Don't Penalize Efficiency, Reward It: Zoghbi on Proposed 2013 Medicare Fee Schedule

July 25, 2012

July 24, 2012 (Washington, DC) — Cardiology is more than two weeks into the public-comment period following the July 6 release of the 2013 Medicare Physician Fee Schedule proposal from the Centers for Medicare and Medicaid Services (CMS) [1], which is slated to end with this year's summer season on September 4. The document calls for cardiology to be hit with a further 3% drop in reimbursements even beyond the 27% overall cut required by the agency's sustainable growth rate (SGR) formula. A large portion of that 3% comes from reduced payments for "advanced imaging" procedures such as echocardiography, single-photon-emission computed tomography (SPECT) imaging, and MRI when more than one is performed on the same day.

In an interview with heartwire , American College of Cardiology (ACC) president Dr William A Zoghbi explained the organization's take on the proposals, its goals for the fee schedule by the time it's finalized in a few months, and what the ACC has been doing to help the process. Zoghbi directs the Cardiovascular Imaging Institute at the Methodist DeBakey Heart & Vascular Center, Houston, TX and has been a pioneer in the use of echocardiography and other cardiovascular ultrasound from its early years to the present day.

heartwire : The CMS proposes full reimbursement for the imaging procedure with the highest reimbursement level and a 25% drop in reimbursement for each successive imaging performed on the same day. The agency says that system reflects inherent cost savings due to "efficiencies" in providing same-day multiple imaging procedures. The CMS must make a lot of assumptions when establishing reimbursement levels-- how appropriate is its reasoning here ?

Zoghbi: We feel that a 25% reduction for the technical component of the less expensive of same-day imaging is quite high and not justified. We understand that some minor parts of those procedures may be duplicative, but they don't amount to 25%, and there are many other factors that play into performing several tests on the same day.

We should all look for win-win situations and evaluate new payment models that reward quality, performance and outcomes.

Say it's an echocardiogram and a stress nuclear study or any other combination for that matter. Often they are done on the same day for efficiency and patient convenience, but usually not one right after the other, so there isn't much duplicated effort. Furthermore, the processes involved and the information gleaned are quite different. In addition, they may not be done at the same facility. All of us are aiming for an efficient healthcare system, but this would be a very inefficient way of providing care. It could drive clinicians to perform different imaging procedures on different days and would be a major inconvenience to the patients.

We want to incentivize the field to provide high-quality care but be efficient at the same time. If we penalize one stakeholder in the whole complex process, we're doing a disservice to the whole healthcare system.

heartwire : Is it inappropriate to target imaging procedures for cuts? There was recently a time of rapid growth in the number of cardiovascular imaging procedures, which some questioned.

Zoghbi: The imaging modalities available provide important clinical information, and we should be using them judiciously and appropriately. Imaging is currently essential to cardiovascular care not only for diagnosis, but for management of disease. Management is often tailored according to heart or valvular function, and most of it depends on imaging. In the past, we depended more on invasive criteria--individuals used to get heart catheterization more often to identify coronary disease or valve disease. Most of it now is done noninvasively, and the cath lab is usually used for catheter-based interventions rather than diagnostics.

There was a significant increase in the use of imaging up to about 2007 or 2008, partly because of introduction of newer imaging modalities that provided additional information. But since then, there has been a substantial decrease in utilization in various imaging modalities, partly because of more education of physicians, emphasizing overall appropriate utilization for the clinical condition at hand.

Putting penalties on one specialty or another is really not the way to go.

That's what was behind publication of appropriate-use criteria for cardiologists as well as radiologists. We're seeing more education in this area for professionals and also the public, as we just saw in the Choose Wisely campaign that was launched by the American Board of Internal Medicine [2]. Many organizations, including the ACC, got together to highlight a few areas where we could have a good conversation with patients about not needing certain tests if they did not help the clinical situation, such as stress imaging in individuals with no symptoms, at low risk, and so on.

heartwire : How is that going? How accepting have cardiologists been, and what is the ACC doing to advance its own proposals to the CMS?

Zoghbi: We physicians in general are very data-driven, and I think if the data show that we are on the right path or show that some correction is needed, we will respond to the data. This points to the importance of registries, like the National Cardiovascular Data Registry (NCDR), be they in the hospital or outpatient setting. With registries, you can look at utilization, appropriateness of care, quality, and outcomes. The data tell us where we are, and without them, it's hard to know whether any adjustments are needed.

We've worked with payers and the CMS in two registries, so far. The first was the NCDR ICD Registry. And the second, most recent one, the [Transcatheter Valve Therapy] TVT Registry, will probably serve as the model going forward for the introduction of newer therapeutic procedures and equipment that alter prognosis: a collaboration between professional societies--in this case the ACC and the Society for Thoracic Surgery--and other stakeholders such as the CMS and the FDA. The TVT Registry is a phenomenal collaboration introducing a revolutionary technology, which is [transcatheter aortic-valve replacement] TAVR. It's important because it looks at utilization, outcomes, and complications, and at the same time it introduces and pays for an exciting new procedure that improves patient outcomes and provides choice.

Once we put the registry data together with our appropriate-use criteria and the guidelines to emphasize quality of care and target appropriate utilization of services--and hopefully decrease waste--I really think we can achieve the kind of high-quality, sustainable care we're looking for.

heartwire : As the CMS finalizes its physician fee schedule proposals in the coming months, what does the agency need to hear from cardiology?

The data tell us where we are, and without it, it's hard to know whether any adjustments are needed.

Zoghbi: We are all in this field together. The message should be to aim for very good quality patient-centered care, appropriate use of tests, and spending enough time with patients for their [evaluation and management] E/M. This is the message for a sustainable healthcare system: ultimately we must consider patient health and outcomes, quality, and the cost-effectiveness of care.

The CMS wants administrative costs to be as low as possible. I think that we, as healthcare professionals, need also to push private insurers to help by decreasing administrative burden and hassles--decrease the precertification requirements that raise administrative costs on our end as well as theirs.

Continued reimbursement reductions and bundling of services for further "savings" have been concerns in every update to the physician fee schedule. And with a looming SGR cut of 27% in January 2013 [by which time Congress will be required to implement the year's fee schedule], it will be very difficult for many physicians to sustain their practices and maintain their patients' access to care.

Putting penalties on one specialty or another is really not the way to go. We all know there is a lot of waste in our current healthcare system, including defensive medicine. If we can eliminate quite a bit of it, we can still provide the same high-quality care by incentivizing individuals to provide quality care without being penalized for it.

So we're working on various ways to incentivize quality. We want to reward it, and we want to reward efficiency. This is what we strongly believe in and want all of us to work for and achieve together. But we won't get it by further squeezing physicians. If there are sacrifices, all stakeholders must be participating in it. We should all look for win-win situations and evaluate new payment models that reward quality, performance, and outcomes where we can reinvest in the healthcare system and make it sustainable.

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