February 2012
Improved Expertise in Determining Relative Value for Geriatrics and Care Coordination Services: News from the RUC
At the American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) meetings in Tucson, Arizona last weekend, a long sought goal was finally attained. Geriatrics now has a PERMANENT seat at the RUC table. The RUC is the deliberative forum where all medical service codes are ascribed a relative value and thus it has a major impact on Medicare reimbursement. The RUC reviews newly defined codes sent to it by the AMA’s Coding and Procedure Terminology (CPT) committee and is also charged by the Centers for Medicare & Medicaid Services (CMS) with periodically reviewing existing codes to prevent “value drift” caused by new methodologies, new therapeutic techniques, or new practice patterns. There have also been three “Five Year Reviews” during the history of the RUC where most of the codes have been re-adjusted to maintain a professionally logical “hierarchy.”
Until now, the only way Geriatrics could vote in this process was to be elected to one of the two rotating internal medicine seats available for a two year term. The make-up of the RUC has been heavily weighted with permanent seats occupied by the surgical specialties – outnumbering the cognitive specialties about 2:1. Of course, members of the committee “take off their specialty hat” when deliberating and voting on the proposed changes in the relative values of codes, but there has been some criticism recently that perhaps there was not enough representation from non-procedure based practices. To that end, the RUC has allocated a new permanent seat at the table to the American Geriatrics Society (AGS). Over the 20 year plus history of the RUC, AGS has been periodically elected to a rotating seat and has been a staunch ally bringing forward the concerns and interests of those physicians who provide cognitive medical services to the elderly such as the AMDA membership. Last year, AGS was invited to submit a formal request to the RUC Administrative Subcommittee to be given a permanent seat to represent the unique complex medical care of the elderly. AMDA whole-heartedly supported this request since there is no possible way our more limited specialty would ever be afforded such an opportunity.
The RUC and the CPT Editorial Board has in addition committed to delivering coding and valuation improvements to better describe and recognize care coordination services. The Chronic Care Coordination Workgroup (C3W) was created to address this issue, and AMDA will be serving on this group. As a further commitment to the concept of care coordination as an area of expertise needed by the RUC, a rotating Primary Care seat on the RUC has just been created as well, the net effect of having this and the geriatric representative seats will be to have better expertise in determining the relative values of services for caring for frail elders.
AMDA, through its membership on the AMA RUC Advisory Committee, will continue to work with other organizations to advocate for our membership and our patients. This is a partnership that has led to such successful outcomes as the complete re-vamping/re-valuing of the Nursing Facility codes reflecting the continuing trend toward higher complexity, the establishment and re-valuing of the Discharge Day codes, the re-defining and re-valuing of the Assisted Living and Housecall codes and now the establishment of a newly proposed set of codes to address Counseling and Coordination of Care.
Return to Top
Fixing the SGR – An Update and A New Solution
In late December, Congress put a two month patch on dealing with the sustainable growth rate formula (SGR) and with each short term patch scheduled Medicare physician payment cuts get steeper and the cost of payment reform continues to grow. Five years ago, the SGR formula could have been repealed for less than $50 billion, but today, the cost is just under $300 billion. In another five years, the combined cost of short term patches and accumulated SGR debt will reach $600 billion.
The American Medical Association (AMA), along with other medical organizations has recommended a three-pronged approach. First, eliminate the SGR immediately. Second, provide five years of stable payment updates, which would allow physicians to plan, invest, and provide time to develop and test new payment models. Third, there needs to be a “phase-in” of multiple payment and delivery models. The major stumbling block to achieve all this is still off-setting the current cost of a full repeal. A new possible solution has recently been proposed in the form of the Overseas Contingency Operations (OCO) funding. This was the source of funding for the temporary two month patch, and many are now calling for it to be the permanent solution.
The OCO funding refers to the discretionary funds for the wars in Afghanistan and Iraq and similar activities. OCO funding levels are established each year in the Department of Defense Appropriations Bill. Because OCO funds are discretionary and subject to annual appropriations, the Congressional Budget Office (CBO) assumes that OCO will be funded at the current year’s level for each of the next ten years when estimating OCO expenditure over the ten year budget window. Even though operations in Iraq and Afghanistan are winding down and are expected to continue to wind down significantly in the coming years, CBO cannot downwardly adjust its estimate for OCO spending over the next ten years until the next (FY 2013) Defense Appropriations bill is passed. This week, the CBO estimated that the OCO would save $838 billion of ten years. The CBO says that keeping physician payments rates at their current level for the same period of time would cost $316 billion, up from the previous estimate of just under $300 billion. Meaning, there are still plenty of war savings left that could be used to pay for fixing the SGR.
The CBO issued their report just one day before congressional leaders met again in conference to publicly negotiate how to pay for either a temporary fix or actually repealing the SGR permanently before the February 29th deadline, which ends the two month patch.
Many see the OCO as an appropriate offset for eliminating the SGR. CBO scoring conventions require it to unrealistically assume that Medicare physician payments will be cut by approximately $290 billion over the next ten years. Members of Congress routinely state that cuts of this magnitude would destroy Medicare and should not be implemented. Bills to temporarily halt the cuts have become routine. Nonetheless, the CBO is required to assume that the cuts will occur because Medicare law requires them to happen absent Congressional intervention. The cost to repeal the SGR actually represents money that has already been spent due to temporary SGR patches passed by Congress that were not fully paid for. Using the OCO baseline as an offset for the SGR baseline essentially amounts to “cleaning up the books,” by eliminating bad fiscal policies and allowing for a more accurate accounting of future government expenditures without increasing the deficit. OCO provides a unique and time‐limited opportunity to resolve a problem that has been a burden to patients, physicians, and to Congress for many years. Passing up this opportunity means that Congress will have an even more costly problem to resolve in future years, requiring even more difficult choices. Bipartisan support for this concept is starting to develop, and the AMA, along with others including AMDA, are trying to continue to build this support for a permanent solution to the SGR problem.
Return to Top
One Year Report on CMS Innovation Center
On January 26, the Center for Medicare & Medicaid Innovation (Innovation Center) held the Care Innovations Summit. As part of this summit, the Centers for Medicare & Medicaid Services (CMS) released a report describing the work of the Innovation Center during its first year in operation. It includes a reference chart of initiatives undertaken by CMS including programs such as accountable care organizations and bundled payments for care improvement. The report indicated that during the first year efforts were focused on improving patient safety, promoting care that is coordinated across health care settings, investing in primary care transformation, creating new bundled payments for care episodes, and meeting the complex needs of patients that are dually eligible for Medicare and Medicaid.
To view the report visit: http://innovations.cms.gov/documents/pdf/CMMIreport_508.pdf
Return to Top
HHS Launches HIT Challenge To Improve Care Transitions For Hospital-Discharge Patients
On January 26, the National Coordinator for Health Information Technology announced the Discharge Follow-Up Appointment Care Transitions Challenge. It is designed to spur innovations in HIT and empower patients and caregivers to better navigate and manage a transition from a hospital.
To learn more visit: http://www.hhs.gov/news/press/2012pres/01/20120126b.html
Return to Top
|