Medicine has changed so much in my lifetime, with rapid innovation and facilitation of new technologies improving patients’ lives. There were typically few if any barriers to incorporating new technology into our patient care. This was an extraordinary environment for innovation but led to problems that we are trying to solve today.
We now lack data proving that IR procedures are safe, effective and cost effective—and must concentrate on research and building strong scientific evidence. We as a nation must now also face the extraordinarily high cost of medical care. IR is not alone in lacking data that proves the efficacy of the health care we provide to patients; all of medicine is grappling with the same issues. As physician experts, we have the opportunity to help rewrite policy to make health care better for patients, providers and the national budget.
As physician experts, we have the opportunity to help rewrite policy to make health care better for patients, providers and the national budget.
We have been talking about the sustainable growth rate (SGR) for years. SGR is the flawed methodology upon which physician payment is determined each year. It was created in 1997 under the Balanced Budget Act as a means to control growth in Medicare spending. However, it soon became obvious that it didn’t work in all economies and, since 2002, the SGR calculation has resulted in potential cuts to physician payments by as much as 28 percent. Congress has always acted to postpone the pay cuts with stopgap measures—sometimes for the next year, sometimes for a few months only, but always at a high cost to physician groups who spend enormous amounts of money to lobby the legislatures to delay the upcoming cut and to change the methodology.
Unfortunately, changing that methodology is very expensive, and it’s hard to come up with the necessary billions of dollars. In order to avert the calculated cuts, the money to pay physicians must be taken out of budgets for expected spending on other health care costs, with the budget paying for imaging procedures a perennial favorite for cutting.
However, there may be a window of opportunity for this change to occur, since the estimated cost of the “fix” is currently only $150 billion (almost half of the estimated cost in 2012). Because of the current relatively low cost of the fix, Congress has been working on ways to change the SGR methodology during 2013. In the latest policy proposals, Congress has discussed replacing the current system with one that moves away from the traditional fee-for-service model and toward a payment model that rewards quality, efficiency and innovation.
However, raising a physician’s pay is not popular with most taxpayers. While Congress may be sensitive to the need to maintain physician salaries at a level where patients receive quality care, they expect to be able to show added value for this expense. The fixes being considered give physicians the opportunity to help determine that “added value,” asking us to propose measures of quality and value.
Advocacy and the need for evidence
SIR members and staff regularly talk to Congress about the significant value IRs bring to health care, explaining why IRs should be recognized for this value—both in our abilities to deliver care to patients and in the manner we are paid. While most members of Congress are not medical experts, their staff advise them on medical issues. They look to us and other medical professionals to give them data they can use as they develop health care policy. They want clear data to facilitate their decision-making process. As reform continues and policy is refined, it is certain that, unless there is good data supporting procedures and technology, it will be more and more difficult to get paid for provision of those services.
Congress has always acted to postpone the pay cuts with stopgap measures—sometimes for the next year, sometimes for a few months only, but always at a high cost to physician groups who spend enormous amounts of money to lobby the legislatures to delay the upcoming cut and to change the methodology.
In parallel, other specialties are advocating for their pieces of the medical pie, and they are also trying to collect data and publish results bolstering the service they provide to patients. In the end, it is to be expected that the groups with the best data will win the ability to provide the services and to be paid for the superior care.
Advocacy and the need for evidence extends beyond congressional policymakers to Current Procedural Terminology/Relative Value Update Committee (CPT/RUC, which currently still sets the valuation for medical services), the U.S. Food and Drug Administration (FDA), and governmental agencies in charge of quality measures.
SIR response
SIR has been keenly aware of the need to develop evidence that supports IR practice and IR services. Led by Joseph R. Steele, MD, FSIR, the SIR Value Task Force (which was developed three years ago) has been critical in identifying key questions on common IR procedures and how to approach federal decision-makers. On a more granular level, within the Economics committee, a Data Analysis work group convened by Michael Brunner, MD, FSIR, has quickly set to work on comparative effectiveness studies,
identifying questions that could be answered by review of Medicare claims databases. This is a relatively inexpensive means of gathering data and, in certain areas, can produce data that provides significant support to IR procedures. To date, they have published two papers in the Journal of Vascular and Interventional Radiology (JVIR); the task force is currently working on its next paper.
SIR Foundation has also carefully reviewed its mission and now places greater priority on research that supports existing IR procedures in addition to looking at new innovations for the future services IRs will bring to patients. In 2013, the Value Task Force came under the auspices of SIR Foundation, and committees led by Jeremy Durack, MD, FSIR, and Stephen L. Ferrara, MD, FSIR, are developing the tools members need to clearly show their value.
These tools will not only help members demonstrate quality individually but will also aggregate data from many IR practices into databases that can be analyzed to document IR outcomes, effectiveness, safety and cost effectiveness. SIR continues to keep the community informed about structured reporting and registries—tools that you will use to contribute to the development of evidence supporting IR.
It is likely that, if new methodology replacing SGR to calculate physician payment becomes law, it will be based in part on quality measures. Because there are currently no quality reporting measures that uniquely allow all IRs a means of reporting quality data, and because it is likely that no single measure will apply to all IRs, the Quality Committee is developing reporting measures applicable to each service line. There is an extensive process to gaining acceptance of each quality measure, but the committee is using national expertise to help get these measures through the system and into place for member reporting.
SIR has also looked at partnering with other entities that can help support its efforts to aggregate and analyze data. Government agencies, grants and other societies can offer support and help us proceed more quickly to fill the data gaps.
The SIR Policy, Research and Planning (PReP) Task Force has been helping SIR and SIR Foundation leadership identify areas of need for members and patients, to help define ways to meet those needs and to help prioritize that work. The group meets regularly to discuss how to give SIR members the data they need to continue to develop thriving practices and to be paid for their services. The task force is also looking at areas of IR currently under heavy attack in payment and/or coverage policy, trying to identify where evidence is most critically needed. They are also trying to look ahead at areas that may become most vulnerable. The vulnerability to payment and/or coverage problems comes from lack of evidence, competition from other specialties, high cost of the procedure, abuse of the procedure/service or competing technology.
If IR can demonstrate that it does provide better service in specific sectors of health care, the goal would be to negotiate the contract to allow IRs to provide those services, with financial incentives aligned so that other specialties are not trying to provide the same services with inferior results or higher costs. But to be in a position to negotiate, we first need data showing where we excel and what we add to patient care and experience.
The PReP Task Force is also working to identify areas where IR is expected to shine, demonstrating exceptional quality, safety, effectiveness and/ or cost-effectiveness. The intent is to help the Society allocate its limited resources most effectively by developing supportive evidence for those procedures where we should most easily be able to prove distinction. Finally, the task force is also reviewing what services are most valuable to patients and IRs, trying to prioritize where efforts would have the most impact.
The future is in your hands
If IR can demonstrate that it does provide better service in specific sectors of health care,
the goal would be to negotiate the contract to allow IRs to provide those services, with financial incentives aligned so that other specialties are not trying to provide the same services with inferior results or higher costs. But to be in a position to negotiate, we first need data showing where we excel and what we add to patient care and experience.
Getting involved with any of the multiple efforts underway can give you a voice in the changes coming to health care. We are at a time of change—change that you have the opportunity to help shape. As a specialty, we will achieve our greatest success by looking at ways we can provide patients with the best possible care in the most cost-effective means. Use of structured reports, participation in registries, volunteering for a committee, participating in congressional advocacy, responding to SIR surveys collecting data to help us best direct our efforts to develop supportive evidence, and submission of your thoughts regarding what evidence would be most helpful to your practice are just a few ways that you can help. For more information or to volunteer your time, contact the Society at (703) 691-1805.
