FEATURE STORY
 
Beyond SGR, Specialty Docs Come to Washington with a Major Goal Already Achieved.
 
This summer, the Alliance of Specialty Medicine will gather in Washington for it's annual Fly-In having accomplished one of their highest legislative priorities – the repeal and replacement of the sustainable growth rate (SGR) in favor of a modernized Medicare payment system that accurately reflects the costs of providing care.
 
On April 16, 2015, the President signed into law H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), permanently fixing the broken SGR formula used by the Medicare program to annually update physician payments. Since the SGR's inception almost twenty years ago, Congress has had to take action 17 times to prevent deep and automatic cuts to Medicare physician payments as a result of the formula. Both the House and Senate passed MACRA with overwhelming bipartisan support.

MACRA repeals the SGR and institutes a 0.5 percent annual payment update for five years, while transitioning to a system that further incentivizes quality care. The law requires providers to receive at least 25 percent of their revenue through alternative payment models by 2019 to 2020, with the threshold percentage increasing over time. The law also consolidates the three existing quality programs – the Physician Quality Reporting System (PQRS), the Value Modifier (VM), and Meaningful Use (MU) – into one value-based performance program known as the Merit-Based Incentive Payment System (MIPS).

This legislation is the culmination of years of hard work on the part of lawmakers and patient and provider stakeholder organizations. The Alliance took an active role every step of the way in submitting feedback and providing comments on the many draft legislative proposals that eventually lead to MACRA and the permanent repeal of the SGR.

With this important policy goal achieved, the Alliance's specialty physicians and specialty society staff will use this year's Fly-In to meet with Members of Congress and staff in an effort to raise bipartisan support for ensuring affordable and reliable specialty care.

The Alliance will hear from R. Lawrence Van Horn, Executive Director of Health Affairs at Vanderbilt University Owen Graduate School of Management, who will discuss health care economics. They will also be joined by Doug Fridsma, MD, PhD of AMIA and previously of the Office of the National Coordinator for Health Information Technology. Dr. Fridsma will speak about interoperability.

The dates for the Fly-In are July 13th through 15th.
 
IN THIS ISSUE...
UPCOMING EVENTS

Physician Advisory Council Meeting: July 13, 2015, Liasion Hotel, Washington, DC

Alliance Legislative Fly In:
July 13-15, 2015, Capitol Hill, Washington, DC

NOTE: Participation in Alliance events is by invitation-only, with some exceptions. To learn more about how you or your organization can participate, please contact your organization's staff liaison to the Alliance or email us at info@specialtydocs.org.

ALLIANCE IN THE NEWS

Health Lobbyists Learn to Love Life After 'Doc Fix' CQ Roll Call.
- May 4, 2015

Modern Healthcare – “Doc Groups Lean on Lawmakers for Medicare SGR Fix.”
- February 18, 2014

EHR Intelligence – “Groups Weigh in on SGR Repeal Plans, Medicare Payment Freeze.”
- February 20, 2014

Inside Health Policy – “Specialty Medicine, Family Docs at Odds on SGR Bill's New RUC Like Process.”
- February 20, 2014

CQ Weekly – “Ending Doc Fix Won’t Be Painless.”
- March 10, 2014

CQ Healthbeat – “Opposition Gathers as House Prepares for Another ‘Doc Fix’ Vote.”
- March 27, 2014

MedPage Today –“House Delays SGR Cuts, ICD 10 for a Year.”
- March 27, 2014

CQ Healthbeat – “ ’Doc Fix’ Bill Includes Key Changes to Diagnostic Coding.”
- March 28, 2014

 
 
 
The Great Unbundling: MACRA Overturns CMS Plan to Convert 10-day and 90-day Global Services to 0-day Globals; Directs Secretary to Collect Data on Globals
 
Dale Blasier, M.D. Co-Chair, North American Spine Society Coding Committee

In the calendar year (CY) 2015 Medicare Physician Fee Schedule (PFS) Final Rule, the Centers for Medicare and Medicaid Services (CMS) finalized its plan to transform global bundles for surgical services over several years; all 10- and 90-day global codes would become 0-day global codes. After this transition, all medically reasonable and necessary visits would have been billed separately during the pre- and post-operative periods outside of the day of the surgical procedure. While CMS had finalized a transition for current 10-day global codes in CY 2017 and current 90-day global codes in CY 2018, Congress halted the implementation following a groundswell of advocacy activity by many physician groups, by including a provision in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

CMS Motivation

CMS finds several problems with the current global packages. They cite that the nature of postop visits has changed since global surgical packages were developed in 1992 and current codes do not reflect current medical practice with respect to the frequency of post op visits. Therefore, CMS is concerned that global code values do not accurately reflect the actual resources expended on the delivery of services. Given that there are no separate PFS values established for the procedures separate from the follow-up care, it makes it difficult to estimate the costs of the individual global code component services. They point out that through the global surgery packages, Medicare pays practitioners who furnish Evaluation and Management (E/M) services during post-surgery periods, regardless of whether the services are actually furnished, while practitioners who do not furnish global procedures with post-operative visits are only paid for E/M services that are actually furnished. This is interpreted to equate to preferential treatment for proceduralists over cognitive specialists.

Problems with revaluing the codes as 0 day global bundles

Many organizations have highlighted the challenges that CMS and the physician community would face in attempting to disassemble the services valued within the global surgical codes. Some services with global periods have been valued by adding the work relative value unit (RVU) of the surgical procedure and all pre- and postoperative E/M services included in the global period. These codes are valued by the so-called “building block” method. These codes may be candidates for subtracting out the postop visits from a 10- or 90-day global to value a corresponding 0-day global. However, in other cases, the total work RVUs for surgical procedures and post-operative visits in global periods are estimated as a single value, without any explicit correlation to the time and intensity values for the individual service components (including the post op visits). These have been valued by the so-called “magnitude estimation” method. These codes may be not be good candidates for subtracting out the post op visits from a 10- or 90-day global to value a corresponding 0-day global because the codes were never valued by adding the component values together to arrive at a total RVU in the first place. Because of this, there are some codes for which subtracting out the post op visits may result in a negative RVU total. The AMA RVS Update Committee (RUC) stated that there are over 4,200 services within the PFS with a 10-day or 90-day global period, so the scope of the proposal is very large for the revaluation of all these codes over a relatively short time line. Even CMS acknowledged the difficulty:

“We are considering a wide range of approaches to all details of implementation from revaluation to communication and transition, and we are hopeful that sufficient agreement can be reached among stakeholders on important issues such as revaluation of the global services and appropriate coding for post-operative care.”

Unintended consequences

In communications with Congress regarding the issue, societies in favor of halting CMS’ plan to eliminate global surgical codes, the groups highlighted that there would also be a likely problem with access to needed post op care for patients in that patients may be less likely to show up for post-op visits if they have increased financial responsibility via co-pays. This is a problem of both patient access to and financial burden for medically necessary and appropriate care. Currently, patient cost-sharing for surgeries with global codes is limited to a single co-pay for the surgery and all related post-op visits. By eliminating the “global period” CMS would have been requiring patients to be responsible for a co-pay for the surgery as well as an additional co-pay for each subsequent post op visit, potentially creating an incentive for patients to refrain from seeking necessary post-operative care from their physicians. In addition, there would be increased administrative burden for physicians in having to submit claims for not only the surgery but for each underlying post op visit. In summary, had CMS been allowed to implement their proposal, would have had significant impact on current practices with concerns for patient access, physician documentation, administration, and reimbursement.

Congressional Action

In its drafting on H.R. 2, the bill to permanently repeal and replace the Sustainable Growth Rate or SGR, the House of Representatives inserted a provision which reverses the CMS decision to eliminate the bundled payment for surgical services that span a 10 and 90-day period. However, the provision does requires CMS to periodically collect information on the services that surgeons furnish during these global periods, beginning not later than 2017, and use that information to ensure that the bundled payment amounts for surgical services are accurate. This means some practices will be subject to a reporting burden for this data, although the breadth of the sample CMS will select and the type of information requested has not yet been announced. Also of note, the provision allows the Secretary of Health and Human Services (HHS) to delay a portion of payment for services with a 10 and 90-day global period in order to incentivize reporting of information needed to assess the accuracy of the global payment amounts. The Secretary can also cease the collection of information from surgeons once the needed information can be obtained through other mechanisms, such as clinical data registries and electronic medical records. This legislation passed the House on March 26th by a vote of 392 to 37 and the Senate by a vote of 92 to 8.

President Obama signed it into law on April 16th as the Medicare Access and CHIP Reauthorization Act of 2015.

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SPECIALTY SPOTLIGHT
Echocardiography Hosts Forum on Value-Based Care
 
Last fall the American Society of Echocardiography Education and Research Foundation (ASEF) gathered leaders from across the healthcare spectrum in the nation's capital to offer a variety of unique perspectives on the transition to value-based healthcare, with a focus on the role of cardiovascular ultrasound, specifically echocardiography, in the changing environment. Speakers at the Value-Based Healthcare: Summit 2014 included U.S. Congressman Jim Cooper (D-TN); Thomas Graf, MD, Chief Medical Officer for Population Health and Longitudinal Care Service Lines for Geisinger Health System; Amol Navathe, MD, PhD, Managing Director at Navigant Consulting and Co-Editor-In-Chief of the first peer-reviewed journal focused exclusively on delivery science and care redesign; and many others. Summit participants included legislators and staffers, private and governmental payers, clinicians, patient advocates, researchers, and industry representatives.

The forum featured a variety of panel discussions and included audience interaction sessions that provided attendees and leaders with the opportunity to engage in a dialogue and to listen to all stakeholder perspectives. This first of its kind event provided a better understanding of echo's impact in both patient care and research, and the value that echocardiography brings to patient-centered healthcare. One of the highlights of the program featured a panel session with three patients whose care was directly impacted by the use of echocardiography. One of the patients had breast cancer and echocardiography was utilized to discover that her heart was being damaged by chemotherapy drugs, and this led to a direct change in her therapy and impacted her ultimate recovery.

In addition to this forum, ASEF also participated in the Care Harbor LA Clinic – a philanthropic program that prides itself on being “a destination for health and hope; a gateway to sustainable care.” Held at the Los Angeles Sports Arena, the Care Harbor LA Clinic provided free medical, dental, and vision care to the uninsured, underinsured and underserved in Los Angeles County, along with follow-up care and prevention resources. ASEF volunteers were able to provide cardiac care to some of Los Angeles’ most at-risk and underserved patients. ASEF volunteers used echocardiography to help detect heart disease. Working to provide patients across the globe with high-quality, standardized cardiac care, ASEF was proud to be part of this tremendous event ensuring that thousands of people received the care they needed.


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New Survey Shows Significant "Burnout" Among U.S. Neurosurgeons
 
Although the practice of medicine can be incredibly meaningful and personally fulfilling, it is also demanding and stressful. To this end, a new survey published in the Journal of Neurosurgery helps to shed light on factors associated with career satisfaction and burnout among U.S. neurosurgeons.

Burnout, defined as "emotional exhaustion, depersonalization, and a decreased sense of accomplishment" has been linked to an increase in medical errors, a decrease in patient satisfaction, and early retirement among physicians.

To investigate this issue, the authors of the survey partnered with the Council of State Neurosurgical Societies (CSNS) to transform a previously published pilot study into a national online survey. The American Association of Neurological Surgeons (AANS) then sent out the updated survey to their membership, which was designed to assess neurosurgeons’ career satisfaction, as well as factors associated with "burnout." Nearly 800 neurosurgeons, or one-quarter of AANS members, responded.

The majority of those responding were mid-career surgeons ages 40-60, who were married, had children and were in a stable relationship. The good news: 81 percent voiced satisfaction with their career and 70 percent stated that they would make the same career choice if they had it to do over again.

The bad news: nearly 60 percent of survey respondents voiced symptoms of burnout in their professional lives. Only 16 percent of respondents felt that their professional life was likely to improve in the future. The factor most associated with career satisfaction included "striking a balance between work (the majority of neurosurgeons work 50-70 hours per week) and home life."

The following key factors associated with burnout where identified by the survey:
  • Uncertainty about the changes brought forth by healthcare reform;
  • Demands of taking emergency call; and
  • Anxiety over future earnings;
This survey, one of the largest to address career satisfaction among physicians, documents higher rates of burnout among neurosurgeons than has been recorded in other healthcare subspecialties in the past. The most important takeaway from this survey is that it's the first to highlight the impact that healthcare reform and regulation is having upon neurosurgical practitioners in our country. Furthermore, and much to neurosurgeons’ dismay, it illustrates that healthcare has turned into an industry, forcing physicians to comply with a growing list of burdensome and unnecessary regulations, rather than focusing on patient care.

This post originally appeared on Neurosurgery Blog which is a product of The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). It was authored by Frederick A. Boop. MD, a neurosurgeon from Memphis, Tennessee.

Reference:
McAbee, JH, Ragel BT, McCartney S, Jones GM, Michael LM II, DeCuypere M, et al: Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg [epub ahead of print February 13, 2015] DOI: 10.3171/2014.12.JNS141348.

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ALLIANCE SPONSORS
 

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Join the most powerful group of specialty physicians!
 
Joining forces with specialty doctors from across the country helps amplify the concerns specialty doctors share. By working together, specialty medical organizations can work more effectively to influence health care policy and ensure our primary goal: to continue to provide our patients the optimal care they need. As a part of the non-partisan umbrella organization representing all of specialty medicine, your organization will:

  • Promote specialty specific issues as part of a larger coalition, increasing visibility and understanding of issues.
  • Help increase exposure for specialty medical care.
  • Gain access to insider information, background materials and research on health policy initiatives and the political landscape.
  • Receive expert analysis on proposed legislation
  • Caucus with other specialty organizations at the AMA House of Delegates and other forums to promote key issues that are important to specialty physicians.
  • Coordinate physician and patient grassroots efforts through a large and robust network.
  • Participate in future Alliance Fly-In events in Washington, D.C. Past events have included Capitol Hill visits and presentations by health policy experts.
For information on joining the Alliance of Specialty Medicine, visit our website at www.specialtydocs.org or contact Vicki Hart at vhart@hhs.com

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