March 15, Glenn Hackbarth, JD Chairman Medicare Payment Advisory Commission 601 New Jersey Avenue, NW Suite 9000 Washington, DC

Transcription

1 March 15, 2011 Glenn Hackbarth, JD Chairman Medicare Payment Advisory Commission 601 New Jersey Avenue, NW Suite 9000 Washington, DC Dear Chairman Hackbarth: The American College of Radiology (ACR), a professional organization representing more than 34,000 radiologists, interventional radiologists, radiation oncologists, nuclear medicine physicians, and medical physicists, appreciates the opportunity to attend meetings and listen to the presentations and discussion of the staff and Commissioners of the Medicare Payment Advisory Commission (MedPAC). In particular, the ACR was interested in the February 23, 2010 MedPAC Session: Improving Payment Accuracy and Appropriate use of Ancillary Services. We are extremely concerned with the tone of this session because it focused on payment cuts as a way to solve the problem of self-referral. You suggested that you are wary of recommending sweeping solutions to the problem of self-referral (such as bans) because the problem consists of a toxic combination of self-referral, fee-for-service (FFS) payment, and the mispricing of services. You went on to explain that recommendations designed to be solutions to selfreferral could damage organizations such as integrated practices. As we have said to MedPAC in past correspondence, the ACR strongly disagrees with the assertion that mispricing of imaging services has driven the increase in utilization and that these services may still be overpriced. Further, we provided MedPAC with extensive comments and analysis to show how previously rapid growth in utilization of diagnostic imaging has been significantly tempered. In fact, since 2007, the only segment of growth in imaging services involves imaging by nonradiologist physicians who self-refer. The ACR applauded the June 2010 MedPAC report which noted that any recommendations to control growth in imaging should include critical review of the current services exempted under the in-office ancillary exception (IOASE) with recommendations to severely limit and/or regulate the practice of self-referral. In the months leading up to the February 2011 MedPAC meeting the ACR had been encouraged by the amount of time and analysis devoted to this issue by MedPAC staff and the Commission, and fully anticipated a workable solution would be offered. Instead, we are now discouraged by the unwillingness of MedPAC to definitively and directly address the self-referral problem. Rather, MedPAC has offered draft recommendations that are nothing more than a continued commentary on the misperception that imaging services

2 are overpriced and that self-referral of advanced imaging will cease if prices are lowered. We view this as ignoring the role that physician ownership plays in skewing clinical decision making and increasing utilization of imaging services. We also are dismayed that the February 2011 recommendations fail to address an issue on which the ACR and MedPAC agree: self-referral has no relationship to patient convenience. In fact, MedPAC staff is aware that current literature largely refutes any validity of patient convenience as a justification for self-referred services since numerous studies, including one in the December 2010 issue of the journal Health Affairs; indicate that significantly less than 15% of studies are performed within a same day office visit. The vast majority of patients are not receiving their imaging studies on the same day as their office visit, so patient convenience is not a consideration, nor is it a defensible argument to support self-referral of advanced imaging. The draft recommendations that were presented and discussed on February 23 rd are very similar to the options that were presented in the June 2010 report; therefore, we must reiterate and reemphasize that payments for imaging services have been cut significantly over the last five years and will continue to be reduced until Even before the enactment of the Deficit Reduction Act in 2005, which dramatically decreased payment for the technical component of imaging services beginning in 2007, the growth in total volume of advanced imaging services had plateaued. Further imaging payment cuts have resulted from changes that CMS made to practice expense (PE) payments including changes to the PE methodology, application of underrepresentative Physician Practice Information Survey (PPIS) which is currently under a four-year transition, an increase in the equipment utilization assumption and the expansion of the multiple procedural payment reduction across families and modalities. In addition, the Affordable Care Act (ACA) increased the contiguous body parts reduction from 25% to 50% in a non-budget neutral manner. Reductions in payment for physician work have also taken place through extensive bundling of services through the Five Year Review process. Despite these years of payment cuts, significant growth in self-referral continues. Facilities, or in-office imaging, where referring physicians have a financial interest can, and have, overcome reductions in payment through increases in volume. This evidence is compelling and should be more than sufficient to dispel the notion that reducing the price of advanced imaging studies will eliminate self-referral. The ACR feels that restricting ownership of the advanced diagnostic and therapeutic modalities is the central and most important remedy to address self-referral and significantly reduce inappropriate utilization. To this end, the ACR offers the following comments regarding the MedPAC Draft Recommendations on improving payment accuracy and the appropriate use of ancillary services. Draft Recommendation 1: The Secretary should request that the RUC and the CPT editorial Panel accelerate and expand efforts to combine discrete services into single comprehensive codes; and develop a bundled payment system that includes multiple ambulatory services furnished during an episode of care. The ACR participates fully in both the RUC and CPT processes and we have already had many of our services bundled. There is no fast track to doing this. Instead, the process is complex and requires extensive analysis and deliberations. Outcomes have shown that there is no one size fits all. Determining how services are packaged and bundled must be done on a case-bycase basis to determine which services, when performed together, comprise a distinct episode of

3 care and which services performed on the same day actually represent unique episodes or events. This function is best served by the expertise represented in the CPT Editorial Panel. Furthermore, the valuation of any bundled services, like of all the other medical services, depends on physician surveys, specialty society review and recommendations and RUC deliberation and valuation. Further, the ACR believes that packaging and/or bundling of services as a mechanism to create incentives to use ancillary care more efficiently is not the best option to deal with inappropriate self-referral. In fact we strongly believe that any financially motivated conflict of interest has no place in an integrated service (Accountable Care) model. As stated in previous comments, packaging and bundling of services are complex issues that are best implemented once Medicare and providers begin operating in an integrated services environment. In fact, the June 2010 MedPAC Report acknowledges that until that goal is achieved, these concepts need to be carefully analyzed before they are put into place. Draft Recommendation 2: Congress should direct the Secretary to apply Multiple Procedure Payment Reductions (MPPR) to the physician work component (of the Physician Fee Schedule) in addition to the technical component. The ACR does not believe that Congress should be directed to apply the MPPR to the physician work component. In fact, there is no justification to apply MPPR to the physician work component and in 2010, CMS decided not to extend its expansion of the MPPR on the technical component to physician work. We maintain that there are few, if any, efficiencies in the physician work component (PC) when two or more interpretive studies are furnished to the same patient by the same physician, whether they involve contiguous or non-contiguous body areas, the same or different modalities, or single or multiple sessions on the same date of service. Each imaging study produces its own unique and extensive set of images that must be interpreted in their entirety, separately dictated and communicated in separate reports to the referring physician. The 2009 GAO report referenced by MedPAC mischaracterizes potential savings based on duplication of pre-service and post-service work. The GAO equates less intense pre-service and post-service work with more intense intra-service work, which dramatically overstates the potential efficiencies. This flaw in the understanding of the valuation of physician work in the MPFS casts doubt on the validity of the entire GAO report. Finally, in order to make its case, the GAO used potential savings from CT abdomen and pelvis as a rationale for blanket reductions. For a number of reasons, this code pair, performed together 90% of the time, had some definable overlap in both pre-service and post-service work, as well as overlap in anatomic coverage of these particular contiguous anatomic areas. This factored into the RUC s decision to lower the intensity of the combined examination versus the single body region examinations. This anatomic overlap is not possible in other situations such as when examinations of the shoulder and knee are performed in the same patient or when different modalities such as CT and US are used. In our opinion, the CT abdomen-pelvis code pair, along with myocardial perfusion imaging (MPI), both of which were recently bundled by the RUC, represented an unusually high t level of efficiency that could possibly be attained when two examinations are interpreted together.. For other examinations performed together, intraservice duplication is exceedingly rare and duplication of pre-service and post-service work is highly variable and almost never 100% as suggested by the GAO. The ACR supports the RUC s position that services performed together should be evaluated on a code by code basis, as was

4 done for the aforementioned CT abdomen / pelvis and myocardial perfusion studies, and that across the board reductions that put expediency ahead of equity and quality are inappropriate. Finally, we believe that the search for efficiencies should continue to be under the jurisdiction of the Relative Value Scale Update Committee (RUC). The ACR has always and will continue to work diligently and cooperatively in the RUC process. Draft Recommendation 3: Congress should direct the Secretary to reduce the work component payment for imaging services (and other diagnostic tests) that are ordered by the same physician. The ACR does not believe that Congress should determine the value of physician services. The AMA/Specialty Society Relative Value Scale Update Committee (RUC) makes annual recommendations to the Centers for Medicare and Medicaid Services (CMS) on the value of physician services and has the experience and expertise to provide a fair and accurate assessment of the current value of services offered across the various medical specialties. This is a lengthy, complicated process based on extensive data analysis, which is reviewed by peer experts in reimbursement and the practice of medicine, with ultimate decisions based on relativity in physician work. Any process that selectively revalues snippets of the Physician Fee Schedule or provides for different physician payments for the same service has the potential to disrupt and damage the entire relative value scale on which physician payment is based. Additionally, policy makers are well aware of behavioral changes resulting in utilization increases when payments are reduced. The continued growth in non-radiologist, self-referred imaging studies in the face of declining reimbursement supports the thesis that self-referrers will maintain their income by increasing their volume. Draft recommendation 4: Congress should direct the Secretary to establish a prior authorization program for physicians who exhibit a significantly higher utilization rate of advanced imaging services as compared to their peers. The ACR does not support a prior authorization program targeted at those physicians who selfrefer because we believe it would be quite simple for those physicians to circumvent authorization requirements and perpetuate the unsustainable cost of self-referral of advanced imaging. We feel the Congress should support efforts to assure appropriate utilization of advanced imaging services by mandating the use of radiology order entry systems by all referring physicians. These systems include integrated clinical decision support derived from transparent and collaboratively developed national professional associations appropriateness criteria. In the Medicare Physician Fee Schedule, physician payments for advanced imaging modalities have been the focus of payment reductions both legislatively and through the regulatory process for several years. These payment reductions are making it increasingly difficult, even impossible, for many radiologists to keep their offices and freestanding imaging centers open in an environment of steadily increasing practice costs. We have noted that many freestanding imaging centers have been bought by hospitals and, as transitioned physician payment reductions are fully implemented, we expect this trend to continue or escalate. When non self-referral outpatient offices are owned by hospitals, examinations performed at these facilities will be paid

5 under the HOPPS, which is currently, and will continue to be, at a higher level than the MPFS. Further cuts to MPFS advanced imaging payments, in a misguided attempt to mitigate selfreferral, will only accelerate the migration of radiologist office practice to the higher cost hospital environment and further encourage the self-referred advanced imaging volume to increase. This is a classic lose-lose strategy. Despite the dramatic payment reductions over recent years, the volume of imaging has remained generally constant. This fact underscores the fallacy of pricing as a cure for self-referral. The vast majority of imaging volume is generated by physicians who have no financial self-interest, and are not influenced by the price of the exam. In fact, based on recent Medicare spending data, the growth of spending for imaging is congruent with that demonstrable for the rest of medicine. Ironically, when fully implemented, the draconian payment reductions for advanced imaging in the Physician Fee Schedule will result in a significant shift in site of service from independent facilities to hospitals where Medicare costs are higher and advanced imaging accreditation is not mandated. Additionally, there will be access issues and significant increases in wait time for some beneficiaries in many locations. Given the reimbursement cuts and supervision requirements, many independent centers will not be able to remain open, which will limit beneficiary access to certain advanced imaging services such as MRI, especially in rural and other underserved areas. In closing we ask that you give our comments careful consideration. We too are concerned about inappropriate utilization and conflict of interest in ownership, and we therefore urge the Commission to choose the only effective, immediate and rational solution: recommend that Congress modify the current language of the in-office ancillary exception (IOASE) to exclude CT, MR, PET, and radiation therapy from the definition of ancillary in the Stark laws and regulations. Sincerely, John A. Patti, MD, FACR Chairman, Board of Chancellors Cc: Bibb Allen, Jr. MD, FACR Chairman, Commission on Economics Paul Ellenbogen, MD, FACR Vice Chairman, Board of Chancellors Harvey Neiman, MD, FACR Chief Executive Officer MedPAC Commission Members Mark E. Miller, PhD Executive Director James E. Matthews, PhD Deputy Director

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