As many of you may know, Gabe Delgado, Antonio Fernandez, and I went to the ACC Legislative conference with Dr. Gilson from 9/12-9/13. It was an eye-opening experience as we are in for a lot of changes in delivery and reimbursement of care - with much of it happening in the next 4-6 months. Some high-lights/low-lights for those who could not attend:
1. SGR: In 1998, a Sustainable Growth Rate (SGR) adjustment to Medicare physician reimbursement was added to that year's budget bill (aka the "Doc Fix"). The SGR was an item added in an attempt to maintain spending neutrality - it ties the growth rate of physician reimbursement to the annual increase in GDP, and any spending beyond this is "due" back to the system - the "Fix." The problem is that health-care costs and expenditures outstrip GDP growth, and this increase in costs and expenditures is not at the physician reimbursement level. Each year, at our lobbying behest, this fix is put off by congress to the next year. But putting it off doesn't mean it isn't due - it is cumulative. So, this year the SGR is up to a 30% cut in reimbursement ($300 billion over 10 years). The ACC and other physician groups have been lobbying for a permanent fix. This year is unique because as a result of the turmoil of the national debt-limit increase, a deficit panel has been appointed by Congress to find $1.5 trillion in cuts or there will be automatic cuts (50% defense and 50% non-defense, Medicare cannot be touched). If the SGR is fixed, it is added on-top of the $1.5 trillion, so that means the impetus is to just let it go through this year. Complicating this is that MedPAC (Medicare Payment Advisory Committee) has advised permanently eliminating the SGR and instead cutting "specialists'" reimbursement by 5.9% per year for 3 years and then freezing them for 7 more (remember inflation is around 2-4%), with PCPs facing a freeze for 10 years. MedPAC is the committee tasked with advising Congress on Medicare expenditure, who every year is ignored - but may not be this year. Basically, be prepared to make less each year for the most "productive" part of your careers.
2. RBMs: Radiology Benefits Managers are for-profit companies that have been widely employed by Insurance companies to deny imaging requests - for us this applies to MPIs. They cropped up in response to an abuse of MPIs, which arguably have now been corrected. The problem is that RBMs use a mix of clinical and non-clinical data that may not be relevant to approve and deny requests - and their financial incentive is to deny. The outcome is that many tests that should not be ordered still get ordered, and ones that should get denies. On top of it RBMs are another layer of expense (for the insurance companies, and practices who need to hire a secretary/nurse to deal with these authorizations). In response, the ACC came up with a tool known as "FOCUS." It basically is a calculator that employs AUC (appropriate use criteria) to determine if a test is advisable. Here in RI, UCF has been piloting it in that every test they order has been put through FOCUS, with the approval process still going through the RBMs we use. I'll leave it to Dr. Gilson to release the prelim results - but let's just say FOCUS does better and saves both the insurance co and us money. Recently there was a case in Delaware where a man was denied a stress three times for typical symptoms, only to show up in the ED in extremis and having to go for an emergent CABG. The result is that the Delaware legislature passed a law requiring the ins. companies to use FOCUS and not use the RBMs.
3. Liability reform - comes up each year, the short is that the ACC considers tort-reform a way to save the system time and money by weeding out frivolous law suits.
4. ACOs (accountable care organizations) - the over simplistic description: grouped health-care providers (not just physicians) who share a pot of money per pt, incentivised to do be more efficient - a fancier bundled-payment scheme.
Atizaz H. Mansoor