On April 14, 2015 the Senate voted 92-to-8 to approve legislation previously passed by the House that puts an end to the SGR-based physician payment formula for Medicare services. At posting time, President Obama said he would sign the bill. The Senate-passed measure is identical to the bill approved by the House; all amendments introduced in the Senate were defeated.
After the vote, many medical societies, including the AMA and AAOS, heaped praise on Congress. In a rare moment of brevity from Capitol Hill, Michigan Rep. Fred Upton told Kaiser Health News (KHN), “Stick a fork in it. It’s finally done.”
But according to KHN, “while the law lays out a structure on how to move to new [Medicare] payment models, much of their development will be left to future administrations and federal regulators.” And an even colder rain on the parade came in a report from Paul Spitalnic, the head actuary at the Centers for Medicare and Medicaid Services (CMS). Spitalnic’s report soberly observes that the legislation about to be signed into law “raises important long-range concerns that would almost certainly need to be addressed by future legislation.” While the bill specifies physician payment-update amounts for all future years, the CMS report says that “the specified rate updates would be inadequate in years when levels of inflation are higher or when the cumulative effect of price updates not keeping up with physician costs becomes too large.”
So while orthopaedists in the twilight of their active-practice careers may be able to “stick a fork in it,” younger surgeons may be distracted by debates about physician Medicare payments that are apt to crop up again.
Despite an overwhelming 392-to-37 vote in the House to scrap the SGR formula for physician Medicare payments, the Senate adjourned for a two-week recess without voting on the measure. Senators were distracted from taking action on the House SGR-repeal bill by a pre-recess “vote-o-rama” on other legislation, mostly budget amendments. Many in Washington expect that the Centers for Medicare and Medicaid Services will postpone Medicare payments during the first two weeks of April, essentially preventing the 21% slash in physician reimbursement set to kick in on April 1. That will buy time for the Senate to reconvene and vote on the SGR bill.
Jennifer Haberkorn of Politico Pro told Kaiser Health News that any amendments to the House-passed SGR measure that the Senate debates—such as a full “pay-for” or four years of expanded funding for the Children’s Health Insurance Program rather than two—“are unlikely to be approved, but [Senators] want to be able to make a point.” Conventional wisdom posits that the delay will not hurt the chances of an SGR repeal finally passing both chambers and being signed by President Obama.
With 12 days to spare before a 21% reduction in physician Medicare payments takes effect, a bipartisan coalition of House and Senate lawmakers introduced identical bills that would scrap the SGR-based formula for physician reimbursement. Medscape.com reported that the SGR Repeal and Medicare Provider Payment Modernization Act of 2015 would boost physician pay by 0.5% during the second half of 2015 and in subsequent years from 2016 through 2019. The legislation redesigns the Medicare payment model from fee-for-service to pay-for-performance, and it also merges Medicare’s EHR and quality-reporting programs for easier administration by providers. Later this week or early next week, the House is expected to amend the legislation to extend the Children’s Health Insurance Program (CHIP) for two more years.
For the first time in recent memory, GOP leaders in both houses are indicating they won’t insist on specifying “pay-fors” for the entire cost of the bill. While Tea Party Republicans in the House are still calling for a complete cost offset, House Speaker John Boehner could get the bill passed amid Tea Party objections if he musters enough Democratic support.
In an online statement responding to the legislative filing, AAOS President Frederick Azar, MD, said, “The AAOS commends congressional leadership for introducing legislation to permanently repeal and replace the SGR formula.”
For most physicians, HR 4302, federal legislation signed into law on April 1, 2014, was important because it delayed until March 1, 2015 drastic SGR-imposed cuts to Medicare physician payments. While many people are wondering what the next chapter of that saga will bring as the deadline approaches, tucked away in Section 218 of HR 4302 is another provision that could have far-reaching effects on daily orthopaedic practice: a Medicare requirement tying payment for advanced diagnostic imaging to appropriate use criteria (AUC).
That section of the legislation requires providers who order advanced diagnostic imaging for Medicare patients—such as CT and MRI—to consult physician-developed AUC, and document such consultation, beginning on January 1, 2017. Beginning on January 1, 2020, 5% of the ordering clinicians deemed to be “outliers” will be subject to a prior-authorization requirement.
In the meantime, the bill requires the Centers for Medicare and Medicaid Services (CMS) to issue rules for imaging AUC, “developed or endorsed by national professional medical specialty societies or other provider-led entities,” no later than November 2015. It also directs the Health and Human Services Secretary to identify, by April 1, 2016, clinical decision-support tools to help physicians navigate the appropriateness criteria.
The goal of appropriateness criteria is to encourage clinicians to practice evidence-based medicine for improved patient outcomes and to use limited healthcare resources more efficiently. But, like any “administrative” task appended to already-complex medical practices, AUC for diagnostic imaging are controversial.
To find out more about the development of imaging AUC and what this pending requirement might mean for orthopaedists, OrthoBuzz recently spoke with three experts:
David Jevsevar, MD, MBA, chair of the American Academy of Orthopaedic Surgeons’ (AAOS) Committee on Evidence-Based Quality and Value and vice-chair of orthopaedics at Dartmouth-Hitchcock Medical Center
Alexandra Page, MD, chair of the AAOS Health Care Systems Committee and an orthopaedic surgeon at Kaiser Permanente
From these interviews, three themes emerged:
- The need for collaboration among radiologists and orthopaedists in developing imaging AUC
- The potential benefits of imaging AUC
- The need for imaging AUC to be as user-friendly as possible
Development through Collaboration
The AAOS has a comprehensive process for developing AUC, but collaboration with other specialty societies is essential. Ideally, AUC are developed from a peer-reviewed evidence base, but such evidence is not always available.
Dr. Jevsevar: As much as we want AUC to be “evidence based,” there’s not a whole lot of imaging-related evidence out there. Ordering a plain radiograph of a patient who presents with symptoms of knee osteoarthritis seems self-evident and is diagnostically useful, but there’s no published evidence to support the practice. Consequently, most of the AUC already in use are based on a consensus methodology.
Dr. McGinty: The ACR’s AUC are evidence-based when there is evidence and consensus-based when there’s not. We also constantly revisit AUC in light of new evidence. When necessary, our AUC committees deploy “rapid response teams” to make sure guidelines are updated quickly and accurately.
Over the last 20 years the ACR has developed AUC for many clinical scenarios, and the process has always involved collaboration with other relevant specialties. The 24 musculoskeletal AUC that we already have established were developed in collaboration with physicians from the AAOS. Collaboration is essential because the evidence from which AUC are developed has to be representative of the specialty that’s going to use them.
Dr. Page: Cross-specialty collaboration among physicians allows us to be stronger negotiators with CMS and other large entities. My interactions with the ACR have always been with people more interested in how we can work together than in the “territorial” issues.
At Kaiser, we also collaborate with primary care doctors to establish AUC for musculoskeletal and other imaging. For example, we agree that advanced imaging is not appropriate in a primary care setting for an initial presentation of routine low back or knee pain. Collaboration helped make this an educational experience rather than an adversarial one.
Dr. Jevsevar: With imaging, interdisciplinary input is necessary for developing AUC because we all see patients through our own lenses. AAOS representation on the ACR working groups to develop AUC ensures that both perspectives are represented. The AAOS has also successfully collaborated with primary care specialties to develop AUC for diagnosis and initial treatment of distal radius fractures, osteochondritis dissecans, and knee osteoarthritis.
The putative benefits of imaging AUC fall into two main areas: improved patient outcomes and lower health-system costs.
Dr. McGinty: Institutions and health systems that have already implemented imaging AUC have shown that they reduce costs to the system, including costs related to unnecessary imaging. We also expect that patient outcomes will improve due to decreased complications from inappropriate surgery.
Dr. Jevsevar: Imaging AUC will also help physicians measure themselves transparently. It will help identify outliers who order more imaging studies than necessary. But instead of a punitive response to that, we’re aiming for an educational response: Why is someone an outlier, and what education can we provide so that person can change behaviors?
Dr. Page: The collaborative process of developing AUC in and of itself makes us better clinicians and more empowered to provide better patient care.
All three experts whom we interviewed insisted that imaging AUC will have to be seamlessly integrated into usual clinical workflows. Extra steps that are not “automatic” will be received unhappily.
Dr. McGinty: The user-friendliness of the platform is key. Ideally, AUC filters would be embedded into the EHR system so they are seamless to the clinician. Even better would be systems that automatically track clinician adherence to AUC for reporting purposes. But for all that to happen, there will have to be ongoing collaboration with EHR vendors.
Dr. Jevsevar: Any process that’s onerous will not be good for anybody. If a procedural step is pushed to doctors, they’ll be more likely to perform it than if they have to go out and get it. I like the AAOS AUC app, but even consulting that requires an additional step. I envision an EHR-based AUC tool that will initially block a doctor from ordering an imaging study that’s not “appropriate.” Or an embedded pop-up message will remind a doctor who’s about to order an MRI or CT in a specific clinical scenario what the evidence base says.
Having said that, even if AUC are seamlessly integrated into the EHR, I don’t think they should be unreasonably rigid. Almost all practice guidelines assume a “routine patient.” But we often see patients who are not routine, so AUC need to allow for flexibility. We’re all trying to find the right balance between providing the best care at the population and system levels and at the same time delivering the best patient-centered care to each individual.
By a vote of 64 to 35, the US Senate approved a one-year “patch” of the current SGR-based Medicare payment formula, rather than entirely replacing the flawed system. President Obama signed the bill, which provides a 0.5% increase in physician Medicare reimbursements for the rest of 2014.
It’s the 17th such temporary stopgap Congress has passed over the last 11 years, and it came despite staunch opposition to another short-term “doc fix” by many physician groups, including the AMA and the AAOS. When the House passed the same measure a week earlier, AAOS president Frederick Azar, MD, said he was “profoundly disappointed.”
There was a last-ditch but unsuccessful effort by Senate Finance Committee chairman Ron Wyden (D-Oregon) to get his colleagues to vote on a permanent repeal of the SGR formula. Had Congress not acted at all, a 24% cut in Medicare reimbursements would have taken effect April 1, 2014. Previous patch votes have been accompanied by congressional promises to use the reprieve to hammer out a bipartisan deal to pay for a permanent SGR repeal. That has never happened, and few are optimistic that it will happen this year.
As physicians are swallowing the bitter pill of another SGR patch, some are relieved with another stipulation in the bill: a one-year delay in the implementation of the ICD-10 code set until at least Oct. 1, 2015. The AMA recently estimated that implementing the new, more complex code set could cost small practices up to $225,000, and last July the AAOS supported a bill to stop the transition to ICD-10 so physicians could develop an appropriate alternative. Another provision in the new bill gives the secretary of Health and Human Services permission to address “misvalued codes” used in the Medicare physician fee schedule.
According to Thomas Barber, MD, chair of the AAOS Council on Advocacy, “The delay in ICD-10 implementation may provide temporary relief for some, but the importance of a permanent SGR policy together with the harmful misvalued codes provision in this patch greatly outweigh any benefits.”
Read a summary of the bill’s provisions here: http://www.massmed.org/Advocacy/Key-Issues/Medicare/Summary–Protecting-Medicare-Access-Act-of-2014/#.UzrNkqJ0lyI