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
legislative strategy to prevent even the 5-7% average cut in January and in particular
reverse the nuclear/stress cuts.
More Important Background
My insider friends in
Congress and the Administration communicated with me later on Friday by e-mail
that CMS as of 2 weeks ago had intended to follow the advice of 90% of
specialties and physicians who wanted them to implement the Rule as originally
proposed, but that ACC and cardiology convinced them not to do that. It’s
important to note that. Our advocacy
efforts have had major effects. We also need to understand that the ‘Phase
In’ affects all doctors, meaning that even the
specialties that were due to get big increases get only one-fourth of that in 2010.
The College was certainly not asleep at the wheel this week
or over the horrific last months of dealing with this. The ads placed last week caused
quite a bit of scurrying around in the White House and in HHS, we’re certain.
We clearly didn’t burn bridges with the White House with the ads, but we got
everybody’s attention. Without these and other efforts, the President wouldn’t
even know anything about the cuts today, and the Secretary would only vaguely
be aware of such details. They’re aware now.
The Congress and the Administration are used to hearing exaggerated
claims and hyperbole. That’s what they likely still think about our admonitions
about the coming unintended consequences of these cuts. Actually, they need to know
that a lot of damage has already been done in anticipation of the rule.
Many practices already are shifting from community-based private practice to
hospital ownership. This means the very essential infrastructures of cardiology
practice, including echocardiography and stress testing, will soon be
reimbursed at two to four times what they cost Medicare in the outpatient
setting (hospitals have secured much higher payments for these same services).
Cardiology overall costs, currently 43 percent of Medicare, will go up (not
down!) as a result. And, because hospital outpatient services will still be
considered Part B Medicare in most instances, this will also cause a rise in
beneficiary premiums in 2010, something the administration will regret.
General internal medicine has already undergone a massive
shift from community practice to hospital employment as “hospitalists.” The same will be true of this federally fueled transition -- it will
severely hurt prevention and chronic disease management and most likely
adversely affect morbidity and mortality in CV disease -- until a new
hospital-based infrastructure can be developed to pick up the access gaps. Even
so, in rural and non-urban America,
this ill-fated policy will mean patients will have
to drive long distances to wait in long queues in hospital clinics to get the
care they need. So disturbing.
Keeping Focused
Both Health and Human Services and the White House are 100
percent focused on the health care reform rapid developments over the past
weeks, and no doubt the ramifications of the 2010 payment rule won't get to the
top of their priority list until its unintended consequences start to manifest
in January, UNLESS WE BRING IT TO THEIR ATTENTION NOW. WE NEED TO SAY THE CUTS MUST BE REVERSED, AND
ACT TO MAKE THAT HAPPEN.
This will be exceedingly difficult because the impending SGR
reversal will be the top priority for all of Congress and all of medicine. Our
issue will be hard to promote without a well orchestrated full court
press.
Next steps
All
the cardiology specialty societies need to come together and put some
legislation on the table to block implementation of the Rule until validated
data can be obtained. One strategy to get this done might be to attach our
“fix” to the SGR legislative proposal. A better way would be to
have a separate vehicle I think -- and we might have more luck achieving this if
we combine our effort with one that accelerates getting real assistance to
primary care as well. This would take the pressure off holding up the
implementation of the Rule’s increases for primaries.
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). ***
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