CMS's proposed physician fee schedule stokes concern in interventional cardiologists

Due to a lack of data, CMS has proposed blending the non-surgical and surgical malpractice factors used in rate setting for cardiology procedures—a possibility met with alarm by interventional cardiologists, who perform riskier procedures and pay higher malpractice premiums than general or non-invasive cardiologists.

“It was out of left field,” said Dawn Gray, the director of reimbursement and regulatory affairs for the Society for Cardiovascular Angiography and Interventions (SCAI). “I at first thought it was a clerical error, that they made a mistake.”

In a call to action to its members, SCAI said CMS’s 2018 Medicare Physician Fee Schedule Proposed Rule would result in an approximate 10 percent reduction in reimbursement for all interventional procedures. In addition to requesting support from the American Medical Association and American College of Cardiology (ACC), SCAI urged its members to comment to CMS and recommend a “crosswalk” to the surgical malpractice factor for cardiac surgery.

CMS will issue its final physician fee schedule rule in November. Before then, a spokesperson said, CMS is unable to comment on any aspects of the proposed rule.

Surgical risk factors, which are tied to malpractice reimbursement, are calculated in relation to the least “risky” specialties. For example, allergists and speech language pathologists have a factor of 1.0 in the current proposal, while cardiac surgeons have a factor of 6.87.

The codes for cardiology procedures have previously been assigned risk factors like those performed by cardiac surgeons, but the 2018 proposed rule doesn’t reflect any difference in risk between surgical and non-surgical work. The “cardiovascular disease (cardiology)” category contains a 1.80 risk factor across the board, despite including some invasive procedures.

In comments to CMS, the ACC pointed out this would reduce cardiology’s surgical malpractice factor by 73 percent, down from 6.98 in 2017.

“This would inexplicably apply a lower surgical risk factor to procedures performed in and on the heart by cardiologists than to procedures performed elsewhere in the body by other specialties,” the ACC wrote. “The ACC opposes this change and recommends CMS apply a crosswalk from the cardiac surgery risk factor of 6.87 to the cardiology surgical risk factor. This would appropriately differentiate the more than three-fold difference that exists in premiums between an office-based cardiologist who manages patients medically and interprets cardiovascular imaging and an interventional or electrophysiologic cardiologist who performs risky procedures in/on the heart.”

The ACC provided CMS with examples of how payments would be reduced for specific interventional procedures based on the new proposed malpractice relative value units. For transcatheter closure of atrial septal defect, the 2018 payment would be $926.72 versus $1,021.75 this year—a 9.3 percent decrease. For revascularization during acute MI, the year-to-year reduction would be greater than 10 percent, from $695.52 to $624.97.

“It’s a nice example of SCAI and the American College of Cardiology working hand in hand for the benefit of patients and physicians,” said Jim Blankenship, MD, former president of SCAI and a practicing interventional cardiologist at Geisinger Medical Center in Danville, Pennsylvania. “Since any decrease in reimbursement tends to decrease access, this to some extent represents a threat to access to patients to get the procedures done. If we are successful in getting this proposal reversed, we will have struck a blow for maintaining patient access for these procedures.”

In the proposed rule, CMS explained it received sufficient data for differentiating surgery and non-surgery premiums for 10 out of 86 specialties. Cardiology wasn’t one of them.

“During the 2015 update, CMS’s contractor collected data regarding major surgery premiums for cardiologists in 41 states,” the ACC wrote. “Three years later CMS’s contractor was only able to collect data in 12 states. The ACC urges CMS and the contractor to work with ACC and other societies to better understand the data it does have and to identify new sources that may be useful in improving this flawed dataset.”

Gray said SCAI has also offered to work with CMS in pursuit of more complete data. The society’s leaders participated in a call with CMS on July 24 and are optimistic their concerns will be addressed when the final rule comes out in November.

“They’re very tight-lipped during the open comment period … but what they were willing to share with us is that historically the recommendation of appropriate crosswalks has been well received by CMS and they have taken action on those recommendations,” Gray said.