By Tom Little, MD, FSCAI
MedPAC Report
The Medicare Payment Advisory Commission (MedPAC) released its March 2018 Report to Congress regarding Medicare payment policy. Among other things, the report includes MedPAC’s recommendations for how Congress should update payment rates in fee-for-service (FFS) Medicare for 2019. These “update” recommendations—which MedPAC is required by law to submit each year—are based on an assessment of payment adequacy that examines beneficiaries’ access to and use of care, the quality of the care they receive, the supply of providers, and providers’ costs and Medicare’s payments. For 2019, MedPAC is recommending that the payment rates for acute-care hospitals (inpatient and outpatient services) and for physicians and other healthcare professionals should be updated by the amount determined under current law, which is projected to be 1.25 percent and 0.25 percent, respectively.
MedPAC included stress tests and PCI for stable coronary disease as possible “low-value care,” which is defined as either a service that has little or no clinical benefit or care in which the risk of harm from the service outweighs its potential benefit. In this section of the report, MedPAC highlighted measures with the highest volume and highest spending, stating that “those with the highest Medicare spending were percutaneous coronary intervention with balloon angioplasty or stent placement for stable coronary disease ($1.3 billion), spinal injection for low back pain ($1.3 billion), and stress testing for stable coronary disease ($1.2 billion).”
The MedPAC report revolves around the Commission’s recommendation to eliminate the Merit-Based Incentive Payment System (MIPS), which measures individual clinicians in traditional Medicare on a set of measures that they choose.
MedPAC’s reasoning behind this recommendation was that “MIPS is premised on the assumption that Medicare can measure and pay for quality at the level of the individual clinician, but a system built on that assumption will be fundamentally inequitable for two reasons: (1) clinicians will be evaluated and compared on dissimilar measures, and (2) many clinicians will not be evaluated at all, because as individuals, they will not treat enough Medicare beneficiaries to produce statistically reliable scores.”
Because of these reasons, MedPAC is proposing a Voluntary Value Program (VVP), which would require providers to self-organize into groups that would be collectively responsible for patient outcomes and costs. The groups would be rewarded based on performance on population-based measures, measuring quality based on mortality and readmissions.
Discussion noted:
- The Committee could provide economic data that shows the cost savings that counter the claim of “no value.”
- The Committee can also provide information on the benefits for quality of life.
- MedPAC believes that registries are beneficial at the local level, but we have also seen benefits at the national level.
- The Committee will convene a working group to provide data regarding cost savings and clinical benefits to counter the “no value” recommendations for stable PCI and possibly for other procedures.
The SCAI Advocacy Committee will convene a workgroup focused on developing messaging promoting the value of interventional cardiology procedures.
Proposed Survey of Regulatory Burden of OUS Members
Cardiologists working in the United States have over 200,000 pages of government regulations. This regulatory burden is excessive and increases the costs of healthcare in the United States. A proposed SCAI survey of international cardiologists to determine the regulatory burden in their countries was approved.
The SCAI Advocacy Committee reviewed the proposed survey questions. Once the Committee approves the survey, the survey will be sent to the SCAI International Committee for review and comment. SCAI Quality and International Committees will ask for volunteers to form a workgroup to finalize the survey and develop a document summarizing the results.
CPT Update
The Proposal for Pericardial Drainage was submitted to the American Medical Association in February 2018. There are some questions regarding imaging, and resulting data noted that imaging is done by another provider or the imaging varies as in cancer centers where they are using CPT or for post open heart procedures where a U.S. probe over the incision from the procedure would be painful to patients.
The Committee is also drafting a proposal for Venous Access pVAD Placement and has convened a workgroup for a proposal to Develop Restructuring of Congenital Cath Codes, ACC-SCAI CPT-RUC. Also, the Committee is developing a CPT proposal seeking a revision to modifier -63.
Regulatory – Hospital Outpatient Prospective Payment System (HOPPS) DCBs
The hospital outpatient new technology add-on payment for Drug-Coated Balloons (DCBs) expired in 2018. Some have expressed concern that the current Ambulatory Payment Classification (APC) assignment will not sufficiently cover the cost of the device, potentially thwarting access to this technology. Last year, SCAI submitted comments to CMS regarding the DCB APC assignment, recommending CMS reconfigure the APCs for cardiovascular interventions to provide the necessary granularity to support differentiation of SFA procedures performed using a new class of devices (DCBs) from SFA procedures performed using PTA with non-DCBs.
Industry stakeholders have taken the lead in modeling possible reconfigurations of the endovascular APCs to allow for a differentiation in reimbursement between DCBs and traditional balloons. They have presented a proposal to CMS to reconfigure the existing APCs from 4 to 6 buckets, creating two new APCs for endovascular procedures. SCAI has been advised that the Renal Physicians Association is submitting an alternative recommendation to CMS. The SCAI Advocacy Committee will be monitoring these developments closely to assess the impact to all the procedures in these APCs that may be positively or negatively impacted.
SCAI has submitted four nominees for consideration to serve on CMS’s HOPPS Advisory Panel.