As we settle into a new congressional session, we are reminded that sometimes the more things change, the more they stay the same. With the recent presidential and congressional election behind us, we shift our focus to the implications of President Obama's re-election for the Society and its members.
As you know, there was very little shake-up or change in our country’s leadership. President Obama and his administration are in power in the executive branch for another four years and the makeup of Congress also remains the same. Yet, despite preservation of the status quo, the future of health care policy has never been more in flux than it is now.
What’s certain
The 800-pound gorilla hanging above the heads of those in policy circles prior to the most recent election was whether the possibility of a new administration meant the end of Obamacare as we know it. Any changes or a repeal of the Affordable Care Act (ACA) could have meant drastic changes as well to the practice of IR. The ACA contains a multitude of provisions that directly or indirectly affect your practice, such as the misvalued code provision, the provision on the multiple-procedure payment reduction (MPPR), the independent payment advisory board (IPAB) provision and a provision relating to self-referral laws. As it stands, all of these provisions remain in place, with most going into effect by 2014. How this will affect you and your practice will need to be determined on a case-by-case basis.
What’s uncertain
While the ACA remains the law of the land, there is still some uncertainty as we move forward with the 113th Congress:
- Physicians are still faced with uncertainty over the SGR despite the recent one-year fix.
- There are constant concerns about medical malpractice reform and whether we are any closer to a resolution now that we still have a divided Congress.
- We still face the continued crisis of the drug shortages.
Perhaps no other issue loomed larger than the proverbial “fiscal cliff” facing Congress at the end of 2012. The fiscal cliff referred to a combination of the expiration of the Bush tax cuts and the $1.2 trillion in spending cuts as a result of sequestration. As you recall, in 2011 Congress faced a crisis on whether to raise the debt ceiling. Republicans were in favor of raising the debt ceiling but did not want to pay for it by raising taxes. Democrats were considering raising taxes but insisted that entitlements not be part of the equation.
The Balanced Budget Act of 2011 was developed as part of a compromise between the two parties. This act called for an immediate spending cut of $1.2 trillion followed by another spending cut of $1.2 trillion divided evenly between discretionary and nondiscretionary spending. If Congress failed to come up with the additional $1.2 trillion in spending cuts by the November deadline, an automatic across-the-board cut would take place known as “sequestration.” Congress failed to reach a compromise and we are currently faced with sequestration.
The direct result of sequestration is a 2 percent across-the-board cut of physician Medicare payment once the deadline expires, but the bigger concern is the potential fallout from the fiscal cliff in general. Although politicians managed to avert going over the fiscal cliff and delayed sequestration for two months, there are still many uncertainties that remain. Congress addressed the expiring tax cuts and provided a temporary patch to the SGR fix but failed to address the looming debt ceiling and spending cuts, which are still part of the equation. As Congress looks for ways to cut spending, every government program is fair game and on the table. It should come to no one’s surprise that health care cuts are very much a part of this discussion. As is always the case, patient benefits will likely remain safe, but provider cuts are certainly in play.
The administration and many in Congress still feel that the best way to reduce health care costs is by practicing preventative medicine. They also believe that the way to enhance the practice of preventative medicine is to provide a financial boost to primary medicine, often at the expense of specialty medicine. Moving forward, physician specialty groups are being forced to play a game of turf battle as these new policies take shape. There has been much talk that Congress will eventually do away with the physician fee-for-service system and replace it with a system that rewards quality.
This is a critical factor and may actually work to the advantage of interventional radiologists because it will force Congress to discount utilization rates as a measurement of value and concentrate on clinical outcomes or efficiency. SIR projects such as the “IR value project” are geared around this fact and will hopefully provide the evidence-based data necessary to present to policymakers as they attempt to create delivery system reform.
The biggest challenge during the next few months will be to prove to policymakers the value of IR. It is our responsibility in these changing times to demonstrate to these key decision makers that the practice of IR provides quality, is efficient and, when applicable, can provide health care savings.The SIR leadership has developed an aggressive advocacy campaign to be implemented over the next six months that will address these concerns. The face of health care reform continues to evolve, but SIR will just as certainly continue be a part of that process.
Immediate economic impact of the ACA breakdown:
Increased taxes: For individuals making $200,000 per year or families making $250,000, there will be an increase in the Medicare payroll tax of 0.9 percent and an increase in investment income tax of 3.8 percent.
PQRS: The ACA extends the current Physician Quality Reporting Initiative (PQRI) program through 2014. Incentive payments for 2011 equaled 1 percent, while payments for 2012–14 equal 0.5 percent. Eligible professionals who do not report quality data measures will be penalized 1.5 percent for 2015 and 2 percent for 2016. In light of these changes, the program is now known as the Physician Quality Reporting System (PQRS).
Equipment utilization rate: The 2011 Physician Fee Schedule (PFS) rule implemented section 3135 of the ACA, which set the equipment utilization rate assumption for expensive diagnostic imaging equipment (equipment priced at over $1 million; e.g., computed tomography [CT] and magnetic resonance imaging [MRI] scanners) at 75 percent beginning Jan. 1, 2011, and exempted the provision from the budget neutrality limitation. CMS did not propose to extend the application of the 75 percent utilization rate to procedures beyond those using CT and MRI scanners. The 2011 PFS rule also applied the 75 percent utilization rate to 24 additional codes—predominantly diagnostic computed tomographic angiography (CTA) and magnetic resonance angiography (MRA)—because they include expensive diagnostic imaging equipment in their practice expense inputs.
Multiple-procedure payment reduction: The 2011 PFS implemented section 3135(b) of the ACA, which increased the multiple procedure payment reduction (MPPR) for the technical component (TC) of certain single-session imaging services to consecutive body areas to 50 percent, effective July 1, 2010, and exempted this change from the budget-neutrality provision. Previously, a 25 percent MPPR was applied to the TC of the second and subsequent imaging services when more than one service in one of 11 imaging families (defined by imaging modality and contiguous body area) was furnished in a single session. As of July 1, 2010, payment is made at 50 percent of the TC for each additional procedure.
