Making sense of the huge Medicare reimbursement cuts in electrophysiology

What caused the large CMS reimbursement cuts in cardiac ablation?

Jones said the cause of the significant cuts was the rapid rise in ablation procedures over the past decade, which doubled between 2013 and 2023. He said this is due to better screenings for patients that are catching more patients with arrhythmias. The ablation procedures themselves also have greatly improved as mapping and ablation technology has advanced quickly over the past 10-20 years. He said this greatly increased safety and efficacy, reducing the number of repeat procedures needed to terminate arrhythmias.

"But those improvements in outcomes came with the use of more equipment. CMS realized we were using things like 3D mapping in the majority of cases and they wanted to bundle these codes. CMS also looked at RVU surveys that showed procedure times have gotten faster. We understand that, but we feel there are flaws in their methodology," Jones said. 

He said cardiologists understand why CMS made these deep cuts, but the reductions cannot be made just on time spent on a procedure alone. When CMS looks at the relative value units (RVU), Jones aid it is supposed to be based on multiple factors that the HRS and ACC do not feel were considered.

"We don't feel they considered the training that goes into this, and electrophysiology has the longest training of any subspecialty. RVUs are also supposed to take into account the technical skill, the complexity, the mental effort, and all of those things have really gone up, even as the times have come down. The complexity of these cases have ramped up much more, and CMS did not consider that at all. They do not understand that these procedures are actually harder now. We are operating on a beating heart and incorporating all those things, and you need to account for that, and you cannot just do it on a time basis. It is not a one-to-one linear relationship," Jones said. 

He also noted that some of the comparators used by CMS were flawed.

CMS is required to work with a fixed budget, Jones explained. This Congressional mandate for "budget neutrality" necessitates that as the number of patients being treated increases, Medicare payments overall need to be reduced to balance the CMS budget. This policy can be changed, but only through Congressional action to change the law.

Cardiac ablation is becoming a front-line standard of care

As more evidence showing the benefits of ablation has been released in recent years, it has turned into a front-line therapy among EPs.

"Anytime you have a procedure that is more effective, safer and has more patients getting diagnosed, higher volumes are just going to happen. The number of ablations are going up and they will continue to go up. But, that is only going to happen if we can get appropriate reimbursement. And that is really the message we wanted to send to the payers and to Congress, that you cannot cut us like that. I don't know of anyone that can take a 40% cut in their main procedure and think that it is ok," Jones explained. 

He pointed to the example of AFib ablation, which has grown in recent years because outcomes from these procedures have improved so much. 

"Over the past 10 years, the procedures have continued to get better and better. That is only going to continue if we push the envelope, and you have got to be able to pay for the technology," Jones said.

Lower Medicare payments may lead to issues with patient access to care

Jones said the message various medical societies have sent to Congress is that the constant annual cuts in reimbursements will at some point impact access to care. 

"We are now having our older physicians looking at 40% cuts and they are just retiring. We are seeing this as part of the Great Resignation ... they say, 'I'm out of here,' and that is not good," he said. 

Combine this with the fact that significant cuts may keep trainees away from a career in EP and it shows how, yes, patient access could be in trouble sooner than later. 

There has been great emphasis placed on health equity in recent years, as COVID magnified the great disparities between upper and lower socio-economic groups and especially lower-income minority populations. At the same time, partly through increased screening efforts to balance health equity in communities, more minorities are being diagnosed with AFib. But, Jones said if the number of EPs decreases and the subspecialty appears unattractive to new doctors, there will always be a shortage of qualified EPs in lower-income, minority and rural healthcare settings. He said it is important to make sure there is a pipeline of new physicians coming into EP, especially since there is a national physician shortage, and that shortfall is increasing each year.

CMS and the U.S. healthcare system are facing major issues

HRS and ACC are among hundreds of medical societies that have signed onto letters to CMS and Congress asking for Medicare Payment reform and to have their physician members involved in those discussions. Most of these physician groups say the current path of just lowering payments each year is absolutely not sustainable to treat Medicare patients in the long run. 

This issue is combined with the fact that healthcare spending now makes up close to 20% of the the U.S. gross national product and it continues to rise, which also is not sustainable. The rising costs are also being questioned because most westernized countries spend much less than the U.S. per capita and their overall healthcare outcomes are much better than that of the high-cost U.S. system. These statistics are pointed out by leadership from most medical societies, and were highlighted at several cardiology conferences by keynote speaker U.S. Food and Drug Administration Commissioner Robert Califf, MD, who also is a cardiologist.  

Read more about Califf's message on the U.S. healthcare system

One of the issues with the current U.S. payment system is that payers often look at the short term and are not looking at the long-term impacts of some procedures. Jones said ablation is a good example where if patients do not under go a procedure, they will be in and out of hospitals, ERs and physician offices for years, often to manage acute episodes and their arrhythmia will be treated as a chronic condition. However, if an ablation can greatly lessen the symptoms or eliminate the arrhythmia, the downstream costs for that patient will be much lower in the long run. 

Some attempts to manage healthcare costs have had negative impacts on care and even on cost containment. One of the biggest issues has been with the rapid rise in prior authorizations, which often delay treatment and cost physicians and hospitals a lot of money because of the additional time clinicians spend on the phone, typing emails and sending documentation. In many cases, hospitals have needed to hire additional staff to process all that is involved with jumping through all the hoops to get a prior authorization. Jones said Medicare Advantage programs are among the worst offenders, with large numbers of prior authorizations that usually delay or prevent tests and treatments that a patient's doctor says the patient needs.

"That patient-physician relationship needs to be sacred, not based on a decision by some administrator who really does not understand this," Jones said. "We need to get back to that. We need comprehensive reform of the entire system, because the things that we are doing now just not working."

Over the past 15 years, there was a lot of pressure, including incentives and reimbursement penalties, for hospitals, clinics and physician offices to migrate to electronic health records (EHRs). This was designed to boost workflow efficiency and aid patient care by providing immediate access to patient information, which was partly aimed at reducing the number of repeat tests because prior results were not easily accessed. However, the efficiencies envisioned have not lived up to real-world implementations where physicians and other clinicians now spend a large amount of time entering or reviewing data in the EHR, rather than working directly with patients. 

"We see that the EHRs are costly, but not actually always giving us what we need," Jones said. 

Another issue related to EHRs is that data collected is now used to generate quality metrics in all areas of healthcare system operations, and to rate the quality of care being delivered by each clinician. "We see tons of quality metrics are being thrown at us all the time and we are graded on those, but the metrics do not always do what they are supposed to, and we also need reform for that," Jones said. 

He noted that there is waste in the healthcare system that does need to be tracked down and eliminated. But looking to cut costs should not be at the expense of the value physicians offer. 

Solutions that may help cut costs in cardiology

Jones said the heart team approach to treating cardiac patients has been expanding outside of decisions about transcatheter vs. surgical heart valves, or surgery vs. stents to now include all cardiac patients in some hospital systems. This could greatly aid earlier identification and prevention of some cardiac issues, including arrhythmias and heart failure. Having a team approach also would make patient handoffs of patients much easier and seamless in the care continuum. 

Another way to increase efficiency and enable clinicians to do more with less is by leveraging new technologies. This includes use of IT solutions for more seamless integration of things like remote patient monitors and implantable devices, use of AI to help watch patients or to speed workflow or offering a second set of eyes or opinion for the doctors, smarter natural language processing, or smart reporting software that can pull important data points from procedure logs to complete reports in near real time. Telehealth is another area that can help change how patients are followed up and help make increasing workloads easier to manage.

"If you look at the expo floor here at HRS, there are a ton of new innovations, and that is how we are going to do it," Jones explained.