rippling Effects on Hospitals <ul><li>Cuts in office/freestanding center payments (TC under MPFS) shifts all services to the hospital facilities </li></ul><ul><li>More expensive for Medicare </li></ul><ul><li>More expensive for the patients </li></ul><ul><li>Accreditation is not mandatory, lower quality </li></ul><ul><li>Are they prepared to handle the full patient load? </li></ul><ul><li>More physicians become hospital-based </li></ul><ul><li>Bundled codes are implemented in HOPPS too </li></ul>
    19. 20. Hospital Packaging/Bundling <ul><li>Medicare packaged many imaging services considered “ancillary” including contrast, diagnostic radiopharmaceuticals, imaging guidance, radiology supervision and interpretation codes and post processing (i.e. 3D and CAD) </li></ul><ul><li>Episodes of care – the development of larger payment groups that more broadly reflect services provided in an encounter. CMS proposes to build these larger groups based on independent services </li></ul><ul><ul><li>Goal is to emulate the inpatient DRG prospective payment system </li></ul></ul><ul><li>CMS encourages hospitals to report all HCPCS codes that describe packaged services that were provided </li></ul><ul><li>Problem – if packaged many say “we are not getting paid for it any more” </li></ul><ul><li>Hospitals need to code accurately and update their charge masters annually! </li></ul>
    20. 21. Patient Protection and Affordable Care Act and Reconciliation Act <ul><li>Accountable Care Organizations (ACOs) </li></ul><ul><li>(Sec. 3022 as modified by Sec. 10307 of H.R. 3590) </li></ul><ul><ul><li>Establishes the Medicare Shared Savings Program to promote accountability and coordination of Medicare Parts A and B services (this is an expansion of the Physician Group Practice (PGP) pilot as it expands it to include additional providers) </li></ul></ul><ul><ul><li>Program would allow groups of providers who meet certain statutory criteria to be recognized as Accountable Care Organizations (ACOs) and be eligible to share in the cost-savings they achieve for the Medicare program </li></ul></ul><ul><li>ACOs could be groups of providers and suppliers who have an established mechanism for joint decision making including: Practitioners in group practices; networks of practices; partnerships or joint ventures between hospitals and practitioners; hospitals employing practitioners; and such other groups are determined eligible by Secretary </li></ul><ul><li>ACOs would be eligible for annual incentive bonus if they achieve a threshold savings amount set by the Secretary, for total per beneficiary spending </li></ul><ul><li>Program would begin no later than January 1, 2012 </li></ul>
    21. 22. Proposed Rule on Accountable Care Organizations <ul><li>On March 31, 2011, CMS published its proposed rule for the Medicare Shared Savings Program: Accountable Care Organizations </li></ul><ul><li>The rule provides for a 60-day comment period ending on June 6, 2011 </li></ul><ul><li>The central theme of the proposed rule is a focus on a “three-part aim” which is: 1) better care for individuals; 2) better health for populations; and 3) lower growth in expenditures </li></ul><ul><li>CMS is proposing to offer two models for an ACO to participate under: </li></ul><ul><li>1) The one-sided model only offers to share in the savings and is at a rate of 50%. This model might be attractive to smaller ACOs (i.e. physician groups) that are starting out and don’t want to deal with accepting risk </li></ul><ul><li>2) An opportunity is also offered to earn a larger percentage of shared savings (60%) by participating in a “shared savings/losses (two-sided) model ” whereby the ACO would accept risk by agreeing to repay losses </li></ul>
    22. 23. ACO Proposed Rule <ul><li>Separate tax ID number </li></ul><ul><li>Not necessarily Medicare participants </li></ul><ul><li>Eligible for shared savings if quality and spending goals are met </li></ul><ul><li>Savings are shared with Medicare </li></ul><ul><li>ACO decides how to distribute savings to its members </li></ul><ul><li>Target spending goals to be set for each ACO by HHS, based on reducing the average per-patient spending by a specific percentage, as adjusted by “beneficiary characteristics” </li></ul><ul><li>25% Withhold </li></ul>
    23. 24. Requirements to be Eligible as an ACO <ul><li>The ACO shall be willing to become accountable for the quality, cost, and overall care of the FFS beneficiaries assigned to it </li></ul><ul><li>The ACO shall agree to participate in the program for a period of not less than 3 years. CMS also offers a 60-day withdrawal period </li></ul><ul><li>The ACO shall have a formal legal structure that would allow the organization to receive and distribute payments for shared savings to participating providers of services and suppliers </li></ul><ul><li>The ACO shall have at least 5,000 beneficiaries assigned to it and include primary care ACO professionals that are sufficient for the number of assigned beneficiaries </li></ul><ul><li>The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies </li></ul><ul><li>The ACO shall meet certain patient-centeredness criteria outlined in the proposed rule (e.g. patient and caregiver assessments, care plans) </li></ul>
    24. 25. Marketing an ACO <ul><li>All ACO marketing materials, communications, and activities developed or revised that are related to the ACO and its participation in the Shared Savings Program, such as mailings, telephone calls or community events, that are used to educate, solicit, notify, or contact Medicare beneficiaries or providers/suppliers regarding the ACO and its participation in the Shared Savings Program, must be approved by CMS before use to protect beneficiaries and to ensure that they are not confusing or misleading. </li></ul><ul><li>This also includes general audience materials such as brochures, advertisements, outreach events, letters to beneficiaries, web pages, mailings, or other activities, conducted by or on behalf of the ACO, or by ACO participants, or ACO providers/suppliers participating. </li></ul>
    25. 26. ACO Proposed Rule <ul><li>65 quality measures in the following areas: </li></ul><ul><ul><li>Patient/caregiver experience of care </li></ul></ul><ul><ul><li>Care coordination </li></ul></ul><ul><ul><li>Patient safety </li></ul></ul><ul><ul><li>Preventive health </li></ul></ul><ul><ul><li>At-risk population/frail elderly health </li></ul></ul><ul><li>If they neglect to report even one measures their agreement will be terminated </li></ul>
    26. 27. Could Be Good for Physicians <ul><li>Standard services are paid under Medicare Physician Fee Schedule on a fee-for-service basis </li></ul><ul><li>Specialists get 0.5% of shared saving regardless of level of involvement of reporting measures </li></ul><ul><li>Specialists can contract with more than one ACO. CMS wants to help facilitate market competition to minimize market power which could lead to fraud and abuse and self-referral </li></ul><ul><li>The use of decision support is mentioned as a suggested measure </li></ul>
    27. 28. Major Areas of Focus for Radiologists in ACOs <ul><li>1) The radiologist should be involved in the front end of care using decision support systems (CPOE) and the radiologist as a consultant on what the patient needs to get it right the first time around. </li></ul><ul><li>2) Much of this effort would be evidence-based . Radiology needs to demonstrate that they provide services that are value-added . Some examples of works in progress: </li></ul><ul><ul><li>CMS pilot study on decision support and the use of order entry systems. </li></ul></ul><ul><ul><li>The Rescue Trial going on with ACRIN shows the clinical differences between patients who receive CCTA vs SPECT diagnostic studies. </li></ul></ul><ul><li>3) Radiologists act as the radiation safety officer with respect to insuring proper equipment calibration (with Medical physicist), proper training for technologists and proper dosage of radiation for patients. </li></ul><ul><li>4) Radiologists should be more involved in the governance structure (i.e. volunteering to be on hospital boards, team leaders for ACOs). </li></ul><ul><li>5) Radiologists should more actively manage all radiology services and services lines to help with more efficient and effective patient care. </li></ul><ul><li>6) Advocate for quality measures that act as an incentive for radiologists to want to improve care. For example, possibly 2% of their salary would be based on contributing to lower mortality rates and/or reducing lengths of stay in hospitals. </li></ul>
    28. 29. Next Steps for Accountable Care Organizations <ul><li>Need to be implemented by January 1, 2012 </li></ul><ul><li>Not going away </li></ul><ul><li>Final rule by November 1 </li></ul><ul><li>Anticipate big changes given push-back on proposed rule </li></ul><ul><li>Pioneer ACOs, first out the gate </li></ul>
    29. 30. Development of Payment Models <ul><li>1) ACO model – published in the May JACR </li></ul><ul><li>2) Hospital Bundling model </li></ul><ul><li>3) Capitation model </li></ul><ul><li>4) Episodes of Care </li></ul><ul><li>5) Working with the AMA and other specialties on payment models </li></ul><ul><li>6) Determine how radiologists get involved in Medicare demonstration projects </li></ul><ul><li>7) Working to develop more comparative effective research for radiology </li></ul><ul><li>Guidelines for radiologists on how they fit in these models, how they may contribute, contract negotiations, how these models might crossover, data and studies to validate positions </li></ul>
    30. 31. What to Watch Out For in Future Regulations as Mandated by PPACA <ul><li>Center for Medicare and Medicaid Innovation (Sec. 3012 of H.R. 3590) </li></ul><ul><li>Announced in November 2010, recent open door forum, focus on patient-centered home, will also handle a capitated model. Some things will move faster than others through their process. </li></ul><ul><li>Pilot Program on Payment Bundling (Sec. 3023 as modified by Sec. 10308 of H.R. 3590) </li></ul><ul><li>Secretary required to develop a national, voluntary bundled payment 5 year pilot program to provide incentives for providers to coordinate care, effective 2013 </li></ul><ul><li>Medical Home Demonstration Program (Sec. 3024 of H.R. 3590) </li></ul><ul><li>Secretary to conduct demonstration program to test payment incentive and service delivery model that uses physicians and nurse practitioner directed home-based primary care teams designed to reduce expenditures and improve health outcomes in the provision of items and services to certain chronically ill Medicare beneficiaries </li></ul><ul><li>Three demonstrations are in development </li></ul><ul><li>Independent Payment Advisory Board (Sec. 3403 as modified by Sec. 10320 of H.R. 3590) </li></ul><ul><li>Establishes the Independent Payment Advisory Board to develop and submit proposals to Congress aimed at extending the solvency of Medicare, slowing cost-growth, improving quality of care, and reducing national health expenditures </li></ul><ul><li>Commission proposals will be automatically implemented unless Congress acts in opposition </li></ul><ul><li>Proposals to modify payments will be effective for payment years 2015 and beyond (2020 for hospitals). </li></ul><ul><li>Evidence based Coverage of Medicare Preventive Services (Sec. 4105 of H.R. 3590) </li></ul><ul><li>Authorizes Secretary to modify the coverage of and withhold payment to any currently covered preventive service to the extent that modification is consistent with the USPSTF recommendations </li></ul><ul><li>The enhanced authority would not apply to services furnished for the purposes of diagnosis or treatment (rather than as preventive services furnished to asymptomatic patients) </li></ul><ul><li>Comparative Effectiveness Research </li></ul><ul><li>A dozen IOM projects focusing on radiology </li></ul>
    31. 32. ACRs Legislative and Regulatory Goals <ul><li>Monitor and participate in the development of accountable care organizations and other payment models. </li></ul><ul><li>Push to place bundled codes in appropriate APCs under HOPPS </li></ul><ul><li>Push for research to better support coverage criteria </li></ul><ul><li>No new imaging cuts in future health care legislation – a great challenge when there must be “ pay fors ” to fund future initiatives (SGR fix, etc.) </li></ul><ul><li>Push to implement more quality imaging </li></ul>
    32. 33. What Can You Do to Prepare for the Future? <ul><li>Be an advocate for radiology </li></ul><ul><li>Hospitals need to code accurately and update their charge masters each year. For bundled codes, does A+B=C? </li></ul><ul><li>Hospital systems need to prepare for larger volumes of patient </li></ul><ul><li>Anticipate change, think about your next move </li></ul><ul><li>Look for ways to demonstrate cost savings preferably through demonstrations and/or publications (e.g. Length of stay, unneeded surgeries, better patient flow) </li></ul>
    33. 34. Live Q&A Session <ul><li>Pam Kassing, MPA, RCC </li></ul><ul><li>Economics and Health Policy, ACR </li></ul><ul><li>[email_address] </li></ul><ul><li>P: (800) 227-5463 x4544 </li></ul><ul><li>Mary Tierney </li></ul><ul><li>VP, Chief Content Officer, Health Imaging </li></ul><ul><li>[email_address] </li></ul>To view this presentation again, please login into the conference and visit the Auditorium. All presentations will be available OnDemand within 48 hours. <ul><li>To Submit a Question: </li></ul><ul><ul><li>Type your question in the white Q&A box. </li></ul></ul><ul><ul><li>Hit send to deliver your question to the speaker. </li></ul></ul>