2007 a Mixed Bag for Radiologists; Imaging Centers in for Strict New Oversight Regulations
This Year on the Hill: What to Expect in 2007
CMS Changes Policies and Payment for Outpatient Services

2007 a Mixed Bag for Radiologists; Imaging Centers in for Strict New Oversight Regulations

The news from Washington is not all bad for imaging professionals, but general practitioners, internists, and other office-based physicians stand to benefit the most from reimbursement policy changes in 2007. Independent diagnostic testing facilities (IDTFs), however, were hit with stringent new oversight restrictions, in addition to reimbursement cuts contained in the Deficit Reduction Act of 2005 (DRA).

On December 21, President Bush signed into law the tax, trade, and health care bill that reversed a 5.1% reduction in physician reimbursement scheduled to cast a pall over the new year. And both Medicare patients and primary care physicians stand to benefit from measures in the 2007 Medicare Physician Fee Schedule (MPFS) final rule that call for increased payment to physicians for time spent talking with Medicare beneficiaries about their health care; in tandem, the Centers for Medicare and Medicaid Services (CMS) also will pay for a broader array of preventive services, including ultrasound and bone density screenings. CMS projects that the new payment rates and policies will result in $61.5 billion paid to physicians and other health care professionals.

By increasing the work component for the relative value units (RVUs) for face-to-face visits—otherwise known as evaluation and management (E&M) services—CMS hopes to boost patient awareness of preventive measures, thereby ultimately reducing costs. The work component for RVUs is increasing as follows:

  • associated with an intermediate office visit, which is the most frequently billed physician service: 37%;
  • an office visit requiring moderately complex decision-making: 29%; and
  • a hospital visit requiring the same degree of decision-making: 31%.

Medicare also will expand its preventive services benefits, a change provided for by the DRA, beginning January 1, 2007. Now, Medicare will pay for preventive ultrasound screening for abdominal aortic aneurysms (AAAs)—the 10th-leading cause of death for men over 55—for at-risk beneficiaries during the Welcome to Medicare physical examination. AAA screening will be free to men aged 65 to 75 who have smoked at least 100 cigarettes in their lifetimes, individuals with a family history of AAAs, and any other individuals recommended for screening by the US Preventive Services Task Force.

The 2007 MPFS expands the number of beneficiaries who qualify for bone mass measurement due to long-term steroid therapy; the dosage equivalent for eligibility will be reduced from 7.5 mg/day of prednisone for a minimum of 3 months to 5 mg/day. Further, colorectal cancer screening is now exempted from the Part B deductible.

Another Hit for IDTFs

Owners of IDTFs will need to scramble to get into compliance with the new oversight restrictions contained in the MPFS final rule.

Physicians are limited to providing supervision to no more than three independent diagnostic testing facilities. Furthermore, supervising physicians will be held responsible for the overall

IDTF operations and administration, including the hiring of competent personnel and compliance with applicable regulations.

The new regulations also prohibit IDTFs from directly soliciting patients, which includes a prohibition on telephone, computer, or in-person contacts. “CMS did clarify that it is not attempting to prohibit public advertising such as television, radio, and direct mailing of its services to beneficiaries, physicians and other suppliers,” Cherrill Farnsworth, former president of the National Coalition for Quality Diagnostic Imaging Services (NCQDIS) and CEO of HealthHelp, Houston, told members at the year-end meeting.

Additional requirements follow:

  • IDTFs also will be required to report to CMS any change in IDTF operations as stated in its enrollment application within 30—previously 90—days.
  • IDTFs are now required to carry comprehensive liability insurance policy of at least $300,000 that covers the place of business, customers, and employees.
  • IDTFs must have “proper medical record storage” and be able to retrieve a record on request from CMS within two business days.
  • IDTFs must permit access to representatives of CMS on demand to conduct unannounced inspections to confirm compliance with standards.
  • IDTFs are required to calibrate and maintain their testing equipment as per manufacturer suggested standards.

—C. Vasko and C. Proval

Question

A

B

C

D

E

A system of reporting errors, such as incident reports, is in place and is supported by a culture of safety that allows for open collection and sharing of the data within the practice.

5%

3%

9%

19%

64%

A protocol to report potential threats to patient safety and near-misses is in place, known to all staff, routinely followed, and supported by a culture of safety that allows for open collection and sharing of the data within the practice.

8%

8%

14%

18%

52%

When errors or near-misses occur, educational efforts are widespread among all clinicians and nonclinical personnel who may make a similar error, rather than remedial and directed only at those practitioners who were involved in the error, and education supports organizational learning and awareness and promotes system changes to decrease the possibility of future error.

4%

4%

16%

25%

51%

When prescribing or dispensing oral liquid medications for patients, a proper measuring device (eg, an oral syringe) is used or suggested, and caregivers are instructed on its use to measure the prescribed dose.

24%

3%

9%

17%

48%

The practice has protocols in place that are known to all staff and are followed on providing emotional support to clinicians and other staff members who have been involved in an adverse event at the practice and encourages staff to utilize it.

41%

12%

9%

13%

25%

Job descriptions for all office personnel include requirements to speak up about safety issues, change practices to enhance safety, share errors, ask for help when needed, and other elements of shared accountability for safe practices.

17%

9%

13%

15%

46%

All office staff receives initial training on HIPAA regulations, and periodic (at least annually) ongoing education, review, and evaluation are offered.

0%

1%

5%

19%

75%

The published literature of errors and adverse events that have occurred in other locations is activity monitored and the practice uses the information to proactively make system changes within the practice.

27%

10%

17%

12%

34%

Patients are instructed on the proper use and maintenance of any devices prescribed or dispensed to them by the practice.

3%

1%

10%

19%

67%

Job descriptions for all clinical personnel include requirements to speak up about safety issues, change practices to enhance safety, share errors, ask for help when needed, and other elements of shared accountability for safe practices.

16%

9%

10%

18%

46%

The practice documents all patient’ complaints and/or concerns about their care or outcomes including problems with communication between the patient and clinicians and staff within the practice and/or consulting or testing center staff. All complaints are periodically reviewed, shared with staff, and responses and resolutions are documented.

5%

6%

12%

22%

55%

The practice encourages patients by verbal or written surveys to share any safety concerns they may have while at the practice, with staff, or at outside referral centers.

18%

12%

12%

17%

41%

Human factors and the key principles of error reduction such as standardization, use of constraints and redundancy are reviewed with all office staff during orientation and during each performance evaluation.

23%

12%

17%

19%

29%

Essential patient information is manually or electronically recorded on a separate intake form or record in such a way that it is clearly evident in the health record and easily accessible to appropriate office personnel.

0%

1%

8%

15%

76%

Patients are informed of HIPAA rules and regulations and how the practice protects patient data and other personal information and the specific circumstances where and to whom patient information can be released.

0%

0%

1%

11%

89%

The practice provides adequate space and a safe environment for treating patients to protect the patient from iatrogenic injury and infection.

1%

1%

3%

12%

82%

Staff feel comfortable requesting time away (schedule changes, breaks, increased requests for double checks or days off) due to illness and fatigue to minimize errors and the potential for compromise to safe care related to these conditions.

3%

3%

6%

19%

68%

The practice utilizes established tools to monitor patient to staff ratio trends, flexible work schedules, sick-day use and attitudinal/burnout for impact of staff fatigue, overwork and understaffing on patient safety.

20%

6%

13%

21%

40%

All practice staff are trained to recognize and manage health literacy issues.

30%

9%

19%

17%

25%

The practice provides training to all staff in team communication including methods to ensure efficient and effective communication.

15%

7%

18%

21%

39%

Procedures are established by the practice for maintenance, distribution and use of devices such as nebulizer units, glucose monitoring devices, intravenous infusion pumps or any other mechanical device used in the medication delivery process, and include standardization of the equipment, annual biomedical evaluation and cleaning. Responsibility for these procedures is assigned to one office staff member qualified to do the review.

3%

1%

5%

6%

47%

N/A: 38%

Office personnel, including physicians, are educated about all devices and associated protocols/guidelines; and competency with their use is verified before they are permitted to use or train a patient on the device.

3%

3%

7%

11%

37%

N/A: 39%

Scoring Key
A. Unaware of this issue or aware, but there has been no activity to implement this item.
B. This item has been formally discussed and considered, but it has not been implemented.
C. This item has been partially implemented in the practice for some areas, patients, drugs, procedures, and/or staff. (For example, the practice is beginning a disease management program for its diabetic patients, but only new patients are currently enrolled.)
D. This item is fully implemented in the practice for some areas, patients, drugs, procedures, and/or staff. (For example, some patients are enrolled in a disease management program, but other patients with chronic diseases are not enrolled in a disease management program.)
E. This item is fully implemented in the practice for all areas, patients, drugs, procedures, and/or staff.
N/A. This item is not applicable to our practice. (This choice is available for certain items and includes a specific definition.)

This Year on the Hill: What to Expect in 2007

By Cat Vasko

The New Year has brought fresh leadership to Capitol Hill, with Democrats in control of both the House and the Senate. Already, speculation has begun about what the blue party has on its agenda regarding health care, particularly in light of the mounting national deficit. Axis Imaging News combs through the rumors and promises to parse the regulatory changes that could be in store for medical-imaging professionals in 2007.

At the Federal Level: Revitalizing Medicare, Price Transparency, and More

The House Ways and Means Committee, which has jurisdiction over Medicare, is under new leadership. Bill Thomas (R-Calif), the former chairman of the committee, has retired, and Representative Charles Rangel (D-NY) has taken his place. Also, former Health Subcommittee Chair Nancy Johnson (R-Conn), defeated in the midterm elections, cedes her role to Representative Pete Stark (D-Calif), author of the Stark antireferral laws. Sharing jurisdiction over Medicare physician payment issues is the House Energy and Commerce Committee, which also has experienced a shift in leadership, with Representative John Dingell (D-Mich) assuming chairmanship of the Health Subcommittee—a position that he held 12 years ago, before Republicans gained the majority.

Democrats have declared that within their first 100 hours in control of the House, their top priorities regarding health care issues will be expanding stem cell research and giving the federal government the ability to negotiate prices with pharmaceutical companies, a practice currently forbidden under Part B. Beyond this initial agenda, Democrats promise to generate more funding for health IT initiatives, expand coverage for the uninsured, and—perhaps most dauntingly—tackle the challenge of permanently repairing the oft-criticized Medicare physician payment system.

Elsewhere, it is anticipated that Democrats will not press forward with Republican plans for adoption of personal health savings accounts (HSAs). Meanwhile, on November 17, Department of Health and Human Services (HHS) Secretary Michael O. Leavitt assured a roundtable gathering of health care industry CEOs that HHS will push forward with pricing transparency initiatives called for by President Bush in an August 22 executive order.1 These measures would make it easy to compare the cost and quality of medical procedures, but also would serve as a first step toward the transition to personal HSAs.

In another issue sure to remain controversial in 2007, Democrats will delay the ongoing development of pay-for-performance systems while the impact of such measures is further analyzed; however, a November 17 Government Accountability Office (GAO) letter to congressional leaders2 urged Congress to seriously consider pay-for-performance as a way to improve Medicare quality and efficiency. The letter also called for improved financial oversight of Medicaid, saying, “Absent reform, Medicare’s and Medicaid’s long-term fiscal sustainability for supporting health care for elderly, disabled, and low-income Americans is in jeopardy.”

In the meantime, two lawmakers from opposite sides of the aisle—Representative Tammy Baldwin (D-Wis) and Representative Tom Price (R-Ga)—are calling for a new method of ensuring government accountability for health care reform measures: test them in the states.

At the State Level: Expanding Coverage, Reforming Financing

Three bills have been introduced in Congress since July to institute a laboratory-like system wherein states would experiment with different measures for expanding coverage and reforming financing. Although the federal government remains divided on health care policy, states—which already have taken the lead in recent years on health care policy reform—could be real-life examples of which ideas work best. The three bills differ slightly; however, all would have states submit proposals to a commission or task force, after which the most promising ideas would be fast-tracked by Congress.

The first bill (S 2772 IS), introduced last May, was co-sponsored by Senator George Voinovich (R-Ohio) and Senator Jeff Bingaman (D-NM); in July, Baldwin and Price, with other co-sponsors, introduced a similar bill (HR 5864) in the House. Senator Russ Feingold (D-Wis) introduced another bill in July. Whether the trend will persist in 2007 remains to be seen, but the concept’s bipartisan support bodes well.

Imaging in the Hot Seat

Of utmost concern to medical-imaging professionals are the Deficit Reduction Act of 2005 (DRA), the Access to Medicare Imaging Act (HR 5704), and the Access to Medical Imaging Coalition (AMIC) legislative retort. At press time, the American College of Radiology (ACR), Reston, Va, intended to continue to fight the imaging reimbursement cuts prescribed by the DRA by pushing for a retroactive delay and eventual repeal (retroactive to January 1) during the first quarter of 2007, in the event that HR 5704 went unaddressed by the December lame duck session of Congress.

But irrespective of the fate of HR 5704, the ACR warns that utilization of imaging services—which account for a healthy percentage of overall Medicare costs—will remain under scrutiny by both Congress and the administration. On a more optimistic note, the ACR predicts that “with a government focused on quality, efficiency, and fiscal restraint, there may be an increasing desire to address Congress’ utilization concerns by taking a closer look at loopholes in the Stark self-referral laws.” The ACR also observes that improvements to the Mammography Quality Standards Act will be possible after its 2007 reauthorization.

Cat Vasko is associate editor of  Axis Imaging News. For more information, contact .

References

  1. Burgess MC. Statement on Bush’s push for health care transparency. Michael C. Burgess Web site. August 22, 2006. Available at: burgess.house.gov/News/DocumentSingle.aspx?DocumentID=49057. Accessed December 6, 2006.
  2. United States Government Accountability Office. Suggested areas for oversight for the 110th Congress. November 17, 2006. Available at: www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-235R. Accessed December 6, 2006.


CMS Changes Policies and Payment for Outpatient Services

In November, the Centers for Medicare and Medicaid Services (CMS) issued a final rule for Medicare payment for hospital outpatient services in 2007. The final outpatient prospective payment system (OPPS) rule includes measures to expand quality reporting services and lengthen the list of services for which Medicare will pay ambulatory surgical centers.

“In this final rule, we are taking one more step toward rewarding hospitals for providing quality care, not just in the inpatient setting, but also in the outpatient department,” Acting CMS Administrator Leslie V. Norwalk said in a statement.

Hospitals will receive an estimated $32.5 billion for outpatient services provided to Medicare beneficiaries; the rule affects outpatient services provided by general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals. The rule includes the required 3.4% market basket update to Medicare payment rates, and CMS projects that after other factors are taken into account, providers of outpatient services will receive an increase in Medicare payments of about 3%.

CMS estimates that hospital outpatient expenditures increased nearly 12% between 2005 and 2006 due to growth in the volume and intensity of services; this rapid rate of growth is of concern to the agency because of its potential impact on Medicare beneficiaries whose monthly premiums cover 25% of Part B expenditures.

To adjust for this rise and promote greater value in the purchase of hospital outpatient services for Medicare beneficiaries, the rule ties OPPS rate increases to reporting of quality measures beginning in 2009. In accordance with recommendations from the National Quality Forum and the privately held Hospital Quality Alliance, hospitals will be required to report more quality measures for inpatient services, and also will report risk-adjusted outcome measures for the first time, including 30-day mortality measures for patients hospitalized with an acute myocardial infarction.

—C. Vasko