Reimbursement challenges raising concerns in cardiology

How does the RUC process impact cardiology funding?

The American Medical Association. (AMA) established the Specialty Society Relative Value Scale Update Committee (RUC) in 1992. This expert panel of physicians makes recommendations to the federal government on the resources required to provide medical services. The recommendations are based on the amount of physician work required, including the time and intensity associated with a service, clinical staff time, supplies and equipment, and professional liability insurance associated with performing the service. 

Biga said the RUC process governs the zero-sum gain distribution of Medicare funding across the house of medicine. This helps Medicare determine how to divide up money between all specialties, from dermatology to cardiology, each year in a way that does not increase the the costs or available funding for the Centers for Medicare and Medicaid Services (CMS). 

The information provided to CMS is based on data collected using RUC surveys sent to physicians for feedback. However, response to these surveys is often very low. Biga said part of the reason for the low response rate is that these surveys are "extraordinarily complicated." She said 

Even if true costs of delivering care are reflected in RUC surveys, the pot of Medicare funding is finite and and more medicare patients enter the system each year, so the slices of pie for all specialities continued to shrink over all each year. Without increases to the Medicare budget, or efforts to cut costs on the provider side, Biga said the result is going to be Medicare payments often do not cover the actual costs of providing diagnostic or therapeutic services to patients. Biga said there is no easy answer on how to solve this issue.

"We have to take some baby steps into who we are going to solve this, because we cannot sustain it and we know Medicare is going to go broke," Biga said.

How ACOs and bundled payments are supposed to help keep Medicare solvent 

Medicare is attempting to innovate with new ways to try and bundle payments for episodes of care and moving away from fee-for-service payment models that reward providers for doing more tests and procedures. Under bundled payments, Medicare gives a hospital a flat payment to diagnose a patient who presents in the ED with chest pain, for example, and it is up to hospital to figure out the most efficient and cost effective way to diagnosis the patient. The same would be true with a flat payment if the patient then moves on to the cath lab for a percutaneous coronary intervention (PCI). Under bundled payments, the hospital has incentive to figure out how to lower costs of the procedure so the hospital can keep more of the payment dollars. This includes motivation to find new ways to lower readmission rates and reduce complications that can greatly increase patient care expenses.

Another CMS approach is the creation of accountable care organizations (ACOs). These are groups of doctors, hospitals and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending fewer healthcare dollars, the ACO will share in the savings it achieves for the Medicare program.

Biga said the ACC has concentrated efforts on education, such as sessions at ACC that focus on guidelines. This helps ensure the appropriate tests for the right patient at the right time are ordered to help cut down on multiple tests being ordered that drive up the costs of care. She said that is a first step to help drive down cardiac care costs.

Preventive cardiology care is rarely reimbursed

A large portion of patient encounters and care in cardiology is reactive to cardiac events and treating a problem that has taken years to develop. Cardiology has been moving toward a larger roll in prevention of heart disease, but spending time with patients to prevent cardiac events does not pay as well as treating these patients for acute cardiac care episodes. Biga said this is also a problem, because it is hard to put large amounts of effort and staff time into prevention efforts when it does not pay the bills.

"Part of the bottom line is that it is rarely paid for, and that becomes a problem for everybody," Biga explained. 

She said advocacy efforts are also needed to educate legislators on the state and federal level about roles of the entire cardiology care team in reducing healthcare costs and that funding should be allocated to these non-diagostic and non-therapy areas. 

"Our pharmacists, dietitians, social workers, hospital palliative care all need to be a part of our team, but are not paid for. They can reduce readmissions, they can extend patients' lives and can keep patients compliant with their skill sets, yet we can't get them paid, so advocacy is absolutely very important," Biga explained.

Another issue ACC and other medical societies want to try and address is increasing patient compliance with doctor's orders regarding preventive efforts, such as taking statins, blood pressure medications, to stop smoking, increase exercise and changing diet. 

"Our patients also need to be with us. We need to have compliant patients watching their blood pressure, BMI because obesity is a big issue, hyperlipidemia continues to be a big issue, that is where we need all of society to come together," Biga said. 

New technologies can help save lives and potentially lower costs

Biga said new technologies may play a big role in lowering healthcare costs and improving patient outcomes. This does not always need to be some major breakthrough technology. She point to the success of automated external defibrillators (AEDs) in dramatically increasing survival in sudden cardiac arrest patients. The success has led to AEDs now being available almost everywhere in society, including aircraft, schools, malls and the convention centers where ACC is held.

Telehealth programs and wearable monitoring systems also can play a roll in cutting costs, simplifying care and improving outcomes. 

Another key example she gave was the development of minimally invasive transcatheter heart valve devices that are replacing or augmenting open heart surgeries that were performed with very invasive open heart surgery just a few years ago. For example, transcatheter aortic valve replacement (TAVR) was first approved for use in the U.S. in 2012, and in just a decade it now makes up more than 84% of aortic valve replacement procedures. She said transcatheter technologies are now moving into mitral and tricuspid valves. 

She said vendors that have developed TAVR and other valve technologies, as well as hundreds of vendors with new technologies on the ACC expo floor, have devices that improve patient care, improve quality of life expectancy. However, these new technologies all come at a cost, and patients cannot benefit from these advances unless insurance and Medicare pays for them. In some cases, changes in payments are very slow for new technologies that can improve outcomes and reduce costs. Examples include paying for tests or procedures that have been used for years as a standard, while newer technologies might be more efficient and lead to the same, or better, outcomes with reduced hospital stays or help reduce the need for additional tests.

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