DOTmed.com – Medicare reimbursement reform clears first hurdle

Medicare reimbursement reform clears first hurdle

by Sean Ruck, Editor-In-Chief
On July 31 the House Energy and Commerce Committee banded together across party lines to unanimously pass the Medicare Patient Access and Quality Improvement Act of 2013. The Act will serve to repeal and replace the Medicare Sustainable Growth Rate program put into place in 1997.

The MSGR, which is used to determine and update physician payments for Medicare reimbursement, is typically updated every year, but since 2010, Congress has continually put this off, extending and altering reimbursement plans causing confusion and uncertainty among physicians.

With the passing of the new Act, the House and Commerce Committee have given medical professionals something to feel optimistic about. One of the benefits to the new plan is the standard reimbursement reduction it will put into place. The plan will ramp down reimbursement at a set amount each year, rather than the wildly shifting rates seen year-to-year. For example, cuts estimated to be above 25 percent were supposed to go into effect on January 1, 2013. However, those cuts never happened, with Congress enacting an extension to again push them off until January 1, 2014.

So although it’s not a resounding win for the industry (reimbursement cuts will still happen) the ability to plan for the inevitable has been seen as a positive. The proposed shift will also set into motion the migration from the fee-for-service health care system currently in play and begin to link physician payments to quality metrics and patient outcomes. “So it’s introducing a new era for how physicians will be reimbursed in the future,” Cynthia Moran, assistant executive director for the American College of Radiology, told DOTmed News.

Still, it’s not a done deal. “This is the first step in a multi-step process,” said Moran. “The Ways and Means Committee may have its own bill, or may decide to just modify the existing bill. Then the same holds for the Senate Commerce Committee.”

Moran says the ACR is particularly pleased about two provisions included in the bill. The first addresses the payment disparity that came out of CMS’ payment policy, regarding the interpretation of multiple images on a given patient, calling for a 25 percent reduction in reimbursement. “The provision calls on CMS to produce the data to justify this policy change,” said Moran.

The second provision introduces the concept of decision support utilizing computerized decision making tools as a means of potentially controlling the utilization of advanced imaging studies. “These tools are embedded with appropriateness criteria developed by physician groups, such as ACR,” said Moran.

The tools will help instruct referring physicians about which imaging studies they should order for their patients based on symptoms presenting and should help to curb unnecessary exams and help to defend better reimbursement rates for studies which are ordered.

Moran said that the current move after years of congressional stalling is in large part due to the reduced cost of health care. “The estimate for a permanent fix for the SGR is half that of previous estimates. Traditionally, it’s been about $300 billion and it’s now about $140 billion,” she said.

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