For the past several months I awaken each morning hoping the CMS 2010 Physician Payment Rule issue is merely a nightmare, and I can get up and help the College once again focus on constructive engagement in health care reform. No such luck. It is a nightmare, but one that is part of our reality.

Friday at 4:30 PM -- 30 minutes before the issuance deadline, the CMS (Centers for Medicare and Medicaid Services or See-a-Mess) dropped a bomb.  In a call from Jon Blum, the top political insider in CMS, he said I have “good news and bad news.”

The BAD news: the Rule adopts the AMA-collected practice costs survey data, meaning cardiology gets an average practice cut of 27-40% in private practices. (Note that academic, hospital, and integrated system salaried cardiology is largely insulated from the cuts initially, but the effects could eventually reach everywhere through market forces).

The allegedly GOOD news: CMS will phase in the cuts over four years, meaning they will impose an average of 5-7% cuts in 2010. But, what he told us is not accurate in the language we see that nuclear codes (SPECT) will be cut as much as 36% in 2010. We are working to analyze the language in the final rule, but this isn’t good news, and the Secretary and the White House have signed off on it.

Bottom line: The Four-Year-Phase-In is far better than having the full impact hit in 2010, because it will allow us to survive to get valid data and reverse the cuts completely in 2010 if necessary. BUT WE NEED TO FIGHT THIS DECISION NOW, NOT WAIT UNTIL NEXT YEAR. We need to mount a strategy to prevent even the 5-7% average cut in January and in particular reverse the nuclear/stress cuts.

Next steps
After all the hard work and excellent advocacy we’ve witnessed from all of you these past months, I regret telling you we’re not through. But, please don’t allow discouragement to cause you or others to give up. We’re not done here.

*** Image from morgueFile (jdurham). ***

As expected, CMS released its final 2010 Medicare Physician Fee Schedule at just a little before 5 today. I'll have more later this weekend, but here's the quick and dirty summary for now...

***********************

Final Rule Includes Phased In Cuts for Cardiology

The Centers for Medicare and Medicaid Services (CMS) today released its 2010 Medicare Physician Fee Schedule final rule, which includes policy proposals that will significantly reduce payments for cardiovascular-related services. While CMS has attempted to mitigate the impacts of the cuts by spreading them out over a four-year period, the impact of the cuts is still enormous both for 2010 and beyond. Cuts of this magnitude—whether enacted this year or spread over four—cannot be absorbed and we will continue to fight the implementation of this data until a rigorous review is conducted.

The ACC understands the very real impacts these cuts will have on your practices, your staff and your patients. The College is exploring all options and staff and leaders are working together to help you understand all of your options. Below is a high-level summary of the policy changes finalized in the rule. In addition, we’ve also provided links to the tools and resources available to you now.

More information over the coming weeks will be provided in Cardiology magazine, ACC News and The ACC Advocate. Please also plan to join ACC CEO Jack Lewin and President Alfred Bove, M.D., F.A.C.C., for an all-member call on Nov. 12 from 4:00 to 5:30 p.m. (EST) to discuss the 2010 rule. To RSVP for the call, click here.

RULE HIGHLIGHTS:

Practice Expense: Despite the hundreds of calls and letters from you, members of Congress and patients, CMS has chosen to incorporate the results of the American Medical Association’s Physician Practice Information Survey into its formula for calculating practice expense relative value units (RVUs). In a slight change from the proposed rule, the agency has said the cuts will be phased in over a four-year period versus all at once. With the exception of evaluation and management services, nearly all services that cardiologists perform will see cuts ranging from 10 percent to more than 40 percent for individual services phased in over 4 years. A few key examples for 2010 alone:

• SPECT Myocardial Perfusion Imaging (78452) – 36 percent cut
• Transthoracic echo with spectral and color flow Doppler (93306)--10 percent cut
• Coronary Stent (92980) - 4 percent cut
• EKG (93000 )-- 5 percent cut
• Level 4 established patient office visit (99214) -- 7 percent increase

As mentioned above, the ACC is exploring several options for stopping the implementation of these cuts. CMS’ decision to phase-in the cuts, while not what we would have hoped, is due in large part to your tremendous efforts over the last few months. Your actions clearly had an impact and we strongly encourage you to continue to email your congressional representatives and CMS detailing the ramifications of these cuts as we move into the next phase of challenging these cuts.

Bundled codes for myocardial perfusion/SPECT imaging
CMS’s continued pressure to bundled together imaging services reported with multiple codes has now hit myocardial perfusion imaging. In 2010 myocardial perfusion imaging/SPECT studies including wall motion and ejection fraction will now be reported with a single code. CMS decided to substantially reduce the payment for myocardial perfusion imaging as part of this rule by reducing both the physician work value and the practice expense value. To make matters worse, because there is a new code for the service, CMS apparently is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value. The result is a 36% cut in payment for 2010. This change alone accounts for more than one-third of the projected payment cut to cardiology. ACC will begin immediately to pursue strategies to mitigate this cut. Specifics on the new codes and tips on how to work with health plans to transition to the new codes will be emailed to you next week and also included in the November issue of Cardiology magazine.

Consultations: Payments for consultations provided in office and hospital settings are eliminated under the final rule. The RVUs assigned to these codes will be redistributed to office and hospital visits and services now billed as consultations will be billed as hospital or office visits. This will reduce payments to varying degrees for consultation services.

Malpractice: CMS has chosen to update the malpractice RVUs with data from a new survey of specialty-level malpractice premiums. In addition, CMS has proposed a new method for determining malpractice RVUs for technical component services. The proposed new malpractice RVUs would reduce cardiology payments by 1 percent. However, the impact will vary depending on the mix of services provided.

Equipment utilization: CMS has finalized its proposal to change the agency’s formula for calculating the per-procedure cost of diagnostic medical equipment worth more than $1 million. The proposal would assume that all diagnostic equipment with an acquisition cost greater than $1 million is used 90 percent of the time an office is open, thus driving down the practice expense RVUs for services using that equipment. Within cardiology, cardiac MR and cardiac CT services will be subject to payments set based on this utilization assumption. CMS did agree not to apply this cut to equipment for non-hospital cardiac catheterization services.

SGR: As required by current law, the final rule includes a 21.5 percent reduction in Medicare Physician Payment as of Jan. 1, 2010. This cut is in addition to the payment reductions that result from the proposed policy changes described above. In short, there could be as high as a 30 percent cut in Medicare payments for cardiology. However, as in previous years, Congress is expected to pass a one to two year fix this fall. CMS did finalize its proposal to remove physician-administered drugs from the accumulated SGR debt, which makes a fix to SGR less expensive.

WHAT’S NEXT
Taken together with the payment cuts cardiology has already experienced, CMS’ final rule represents a grave threat to cardiology practices and to patient access. The consequences, whether intentional or not, are already being felt. The ACC and its partners in the cardiology community are prepared to help you and your practice navigate these challenging times, while also pulling out all the stops to stop the practice expense cuts and find real solutions to payment. The following resources are available to you now. Your feedback on the tools and resources you’d like to see in the coming months is also appreciated. Please email advocate@acc.org with your thoughts.

• Practice Management Toolkit: This newly updated site contains information designed to help you best manage your practice. While continually being updated, you’ll find information on practice solutions, health IT, coding and billing, working with health plans, quality and educational tools, and more.
  
  
• Medicare Provider Enrollment Website: This CMS site provides you information about Medicare enrollment. The ACC will provide information to members on options in future communications.
  
  
• ACC CardioAdvocacy Network / ACC Political Action Committee: The ACC’s CardioAdvocacy Network (CAN) keeps you up to date on ACC’s grassroots efforts and ways you can get involved. Currently the site contains links to a sample congressional letter regarding the final rule. The ACC Political Action Committee (PAC) is another way to ensure the cardiovascular voice is heard on Capitol Hill. There’s no better time to get involved with either or both of these key advocacy programs.

We still have no responses from HHS or CMS (Medicare) to the strong letters of concern we sent to them from an impressive number of more than 25% of the members of Congress regarding the impending and flawed 2010 Medicare Physician Payment Rule. Our campaign on this issue has been and continues to be powerful. This silence is both frustrating and unnerving.

We are hopeful the White House and HHS will be motivated to meet with us and to modify the Rule at this point. I did have a chance to meet with Health Czar Nancy Ann DeParle and her team about our concerns with the Rule in the White House this week. They are all aware it is a mess.

What are our options at this point? As we draw ever closer to the Nov. 1 deadline for the issuance of CMS' final rule, many of us are hearing conflicting reports about our options and what CMS may or may not do now.

Here’s the story: CMS by law must have a rule publicly issued by Nov. 1 (that’s a Sunday, so we’re expecting news by close of business Friday, Oct. 30).  That rule, of course, needn't be the current proposed rule. CMS can:

1. Place a moratorium on implementation until it can analyze the data and recommend changes;
2. Use the 2005 data with or without inflation adjustment;
3. Blend the 2005 and Physician Practice Information Survey (PPIS) data;
4. Phase in new recommendations as outlined above in No. 2 and No. 3; or
5. Let the rule stand.

We are urging the first possibility. We would have to evaluate the details of the following three bullets, if proposed. We would vigorously oppose letting the Rule stand, of course. While CMS can change the PROPOSED rule, only Congress could change or prevent the FINAL rule. One other important point: The Secretary of HHS signs off on the Rule, but must have the review and approval of the White House OMB (Mr. Orszag) as well -- so advocacy there may be important going forward if HHS isn’t communicating a workable option to prevent the demise of outpatient and community cardiovascular practices.

In any case, even with the temporary reprieve resulting from option 1, there would likely still be modest cuts to payment for cardiologists -- just not as draconian as those that would result if the proposed Rule went into effect. 

Continue your calls to your lawmakers about this critical issue. This battle is not about preventing the cuts; it's about saving the private practice of cardiology, and preserving access to care for the vast majority of CV patients who rely on these practices.

*** Image from Flickr (Suviko). ***

The HHS Health IT Policy Committee (HIT PC) held its first meeting last week under the direction of (our friend) David Blumenthal, formerly of Partners and Harvard and now Obama’s National Coordinator for health IT in HHS. The HIT PC is going to develop policy recommendations and health IT dollar-distribution strategies for those who show "meaningful use" of an EHR.

That’s $20 billion worth of power theoretically, but only $2 billion of the funding is actually in Blumenthal’s direct oversight. Blumenthal wants to spend at least $300 million training health care workers in how to deploy health IT. He will also deal with privacy insecurity issues, and hire a chief privacy officer; but he seems open to standing up to the bludgeoning he may experience by suggesting a unique patient identifier (UPI) is needed to help track patients in the chronic disease continuum. We strongly agree, David.

The big coming arguments of the HIT PC will be around what the "meaningful use" definition actually means. They have a workgroup to help define that, as well as workgroups on privacy and safety, and another one on interoperability standards. Keep in mind that if your practice isn’t deemed 'meaningful,' you ain't gettin' any money here. It’s worth paying attention to. Believe me, we will not miss those meetings or fail to get involved with the workgroups Blumenthal is forming.

***Image from Flickr (Prasan Naik)*** 

ACC President Fred Bove, M.D., F.A.C.C., staff Senior Vice President of Advocacy Jim Fasules, M.D., F.A.C.C., and I attended the HHS Secretary Kathleen Sebelius’ testimony before the House Ways and Means Committee last week. She did very well and stressed the need for measuring quality, for choice of doctor and hospital and for reducing rising costs. She implied the choice of a "public plan" to compete with private insurance was an option still on the table.

We issued a response to her testimony: “Leaders in both parties and the health care community agree: The American health care system needs to change. What we heard from Secretary Sebelius and committee members is that change needs to come sooner rather than later. The ACC has long advocated for several of the reforms Secretary Sebelius testified about today including payment reforms and the development of a health information technology infrastructure.”

Sebelius also mentioned two annual reports HHS issued last week that all of us should take note of:

• The annual 2008 National Healthcare Quality Report — the highlights are that between 40 and 50 percent of patients do not receive evidence-based (guidelines, performance measures, appropriate use criteria) care in the average inpatient or outpatient encounter. Also, in terms of patient safety, huge gaps continue to be documented. For example, we could save $20 billion by reducing variation and eliminating preventable inpatient nosocomial infections (IHI has demonstrated this is possible).
  
  
• The annual 2008 National Healthcare Disparities Report — Health care is still doing an abysmal job of reducing and changing the disparities problem, despite all the related rhetoric. The ACC is working on a couple of things that would hopefully help this problem: ACC’s CREDO (The Coalition to Reduce Racial & Ethnic Disparities in (CV) Outcomes) project, which will provide new insights for how to solve this problem with respect to CV disease, and using the IC3 Program to improve adherence to guidelines and performance measures.

*** Official photo of Kathleen Sebelius. From Wikimedia Commons. ***

Last week the Senate Finance Committee considered the nomination of Kansas Gov. Kathleen Sebelius to head the Department of Health and Human Services. Senators questioned Gov. Sebelius about health care reform, and she underscored the administration’s commitment to reform this year. The Governor also promised to work on reforming physician payment, which is promising.

Gov. Sebelius also revealed to the Finance Committee that "unintentional errors" prompted her and her husband to file amended 2005, 2006 and 2007 tax returns and pay about $8,000 in additional tax and interest. Compared to other nominees’ tax nightmares, this seems a relatively minor issue.

A positive vote on her nomination is expected after Congress returns from the spring recess. But there is still no mention of what’s happening with Surgeon General, final NIH director, or the CMS Administrator.

*** Kathleen Sebelius. Image from Wikimedia Commons (Dayton Mitchell) ***

I was invited this week to testify on behalf of ACC before the House Appropriations Subcommittee on Labor-HHS this week. We advocated for a 7 percent increase in funds for NIH in 2010. The NIH received $10 billion in additional funds over the next two years in the stimulus package. But the ACC, along with other patient advocates, believes NHLBI still needs a 7 percent increase from 2009 funding for fiscal 2010. A critical part of our quality agenda is support for the evidence that should form the foundation of care. WE also recommended increases for AHRQ for comparative effectiveness and registry projects beyond the stimulus dollars they got. We also asked for more CV prevention dollars for CDC, and for more AED education and funding for the HHS Health Resources and Services Administration (HRSA).

Kathleen Sebelius has gotten the nod today to be HHS Secretary. She was insurance commissioner before being Governor; worked in an insurance world for a while. Don’t know how good that is for us. She was one of the first Obama Governors though. Seems to have done a good job with their state Medicaid program. I hear good things about her. Must have her taxes in order. So, then -- let’s get moving!

Still no real word on the Secretary of HHS. Governor Sebelius of Kansas is being background vetted, so may be #1 choice. Ted Kennedy has come out for her.  But no word really. The FDA job seems down to Margaret Hamburg, M.D., former NYC Commissioner of Health, and Baltimore Health Commissioner Scharfstein (Kennedy’s favorite), and former Henry Waxman (D-Calif.) staff person. Hamburg is a very effective person. Everything else seems on hold still.

*** Kathleen Sebelius. Image from Wikimedia Commons (Dayton Mitchell) ***