ACC: Fee schedule remains a thorn in cards' side

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CHICAGO—Changes to the physician fee schedule have overturned practices, leaving some private practice physicians running for cover at nearby hospitals. The future of the physician fee schedule and the changes linked to it remain a mystery, said Cathleen D. Biga, RN, president and CEO of Cardiovascular Management of Illinois, during a presentation March 25 at the 61st annual American College of Cardiology (ACC) scientific session.

“With the stroke of a pen your life has been changed very quickly,” Biga said. “One of the drivers for integration is this fee differential.” It will be imperative that private practices avoid integrating for the wrong reasons, as “these fees can change at any time,” she said.

She noted the two different fee schedules—physician schedules and DRGs (inpatient components). Everyone is competing for the cap in the RVUs (relative value units), Biga noted.

“The SGR [sustainable growth rate] is so broke and they keep kicking it down so far that I I’m not sure how it is ever going to get fixed,” Biga noted. “Each piece of this fee schedule does impact you … it continues to evolve and sometimes does change in the middle of the year.”

Two major components in the fee schedule exist: the technical component (technology, costs of equipment, etc), and the professional component or the “brain power for performing procedures and providing care,” she said.

“So you say, why do these fees keep changing every year?” Biga said that the Relative Value Scale Update Committee (RUC) has a lot to do with these changes, as parts have been bundled, Current Procedural Terminology (CPT) codes have changed.

In fact, she noted reimbursement for an echocardiography test was $230 in the office setting in 2005 and $156.17 in 2011 (technical, in-office costs in Chicago). For reimbursement for stress echo, in 2012, practices received $227 vs. the $580 received by hospitals. And for nuclear scans, practices received an estimated $504 vs. the $850 received on the hospital side.

“But we need to make sure we compare apples to apples,” she said. She noted that these services should all be bundled the same way. These profit margins vary widely and “they keep getting ratcheted down. The question is, are these hospitals' overheads that much more to account for this large differentiation?”  

Biga said whether the fee schedule will survive and what the overall picture of payment reform will look like in the future remains a mystery. “There is no doubt … the fee schedule is very complex," she summed.