Medicare Cuts Are In Effect: Congress Needs to Respond
CMS Releases Final Rule on Interoperability and E-Prior Auth
AAO-HNS Leads Letter in Opposition to Federal Scope of Practice Legislation
Rheumatologists, Providers, and Patients Seek Improvements in Exchange Policy Proposals
A Journey Through Interventional Echocardiography (Specialty Spotlight)
Medicare Cuts Are in Effect
Congress Needs to Respond
On November 2, 2023, The Centers for Medicare & Medicaid Services (CMS) released its calendar year 2024 final rule for the physician fee schedule. The rule, which went into effect on January 1 of this year, cut physician reimbursement by 3.4%. This is the 4th straight year that physicians will have to endure a cut. By contrast, most of the other Medicare providers will again anticipate sizeable increases in their 2024 payments (e.g., inpatient hospitals (3.1%); inpatient rehabilitation facilities (3.4%); hospices (3.1%); hospital outpatient departments (2.8%); and Medicare Advantage plans (3.32%)).
Labor prices, rent, medical equipment, and supplies have increased rapidly over the past several years. Inflation impacts physician practices as much as it affects other Medicare providers, but the Medicare Physician Fee Schedule (MPFS) is the only Medicare payment system that lacks a mechanism to reflect annual inflation.
Medicare reimbursement volatility has system-wide impacts. One such consequence is that the increasing financial pressure on physicians continues to result in them being forced to sell their practices to larger, better-resourced entities. According to an American Medical Association survey of physicians, horizontal or vertical practice integration is driven by the need to reduce administrative burden and associated costs, improve access and lower the cost of needed practice resources, and improve negotiating power with private plans.[1] Consolidation remains a concern due to its impact on program spending. For example, recent research shows that hospital outpatient department charges can be more than double for the same service in the office setting.[2] Potential Medicare savings resulting from payment parity between the two settings have been predicted by the Congressional Budget Office (CBO).[3] Additionally, MedPAC has observed that “Physician–hospital integration, specifically hospital acquisition of physician practices, has caused an increase in Medicare spending and beneficiary cost-sharing due to the introduction of hospital facility fees for physician office services that are provided in hospital outpatient departments. Taxpayer and beneficiary costs can double when certain services are provided in a physician office that is deemed part of a hospital outpatient department.”[4]
Thus, a domino effect results from Medicare’s reimbursement instability for physicians: fewer physicians participate in the program, more physicians are forced to sell their practices, and as noted above, costs for both the program and beneficiaries increase due to consolidation. This dynamic directly impacts access to care, especially for low-income beneficiaries and those living in rural or underserved areas.
Despite the physician community’s persistent advocacy to stop these cuts from going into effect, Congressional response to this cut has been slow. While the various committees of jurisdiction have passed or are considering bills to reform Medicare physician reimbursement, there has been no consensus on a way forward to alleviate or reverse the cuts, which are now in effect. The timeline by which the Medicare program processes claims for payment meant that physicians did not feel the impact of the reduction right away in the new year. However, once the program began sending out payment for services provided in January, reimbursements began to reflect the reduction – and will continue to reflect it, unless and until Congress acts to reverse the cut.
To that end, Congress is negotiating a bipartisan package of health policy provisions with the goal of having that ready by the March 8 deadline when a new batch of federal spending bills must be passed. Reversing the MPFS cut is on the table as one of the provisions that could be included in that package. If that happens, Congress may seek to avoid the expensive and complicated process of reprocessing claims from January and February. This could mean that a potential fix might not be retroactive and could instead provide a larger increase for the remaining ten months of the year. Whether this package comes together remains questionable, as there is a large list of other healthcare priorities to be negotiated, including pharmacy benefit manager reform, mental health funding, certain Medicaid policies, and more.
[1] https://www.ama-assn.org/system/files/2022-prp-practice-arrangement.pdf
[2] EBRI Issue Brief No. 525: “Location, Location, Location: Cost Differences in Health Care Services by Site of Treatment — A Closer Look at Lab, Imaging, and Specialty Medications” by Paul Fronstin, Ph.D., Employee Benefit Research Institute, and M. Christopher Roebuck, Ph.D., RxEconomics, LLC (Feb. 18, 2021).
[3] See, e.g., Congressional Budget Office cost estimate for H.R. 5378, the Lower Costs, More Transparency Act, section 203 (“Parity in Medicare Payments for Hospital Outpatient Department Services Furnished Off-Campus”).
[4] MedPAC, March 2020 Report to the Congress, Chapter 15 (“Congressional request on health care provider consolidation”).
CMS Releases Final Interoperability and E-Prior Authorization Regulation
The Centers for Medicare and Medicaid Services (CMS) released its final rule on advancing interoperability and improving prior authorization processes. The regulation 
would impose new requirements aimed at enhancing the electronic exchange of healthcare data and improving prior authorization processes. Provisions in the final rule apply to Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the Federally Facilitated Exchanges. The rule requires impacted payers to implement an HL7 FHIR Patient Access application programming interface (API), a provider access API, a payer-to-payer API, and a prior authorization API. It also includes provisions to require impacted payers to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests, to provide a specific reason for denied prior authorization decisions, and to publicly report certain prior authorization metrics on an annual basis.
The regulation also adds a new “Electronic Prior Authorization” measure for Merit-based Incentive Payment System eligible clinicians and hospitals, including critical access hospitals. The regulation was praised by the congressional champions of the Improving Seniors’ Timely Access to Care Act, who stated that the regulation will “make a big difference in helping seniors access the medical care they are entitled to without unnecessary delays and denials.” Rep. Suzan DelBene (D-Wash.) explained that although the rule addresses many of the things that were in the bill, there are areas where CMS “could have gone further, especially in terms of speed of decision-making.” She and the other bill sponsors plan to review the final rule and “see what else we can do legislatively to not only solidify and codify what is in the rule but also look at what we can do to try to increase the speed of responses.”
Reform of the Prior Authorization process has been a priority of the Alliance of Specialty Medicine for several years, and they participated in a CMS-led roundtable that examined documented abuses in the system and prevented patients’ access to timely care. The Alliance looks forward to working further with Congress on this issue.
AAO-HNS Leads Letter in Opposition to Federal Scope of Practice Legislation
Earlier this month, the American Academy of Otarlaryngology-Head and Neck Surgery spearheaded a letter to Congress signed by 111 physician organizations that stated our strong opposition to legislation that would 
inappropriately expand the scope of practice for audiologists and threaten patient safety. The Medicare Audiology Access Improvement Act of 2023 (S. 2377 / H.R. 6445) would reclassify audiologists as providers under Medicare and put seniors at risk by undermining physician-led team care. Our letter stresses that bypassing a physician evaluation of hearing loss can result in failure to treat reversible causes of hearing loss or inappropriate treatment that could cause lasting harm and increased costs to patients. The Academy strongly believes that physician-led team care is the best approach for providing the highest quality care to patients and will continue to oppose this legislation as it undermines this important principle.
Rheumatologists, Providers, and Patients Seek Improvements In Exchange Policy Proposals
Last year, the Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) issued its 2025 Notice of Benefit and Payment Parameters (NBPP), which proposed changes to plans established by the Affordable Care Act (ACA), commonly referred to as Exchange or Marketplace plans. Some of the proposed changes addressed network adequacy, the provision of essential health benefits (EHBs), prescription drug benefits, and non-standardized plan options, among other things.
The Coalition of State Rheumatology Organization (CSRO), independently and as part of the Alliance of Specialty Medicine (ASM) and the All Co-pays Count Coalition (ACCC), urged the Agency to better protect access to specialty drugs for consumers in Exchange plans, highlighting emerging challenges with “alternative funding” practices that may diminish access. All three groups also urge the Agency to provide enhanced oversight when it comes to non-standardized plan options in the health insurance marketplace based on concerns that such options might further hinder access to care for those with chronic and high-cost conditions and to ensure specialty and subspecialty providers are able to join and remain in Exchange plan networks. Read more of our letters linked below.
A Journey Through Interventional Echocardiography
Contributed by Varun Khanna, MD, Oklahoma Heart Hospital, Oklahoma City, OK
My dad always told me to keep an open mind when it came to choosing my specialty. This showed the foresight of an astute physician and caring father because it gave me the room to pursue the new and exciting world of interventional echocardiography. Fast forward nearly 20 years, and I find myself entering my eighth year as an 
interventional echocardiographer and general cardiologist at a large cardiology practice in the middle of the country.
As a CCU resident at Beth Israel Deaconess, I took care of patients enrolled in the CoreValve trials in the post-procedural setting and witnessed near-immediate improvement in their symptoms. By the second month of my general fellowship at Boston Medical Center, I knew I wanted to be an echocardiographer. I spent the next three years cultivating that interest and building a strong foundation of knowledge. I was fortunate to be accepted as an advanced echocardiography fellow at Columbia, one of the largest structural heart programs in the country. During that year, I was exposed to an incredible volume and variety of cases and pathology. We were involved in transcatheter-based interventions using the few FDA-approved devices at that time but also with multiple other devices that were under investigation. Working with Dr. Hahn and the valve team, there was the opportunity of a lifetime, one that solidified my decision to become an interventional echocardiographer while also providing me with a fund of knowledge that has shallowed my learning curve for the newer devices I have encountered since finishing fellowship. While I spent that year honing my TEE skills with my attendings and co-fellows, my training was just the beginning, especially in a relatively new and rapidly moving field. The foundational skillset I acquired during fellowship was crucial to my future plans.
As I approached graduation from my fellowship, interventional echocardiography was emerging as a burgeoning clinical need, one no longer confined to large academic centers. So, when the call to return to family tempted me to look for a job in my hometown of Oklahoma City, I was fortunate to find a large, forward-thinking private practice at the Oklahoma Heart Hospital. This, I knew, was an ideal fit for my desired career path, and I started to negotiate in earnest a contract, one that was as novel to them as it was to me fresh out of fellowship.
My vision was to have general clinical practice but also a predominant role as an imager involved in diagnosis, evaluation and treatment of valvular heart disease. We quickly agreed on an arrangement that directly reimbursed me for the time I spent with the valve team and being the medical director of the echocardiography lab while also supporting my clinical practice with productivity-based model. This was a great start, one that has allowed our institution to nearly double our transcatheter valve procedure volume since I began and expand from the left heart to the right heart, all while supporting excellent transcatheter outcomes. We did not step out of our comfort zone; we expanded our comfort zone.
To this day, contract negotiation remains a challenge for new interventional echocardiographers, as many institutions do not have precedent to lean on. My negotiation was a smooth process as we shared a vision for my role in the hospital. Interventional echocardiographers should be reimbursed for their time, especially given the anticipated increase in volume and complexity of these cases.
With the number of new devices entering the market, we need flexibility in our schedules to attending device trainings and conferences in order to maintain our ability to support these procedures moving forward. We will increasingly find ourselves caught between our responsibilities at our institutions providing imaging support for scheduled cases and our duty to evolve and learn about new devices and the techniques needed to ensure safe and successful interventions in the future. Over the years, I have attended both in-person and virtual conferences in addition to live device trainings. I especially enjoy webinars put on by my fellow interventional echocardiographers that explore the intricacies of imaging for these complex interventions and the newer devices. I am also excited to see how the ASE Interventional Echocardiography Council continues to grow as there is a need to have advocacy for our small and important community.
We are a small sect of cardiologists, whose colleagues are increasingly relying on our expertise in the pre- and intraprocedural settings. As transcatheter-based therapies grow, institutions will need to adapt and consider hiring interventional echocardiographers to ensure that these transcatheter-based procedures are adequately covered by individuals with the necessary training. Our expertise is needed and our time is valued.
Keep an open mind. I’m glad I did.
This article was originally published in Echo Magazine
