ACC Aghast at Proposed Cuts to Cardiology Payments in Medicare Physician Fee Schedule for 2010

July 06, 2009

July 6, 2009 (Baltimore, Maryland) — The US Centers for Medicare & Medicaid Services (CMS) has announced its planned 2010 Medicare Physician Fee Schedule (MPFS), colloquially known as "the update," which includes proposals expected to result in an overall payment cut of 11% for cardiology [1].

The update affects all areas of medicine, and payments for more than 7000 types of services; proposals this year expected to adversely affect cardiologists include new ways to calculate practice expenses, equipment-utilization rates, and fees for consultations. In contrast, GPs, family physicians, internists, and geriatricians will likely see an increase in payments of around 6% to 8% if all the new proposals come into effect, says the CMS.

Cardiology organizations are up in arms about the changes, which they claim will adversely affect patient care. The American College of Cardiology (ACC) predicts that under the new proposals as they stand, nearly all services that cardiologists perform would see cuts ranging from 10% to more than 40%--with certain imaging procedures being particularly hard-hit. Cathy Kerr, director of communications for the American Society of Echocardiography (ASE) told heartwire that the ASE "is working with the ACC and other imaging-related specialty groups to combat the impact of the MPFS changes."

In a statement [2], the president of the ACC, Dr Alfred Bove (Temple University Medical Center, Philadelphia, PA) says: "The ACC is shocked. These proposed cuts are based on the incorporation of a few esoteric pieces of data into a complex formula . . . [that] completely ignores the very important issues of access that are certain to be created by these huge slashes in payment. Services that have improved countless lives by diagnosing and treating cardiovascular disease are scheduled to have payment cuts in the range of 25% to 42%." forum moderator and practicing cardiologist Dr Melissa Walton-Shirley (TJ Samson Hospital, Glasgow, KY), told heartwire : "Robbing subspecialist Peter to pay general practitioner Paul is a dangerous proposal for our patients. Instead of devaluing subspecialist services in order to find the revenue, why not implement some simple new practices for our country that will yield huge payoffs immediately?" Preventive measures such as smoke-free legislation and better food labeling would save the CMS more money in the long run, she suggested.  

Walton-Shirley also notes: "Blue Cross and Blue Shield private insurance look to Medicare to set payments for office visits, echos, etc. So, any decrease in Medicare payment will soon be followed by third-party cutbacks as well."

But Will All These Proposed Changes Really Happen?

Every year, the CMS releases its update, which uses a complicated set of calculations designed to set Medicare payment rates for thousands of medical services. Interested parties have 60 days, until August 31, to comment on the proposals, CMS spokesperson Ellen Griffin explained to heartwire : "All the professional bodies, such as the ACC, will submit comments on the parts of the rules that affect them." The final rule is issued on November 1, and the new payment rates and policies come into force the following January 1.

Often, changes are made to the update as a result of the comments received in this 60-day period, and these will be reflected in the final rule. "But until we publish the final rule, we can't say what is likely or not likely to happen," Griffin says.

In addition, Congress can intervene at two time points, enacting legislation to change things: after November 1, it has a 60-day review period, during which time it can adopt a resolution basically disallowing the rule or parts of it "and then we have to go back and do something else," says Griffin. Also, in January, "Congress can say we're disallowing this particular provision--essentially they are overruling a part of the rule if they feel we've done something wrong," she noted.

Echo Payments Cut by 42%, Caths by 24%, and ECGs by 21%

The ACC staff spent this week trying to digest the new 1000-plus page CMS report, which was issued on July 1 and is available online [3].

The CMS says some of the changes to equipment-use rates are designed to address concerns about the rapid growth in high-cost imaging services.

Among these is a proposal to change the agency's formula for calculating the per-procedural cost of medical equipment worth more than $1 million, thus driving down payments for procedures such as cardiac MRI, cardiac CT, and nonhospital cardiac-catheterization services, says the ACC.

ACC staff has calculated, for example, that there would be a 42% reduction in payment for transthoracic echo, a 24% cut for left heart catheterization, and a 21% fall in payments for ECGs.

"A 42% decrease in echo reimbursement will force subspecialty offices to lay off important employees in their infrastructure," Walton-Shirley told heartwire . "As a consequence, fewer patients will be able to get onto already-crowded office schedules. Valuable nurse-practitioner services, a lifeline for many patients, will have to be cut back or eliminated altogether in some offices. Furthermore, benefits like health insurance for our employees will also have to be considered for cutbacks." 

And Kerr told heartwire : "The ASE is very much aware that the 2010 MPFS includes provisions that would mean a 42% cut for our primary code, 93306 [transthoracic echo with spectral and color flow Doppler]. The hospital outpatient-payment system rule also includes reductions, although these are much less severe; a memo outlining the impact for echocardiography in the hospital setting has been posted to the advocacy pages of the ASE website [4]." 

But Kerr added that there was also "a glimmer of good news: the CMS has accepted the ASE's request for increased payment for stress tests/stress echos performed in hospital outpatient departments."

New Practice Expense Proposals Based on "Shoddy and Incomplete Data"

The ACC is particularly concerned about one of the 2010 proposals, the way the new practice expenses have been calculated, because it says the CMS based this on a small survey from the American Medical Association (AMA).

"The CMS had put policies in place to ensure that the data and their decisions were based on quality standards, but they deviated from that by using a survey that the AMA put together that only got responses from 55 practices," media spokesperson for the ACC, Amy Murphy, told heartwire .

"The ACC is very concerned that the CMS chose to disregard the standards it previously put in place to ensure the quality of practice expense data," Bove notes. "We believe this is a significant departure from previous policy and may be a violation of statute. It is ironic that the agency that purports to support an evidence-based approach to medicine is making major decisions based on such shoddy and incomplete data."

Eliminating Payments for Consult Codes Would Hit Revenues Hard

The ACC also says that another of the plans--eliminating payment for consultation codes, which states that services currently billed as consultations would from 2010 be billed as hospital or office visits--would reduce payments to varying degrees for cardiology consultation services.

"Taken together with the payment cuts cardiology has already experienced, the CMS's proposed rule represents a grave threat to cardiology practices and the patients they serve," the ACC says [5].

The only payment that is slated to rise under the new recommendations is for office visits, which would see an 11% increase, ACC noted.


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