ACC Corner: Medicare Payment, Health Reform Driving Need for Cardiology to Get Tough

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 - Jack Lewin, MD
Jack Lewin, MD

Based on surveys distributed throughout 2009, the ACC estimates that nearly half of private practice members have sold their practices to become employees of hospital systems, with many more heading in that direction. The cuts in payment for cardiovascular services included in the final 2010 Medicare Physician Fee Schedule (MPFS) have forced the hands of many practices struggling to remain viable.

The college is in the process of surveying how members feel about this trend, but we are hearing anecdotally from those with experience as hospital-employed physicians. Many are optimistic, citing more predictability and stability, while others have raised concerns about loss of autonomy and limited control over ancillary services. This may vary from facility to facility and doctor to doctor, but it’s amazing what a dramatic effect a single policy has had on cardiology practices and patients in one year.

A preview of the proposed 2011 MPFS indicates it does not include any egregious policy proposals on the scale of those included in the 2010 rule, and while there were some positives, cardiology will continue to feel the downstream impacts of the 2010 policies.

Among the residual impacts is a 2 percent cut for cardiology as a result of the second year phase-in (of four) of the AMA Physician Practice Information Survey (PPIS). The cuts to myocardial perfusion imaging were not phased-in, so the proposed RVU is nearly identical to this year. CMS substantially reduced the payment for myocardial perfusion imaging in 2010 by reducing both the physician work value and the practice expense value. To make matters worse, because there was a new code for the service, CMS did not apply the four-year transition of the practice expense cuts and instead used the fully implemented value.

New for 2011, CMS proposed some changes to the technical underpinnings of the RVUs, including reallocating the shares of total physician fee schedule payments for each of the RVU components—physician work, practice expense and malpractice expense. Under the proposal, all practice expense and malpractice RVUs would be adjusted slightly upward to reflect data showing that practice expenses and malpractice expenses have grown relative to physician earnings. Since the entire payment pool must remain budget neutral, this would require a downward adjustment to work RVUs, but CMS proposes instead a small decrease to the conversion factor to maintain stable work RVUs. CMS projects that the effect of the reallocation will be neutral for overall cardiology payments.

The proposed rule also includes CMS' estimate of the 2011 conversion factor based on the flawed sustainable growth rate formula and does not reflect the six-month patch signed into law in late June. Congress will have to act again to prevent the 2011 cuts, currently estimated at 6 percent on top of the 21.5 percent cut that must be averted before Dec. 1.

Without real payment reforms, the trends that started last year are likely to continue. There may still be time, however, for a resurgence of physician leadership in this evolving future. Patients would still support this. To do it properly, we will need real leaders within the government, insurance companies and hospitals that can head the charge and guide the way to needed change that is patient centered. The ACC and other societies have an opportunity—and a duty—to get more involved. 

We don’t want to be victims. Society will be better served if we can avoid becoming ensnarled in the issues that separate and instead come together around our shared goals. We can’t afford to blow this opportunity as a profession. There are paths to more positive outcomes, particularly when it comes to physician payment, and we need to get tough and figure out how we will protect private practices, academic and hospital-based practices and all cardiovascular care in this unbelievably difficult environment for doctors, care teams and patients.

Dr. Lewin is CEO of the American College of Cardiology.