The ACC Corner | Physician Fee Schedule: Whats Next for Cardiology?

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 - Vincent Bufalino
VIncent Bufalino, MD, FACC

The cuts to cardiology payment planned by the Centers for Medicare & Medicaid Services (CMS), as part of the final 2010 Physician Fee Schedule, are bad public policy. Not only that, but they represent a grave threat to cardiology practices and patient access.

The biggest cuts in the rule are related to practice expense. With the exception of evaluation and management services, nearly all services that cardiologists perform will see cuts ranging from 10 percent to more than 40 percent for individual services phased in over four years. SPECT imaging is hit the hardest with a 36 percent cut in 2010 alone. SPECT is impacted so intensely due to the bundling of two add-on codes and because the four-year phase-in was not applied.

In addition, CMS eliminated payments for consultations provided in office and hospital settings under the final rule, choosing to redistribute relative value units (RVUs) previously assigned to these codes. On malpractice, CMS chose to update the malpractice RVUs, which will reduce payments to cardiology by 1 percent, depending on the mix of services provided. CMS also finalized its proposal to change the agency’s formula for calculating the per-procedure cost of diagnostic medical equipment worth more than $1 million to assume a 90 percent utilization rate.

The final rule, of course, also includes the now-yearly sustainable growth rate (SGR) cut—an unbelievable 21.5 percent this time. As of press time, the U.S. House of Representatives had repealed this cut. The legislation, if passed by the Senate, would eliminate all SGR debt accumulated over the years because of temporary, unfunded fixes. It also would establish updates based on two new targets with significantly higher spending growth allowances than the SGR.

When the final rule takes effect at the beginning of this month, many cardiology practices will be unable to continue performing some services in the office when Medicare’s reimbursements stop covering the cost of providing care. In fact, a recent ACC member survey found that 33 percent plan to eliminate service lines once the cuts go through. In addition, 42 percent of those surveyed will have to lay off staff, and 14 percent will limit office hours as a result of the rule. Solo practitioners will be hit the hardest with anticipated cuts across the board in staff, service lines, Medicare payments and office hours.

What’s most disconcerting is that our patients also will be affected. About 13 percent of practices—17 percent of private practices—anticipate a need to reduce the number of Medicare patients. Given that about 50 to 60 percent of cardiovascular practices’ patient volume is Medicare patients, calculations reveal that at least 14 percent of the Medicare population receiving cardiovascular care would be directly impacted by the anticipated cuts.

With fewer services performed in the office—with less time and fewer staff—patients will have to receive services that were formerly performed in an office from hospitals. The consequent shift from the physician office to the outpatient hospital setting will, in many cases, more than double the costs of services. Medicare patients will feel an immediate impact from higher copayments and another impact in the near future as Medicare Part B premiums increase to cover the increased expenditures.

With cardiology as we know it endangered, the ACC has launched a massive effort to both fight the cuts and provide tools to practices to help survive in these challenging times. The odds against completely stopping the cuts are high, but everyone affected by the cuts to cardiology—physicians, patients, practice staff—must get involved in the fight for survival.