SPECT Imaging: Surviving the Reimbursement Cuts
Anticipated fearsA survey conducted in November 2009 by the American Society of Nuclear Cardiology (ASNC) of its members found that more than one-third of rural respondents believed they would be forced to close if the cuts (proposed at the time) became a reality and 23 percent reported they would be forced to turn away Medicare patients. Overall, 94 percent of respondents said they would most likely have to reduce staff including nurses and technicians, 80 percent said they would need to cut benefits, 67 percent would elect to retire earlier than planned and 97 percent said they believed the hospital setting would experience an increase of Medicare patients at the expense of private practices.
“We are hit with a perfect storm from the government,” says ASNC President Mylan C. Cohen, MD, from Maine Cardiology Associates in South Portland. “If you add up the cuts to SPECT and other cardiac imaging, such as echo, coupled with an unreasonable sustainable growth formula, depending on how one calculates it, the reduction in reimbursement could be up to 50 percent.”
Echocardiography and nuclear cardiology are equally essential tools to practicing cardiologists, Cohen says. Both modalities have years of documented validity regarding diagnosis and prognosis of cardiac pathology. “When practices begin to lose money on these services, it will be difficult for many to continue to offer them,” he says.
Shift to hospitalsWithin the last five years, 30 percent of outpatient practices have been purchased by hospitals, according to Leslee J. Shaw, PhD, professor of medicine at Emory University School of Medicine in Atlanta, Ga. Because of the payment cuts in the 2010 MPFS, Shaw expects more SPECT imaging to migrate to the hospital setting, which requires higher out-of-pocket expenses for patients.
As this migration takes place, many patients who once depended on local cardiology facilities will have to travel farther, sometimes 10 to 20 miles more, to a hospital setting. “Transportation will become an even more critical issue for Medicare patients,” says Shaw.
The cost of operating an office-based nuclear cardiology lab is already high—coupled with payment cuts, keeping these labs open will be a challenge, says Dennis A. Calnon, MD, director of nuclear imaging at MidOhio Cardiology and Vascular Consultants in Columbus, Ohio. Calnon’s practice was recently purchased by a hospital system. “The economic pressures—increasing costs in the setting of decreasing reimbursement—were the motivations for our decision. We came to the conclusion that the private practice of cardiology was no longer a viable option in today’s healthcare environment,” he says, adding that such a decision would have been “unthinkable” five years ago.
|Paying for Quality Healthcare Pays Off|
|CMS has touted the success of several of its demonstration projects, also called value-based purchasing, which provide incentive payments to physicians based on the quality of care they provide and the estimated savings they generate in Medicare expenditures. |
In the Hospital Quality Incentive Demonstration, for example, participants raised overall quality by an average of 17 percentage points over four years, based on their performance of more than 30 nationally standardized and widely accepted care measures for patients in five clinical areas—heart attack, coronary bypass graft, heart failure, pneumonia and hip and knee replacements. CMS has awarded nearly $40 million to top performers thus far.
In the first three years of the Physician Group Practice Demonstration, providers increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 congestive heart failure measures, six points on seven coronary artery disease measures and one point on three hypertension measures. CMS has awarded nearly $33 million so far to providers, with approximately $25 million going to the top five physician groups.
In the first year of the Medicare Care Management Performance Demonstration, CMS has awarded nearly $8 million to more than 560 practices based on 26 quality measures. An additional bonus is paid when practices report the data using an EHR.
Survival strategiesCohen’s group has 21 cardiologists in three different locations and for now, the practice is conducting business as usual, waiting to see how they can weather the storm before taking any drastic measures. “If you start to lay off staff, you may create a situation where you irreversibly impact the field. I would suggest that people exercise caution,” he says.
But layoffs have already started. “We have an administrator for cardiology diagnostics and unfortunately had to cut her time to 20 hours. That was our first move. Out of the 10 cardiologists in our overall division, we had to lay off one of our patient liaison physicians,” says Gregory S. Thomas, MD, from Mission Internal Medical Group in Mission Viejo, Calif.
Shaw outlined a few options for helping the bottom line. Practices can participate in Medicare demonstration projects (see sidebar) or they can work with private payors to identify appropriate candidates for testing using approved appropriateness criteria, thus reducing denial time and administrative work.
PET reimbursement is more robust than SPECT and some practices might want to consider cardiac PET as an option. However, not everyone can shift to PET, says Thomas. “PET has some advantages, but the cost to perform the test is twice as much. For most patients, you don’t need a test that costs twice as much.” Besides, reimbursement for PET could go up and down as well by as much as 40 percent in a particular year, Thomas says.
The numbers don’t lie, Thomas says. “SPECT imaging is one of the reasons why we have a decrease in mortality in cardiac disease—about a 30 percent drop in the last 10 years and even higher in the last four years.”
While ASNC and the American College of Cardiology (ACC) are fighting the reimbursement cuts via several different avenues, Shaw and Thomas agree that individual practitioners also have to take part in the fight. This means contacting Congress and CMS and letting them know how much the patients value the current imaging tests as a means to provide quality care. Both ASNC and ACC offer means to contact the government on their respective Web sites. “We need to be heard until CMS provides a better strategy to get appropriate reimbursement for physicians providing any type of imaging,” says Shaw.