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LAS VEGAS – A coalition working to address dual-energy X-ray absorptiometry access issues is developing draft legislation that would establish a geographically adjusted national minimum payment for DXA, according to Dr. Michael Schweitz.
Under the draft legislation – a response to a series of reimbursement cuts over the past several years – DXA CPT codes 77080 and 77082 would be paid at $98 and $35, respectively, and a bundled code or bundled payment for bone density and vertebral fracture assessment studies would result in a national minimum payment of $133, Dr. Schweitz, president of the Coalition of State Rheumatology Organizations, said at Perspectives in Rheumatic Diseases 2013 during an update on federal legislative and regulatory issues facing rheumatologists.
Restoring reimbursement is an issue on the "front burner," he said, noting that studies have demonstrated an increase in hip fracture rates in the wake of declining reimbursement as some practices have abandoned DXA.
The DXA draft legislation is just one of a number of current legislative initiatives and issues that should be on rheumatologists’ radar, Dr. Schweitz said.
Sequestration
Under sequestration – a "heavy hammer" proposed as a way to push for agreement on a deficit-reduction plan and implemented when that agreement didn’t materialize – Medicare provider reductions are limited to 2% per year. Claims are reduced by 2% after beneficiary coinsurance or deductible. H.R. 1416, the Cancer Patient Protection Act of 2013, would terminate sequester cuts for all part B drugs, not just cancer drugs.
Medicare physician payment
Based on the formula for the Medicare sustainable growth rate, or SGR, physician payments will be cut by 24.4% if Congress does not intervene by Jan. 1, 2014. The latest cost estimate by the Congressional Budget Office for repeal of the SGR is $176 billion – far less than previous estimates and far less than the combined cost of prior short-term patches. President Barack Obama’s 2014 budget, as well as Congressional budgets and recent federal rulemakings, all assume that Congress will fix the SGR this year. Draft legislation released in July based on a replacement proposal from the bipartisan House Energy & Commerce Committee calls for a two-phase approach. Phase I would repeal the SGR entirely and replace it with a 5-year period of stable payments, including a 0.5% increase across-the-board, and phase II would involve implementation of an enhanced "PQRS-like Update Incentive Program." This would maintain fee-for-service as an option, allow providers to move into other models at any time, and would involve physician-driven quality measurement.
"This is something all of us should be aware of ... you can be sure that this whole system of reimbursement for what we do is going to change in the future," said Dr. Schweitz, who has a private practice in West Palm Beach, Fla.
How the changes would be paid for has not been defined, but there is a proposal from the House Ways & Means Committee that involves entitlement reform with increased part B/D deductibles and an increased age for eligibility.
Part B drug payments
A new bill (H.R. 800) that would affect physicians who provide in-office drug infusion excludes prompt pay discounts from manufacturers to wholesalers from the average sales price (ASP) calculation for part B drugs. This would improve payment for physicians who do not receive the discounts. However, the president’s 2014 budget assumes part B drugs are overpaid and proposes reducing Medicare payment from ASP plus 6% to ASP plus 3%.
This would require legislation to enact. The House and Senate budgets do not include any assumption regarding ASP.
"There’s very little chance, I think, that either side is going to be successful with this," Dr. Schweitz said.
The Independent Payment Advisory Board
The IPAB, a 15-member board created as part of the Affordable Care Act to make recommendations to cut spending when costs exceed growth targets, has been a contentious issue.
"There is a huge outcry in Congress against this IPAB," Dr. Schweitz said, explaining that there is a sense that the IPAB represents a usurping of the authority of Congress in controlling this part of Medicare activity.
A bipartisan repeal effort is underway in the form of H.R. 351/S. 351, the Protecting Seniors’ Access to Medicare Act. This has a chance of moving forward, but opposition in the Senate could hold it back, Dr. Schweitz said.
Of note, the president’s 2014 budget would lower the target rate that triggers IPAB recommendations from gross domestic product plus 1% to GDP plus 0.5%. Also, House Speaker John Boehner (R-Ohio) and Senate Minority Leader Mitch McConnell (R-Ky.) are on record saying that they will not nominate members to the IPAB, he said.
Private contracting
Private contracting is permitted under current law, but physicians who engage in it must opt out of Medicare for 2 years; patients who sign a private contract must pay out of pocket, even for services covered by Medicare. Under S. 236/H.R. 1310 – the Medicare Patient Empowerment Act – the 2-year opt-out requirement would be eliminated and beneficiaries could use their benefits to offset a portion of the fee set by their physician. This would protect low-income patients, "dual-eligibles," and patients with certain emergent or urgent health conditions. It is opposed by the Democratic Party and AARP, who see it as a cost-shifting mechanism; others feel it is a way to help reduce Medicare spending, he noted.
Medical liability reform
There’s been "a lot of noise but not much action" when it comes to medical liability reform, Dr. Schweitz said.
A House bill that would have included a $250,000 cap on noneconomic damages was paired with the IPAB repeal bill in the 112th Congress but did not make it to the Senate.
"There’s no such bill active in this [113th] Congress, but there are other kinds of liability reform acts that are more focused," he said.
These include H.R. 36/S. 961, the Health Care Safety Net Enhancement Act of 2013, which would extend Federal Tort Claims Act liability protections to on-call specialty physicians; H.R. 1733, the Good Samaritan Health Professionals Act of 2013, which would limit liability of health care professionals who volunteer to provide health care in response to a declared natural disaster; and H.R. 1473, the Standard of Care Protection Act, which would protect physicians from the use of quality measures for reimbursement issues in other federal health care laws to be used as standards of care in liability lawsuits.
Biosimilars
The president’s 2014 budget proposes to reduce the exclusivity for brand names from 12 years to 7 years beginning in 2014 and to prohibit "evergreening" – the securing of additional periods of exclusivity for brand biologics because of minor changes in product formulations.
Additionally, the Coalition of State Rheumatology Organizations is lobbying state legislatures to ensure that biosimilars legislation includes appropriate patient protections, such as physician notification of any substitution, appropriate record keeping, and "dispense as written" requirements. To date, five such bills have passed, with North Dakota, Utah, Virginia, and Oregon including all of these measures and Florida including all but notification.
Graduate medical education
Workforce shortages aren’t just a primary care issue. They also affect multiple specialties, including rheumatology. Though not unique in this regard, rheumatology is representative of an aging specialty, with more physicians reaching the end of their careers than young physicians entering the field. Coupled with the aging population, this raises concerns. The coalition and the Alliance of Specialty Medicine Policy Roundtable on Workforce sought cosponsors for H.R. 1180 and S. 577, the Resident Physician Shortage Reduction Act of 2013, and H.R. 1201, the Training Tomorrow’s Doctor Today Act. These legislative initiatives seek to address the problem of residency-slot shortages.
Dr. Schweitz reported having no disclosures.
LAS VEGAS – A coalition working to address dual-energy X-ray absorptiometry access issues is developing draft legislation that would establish a geographically adjusted national minimum payment for DXA, according to Dr. Michael Schweitz.
Under the draft legislation – a response to a series of reimbursement cuts over the past several years – DXA CPT codes 77080 and 77082 would be paid at $98 and $35, respectively, and a bundled code or bundled payment for bone density and vertebral fracture assessment studies would result in a national minimum payment of $133, Dr. Schweitz, president of the Coalition of State Rheumatology Organizations, said at Perspectives in Rheumatic Diseases 2013 during an update on federal legislative and regulatory issues facing rheumatologists.
Restoring reimbursement is an issue on the "front burner," he said, noting that studies have demonstrated an increase in hip fracture rates in the wake of declining reimbursement as some practices have abandoned DXA.
The DXA draft legislation is just one of a number of current legislative initiatives and issues that should be on rheumatologists’ radar, Dr. Schweitz said.
Sequestration
Under sequestration – a "heavy hammer" proposed as a way to push for agreement on a deficit-reduction plan and implemented when that agreement didn’t materialize – Medicare provider reductions are limited to 2% per year. Claims are reduced by 2% after beneficiary coinsurance or deductible. H.R. 1416, the Cancer Patient Protection Act of 2013, would terminate sequester cuts for all part B drugs, not just cancer drugs.
Medicare physician payment
Based on the formula for the Medicare sustainable growth rate, or SGR, physician payments will be cut by 24.4% if Congress does not intervene by Jan. 1, 2014. The latest cost estimate by the Congressional Budget Office for repeal of the SGR is $176 billion – far less than previous estimates and far less than the combined cost of prior short-term patches. President Barack Obama’s 2014 budget, as well as Congressional budgets and recent federal rulemakings, all assume that Congress will fix the SGR this year. Draft legislation released in July based on a replacement proposal from the bipartisan House Energy & Commerce Committee calls for a two-phase approach. Phase I would repeal the SGR entirely and replace it with a 5-year period of stable payments, including a 0.5% increase across-the-board, and phase II would involve implementation of an enhanced "PQRS-like Update Incentive Program." This would maintain fee-for-service as an option, allow providers to move into other models at any time, and would involve physician-driven quality measurement.
"This is something all of us should be aware of ... you can be sure that this whole system of reimbursement for what we do is going to change in the future," said Dr. Schweitz, who has a private practice in West Palm Beach, Fla.
How the changes would be paid for has not been defined, but there is a proposal from the House Ways & Means Committee that involves entitlement reform with increased part B/D deductibles and an increased age for eligibility.
Part B drug payments
A new bill (H.R. 800) that would affect physicians who provide in-office drug infusion excludes prompt pay discounts from manufacturers to wholesalers from the average sales price (ASP) calculation for part B drugs. This would improve payment for physicians who do not receive the discounts. However, the president’s 2014 budget assumes part B drugs are overpaid and proposes reducing Medicare payment from ASP plus 6% to ASP plus 3%.
This would require legislation to enact. The House and Senate budgets do not include any assumption regarding ASP.
"There’s very little chance, I think, that either side is going to be successful with this," Dr. Schweitz said.
The Independent Payment Advisory Board
The IPAB, a 15-member board created as part of the Affordable Care Act to make recommendations to cut spending when costs exceed growth targets, has been a contentious issue.
"There is a huge outcry in Congress against this IPAB," Dr. Schweitz said, explaining that there is a sense that the IPAB represents a usurping of the authority of Congress in controlling this part of Medicare activity.
A bipartisan repeal effort is underway in the form of H.R. 351/S. 351, the Protecting Seniors’ Access to Medicare Act. This has a chance of moving forward, but opposition in the Senate could hold it back, Dr. Schweitz said.
Of note, the president’s 2014 budget would lower the target rate that triggers IPAB recommendations from gross domestic product plus 1% to GDP plus 0.5%. Also, House Speaker John Boehner (R-Ohio) and Senate Minority Leader Mitch McConnell (R-Ky.) are on record saying that they will not nominate members to the IPAB, he said.
Private contracting
Private contracting is permitted under current law, but physicians who engage in it must opt out of Medicare for 2 years; patients who sign a private contract must pay out of pocket, even for services covered by Medicare. Under S. 236/H.R. 1310 – the Medicare Patient Empowerment Act – the 2-year opt-out requirement would be eliminated and beneficiaries could use their benefits to offset a portion of the fee set by their physician. This would protect low-income patients, "dual-eligibles," and patients with certain emergent or urgent health conditions. It is opposed by the Democratic Party and AARP, who see it as a cost-shifting mechanism; others feel it is a way to help reduce Medicare spending, he noted.
Medical liability reform
There’s been "a lot of noise but not much action" when it comes to medical liability reform, Dr. Schweitz said.
A House bill that would have included a $250,000 cap on noneconomic damages was paired with the IPAB repeal bill in the 112th Congress but did not make it to the Senate.
"There’s no such bill active in this [113th] Congress, but there are other kinds of liability reform acts that are more focused," he said.
These include H.R. 36/S. 961, the Health Care Safety Net Enhancement Act of 2013, which would extend Federal Tort Claims Act liability protections to on-call specialty physicians; H.R. 1733, the Good Samaritan Health Professionals Act of 2013, which would limit liability of health care professionals who volunteer to provide health care in response to a declared natural disaster; and H.R. 1473, the Standard of Care Protection Act, which would protect physicians from the use of quality measures for reimbursement issues in other federal health care laws to be used as standards of care in liability lawsuits.
Biosimilars
The president’s 2014 budget proposes to reduce the exclusivity for brand names from 12 years to 7 years beginning in 2014 and to prohibit "evergreening" – the securing of additional periods of exclusivity for brand biologics because of minor changes in product formulations.
Additionally, the Coalition of State Rheumatology Organizations is lobbying state legislatures to ensure that biosimilars legislation includes appropriate patient protections, such as physician notification of any substitution, appropriate record keeping, and "dispense as written" requirements. To date, five such bills have passed, with North Dakota, Utah, Virginia, and Oregon including all of these measures and Florida including all but notification.
Graduate medical education
Workforce shortages aren’t just a primary care issue. They also affect multiple specialties, including rheumatology. Though not unique in this regard, rheumatology is representative of an aging specialty, with more physicians reaching the end of their careers than young physicians entering the field. Coupled with the aging population, this raises concerns. The coalition and the Alliance of Specialty Medicine Policy Roundtable on Workforce sought cosponsors for H.R. 1180 and S. 577, the Resident Physician Shortage Reduction Act of 2013, and H.R. 1201, the Training Tomorrow’s Doctor Today Act. These legislative initiatives seek to address the problem of residency-slot shortages.
Dr. Schweitz reported having no disclosures.
LAS VEGAS – A coalition working to address dual-energy X-ray absorptiometry access issues is developing draft legislation that would establish a geographically adjusted national minimum payment for DXA, according to Dr. Michael Schweitz.
Under the draft legislation – a response to a series of reimbursement cuts over the past several years – DXA CPT codes 77080 and 77082 would be paid at $98 and $35, respectively, and a bundled code or bundled payment for bone density and vertebral fracture assessment studies would result in a national minimum payment of $133, Dr. Schweitz, president of the Coalition of State Rheumatology Organizations, said at Perspectives in Rheumatic Diseases 2013 during an update on federal legislative and regulatory issues facing rheumatologists.
Restoring reimbursement is an issue on the "front burner," he said, noting that studies have demonstrated an increase in hip fracture rates in the wake of declining reimbursement as some practices have abandoned DXA.
The DXA draft legislation is just one of a number of current legislative initiatives and issues that should be on rheumatologists’ radar, Dr. Schweitz said.
Sequestration
Under sequestration – a "heavy hammer" proposed as a way to push for agreement on a deficit-reduction plan and implemented when that agreement didn’t materialize – Medicare provider reductions are limited to 2% per year. Claims are reduced by 2% after beneficiary coinsurance or deductible. H.R. 1416, the Cancer Patient Protection Act of 2013, would terminate sequester cuts for all part B drugs, not just cancer drugs.
Medicare physician payment
Based on the formula for the Medicare sustainable growth rate, or SGR, physician payments will be cut by 24.4% if Congress does not intervene by Jan. 1, 2014. The latest cost estimate by the Congressional Budget Office for repeal of the SGR is $176 billion – far less than previous estimates and far less than the combined cost of prior short-term patches. President Barack Obama’s 2014 budget, as well as Congressional budgets and recent federal rulemakings, all assume that Congress will fix the SGR this year. Draft legislation released in July based on a replacement proposal from the bipartisan House Energy & Commerce Committee calls for a two-phase approach. Phase I would repeal the SGR entirely and replace it with a 5-year period of stable payments, including a 0.5% increase across-the-board, and phase II would involve implementation of an enhanced "PQRS-like Update Incentive Program." This would maintain fee-for-service as an option, allow providers to move into other models at any time, and would involve physician-driven quality measurement.
"This is something all of us should be aware of ... you can be sure that this whole system of reimbursement for what we do is going to change in the future," said Dr. Schweitz, who has a private practice in West Palm Beach, Fla.
How the changes would be paid for has not been defined, but there is a proposal from the House Ways & Means Committee that involves entitlement reform with increased part B/D deductibles and an increased age for eligibility.
Part B drug payments
A new bill (H.R. 800) that would affect physicians who provide in-office drug infusion excludes prompt pay discounts from manufacturers to wholesalers from the average sales price (ASP) calculation for part B drugs. This would improve payment for physicians who do not receive the discounts. However, the president’s 2014 budget assumes part B drugs are overpaid and proposes reducing Medicare payment from ASP plus 6% to ASP plus 3%.
This would require legislation to enact. The House and Senate budgets do not include any assumption regarding ASP.
"There’s very little chance, I think, that either side is going to be successful with this," Dr. Schweitz said.
The Independent Payment Advisory Board
The IPAB, a 15-member board created as part of the Affordable Care Act to make recommendations to cut spending when costs exceed growth targets, has been a contentious issue.
"There is a huge outcry in Congress against this IPAB," Dr. Schweitz said, explaining that there is a sense that the IPAB represents a usurping of the authority of Congress in controlling this part of Medicare activity.
A bipartisan repeal effort is underway in the form of H.R. 351/S. 351, the Protecting Seniors’ Access to Medicare Act. This has a chance of moving forward, but opposition in the Senate could hold it back, Dr. Schweitz said.
Of note, the president’s 2014 budget would lower the target rate that triggers IPAB recommendations from gross domestic product plus 1% to GDP plus 0.5%. Also, House Speaker John Boehner (R-Ohio) and Senate Minority Leader Mitch McConnell (R-Ky.) are on record saying that they will not nominate members to the IPAB, he said.
Private contracting
Private contracting is permitted under current law, but physicians who engage in it must opt out of Medicare for 2 years; patients who sign a private contract must pay out of pocket, even for services covered by Medicare. Under S. 236/H.R. 1310 – the Medicare Patient Empowerment Act – the 2-year opt-out requirement would be eliminated and beneficiaries could use their benefits to offset a portion of the fee set by their physician. This would protect low-income patients, "dual-eligibles," and patients with certain emergent or urgent health conditions. It is opposed by the Democratic Party and AARP, who see it as a cost-shifting mechanism; others feel it is a way to help reduce Medicare spending, he noted.
Medical liability reform
There’s been "a lot of noise but not much action" when it comes to medical liability reform, Dr. Schweitz said.
A House bill that would have included a $250,000 cap on noneconomic damages was paired with the IPAB repeal bill in the 112th Congress but did not make it to the Senate.
"There’s no such bill active in this [113th] Congress, but there are other kinds of liability reform acts that are more focused," he said.
These include H.R. 36/S. 961, the Health Care Safety Net Enhancement Act of 2013, which would extend Federal Tort Claims Act liability protections to on-call specialty physicians; H.R. 1733, the Good Samaritan Health Professionals Act of 2013, which would limit liability of health care professionals who volunteer to provide health care in response to a declared natural disaster; and H.R. 1473, the Standard of Care Protection Act, which would protect physicians from the use of quality measures for reimbursement issues in other federal health care laws to be used as standards of care in liability lawsuits.
Biosimilars
The president’s 2014 budget proposes to reduce the exclusivity for brand names from 12 years to 7 years beginning in 2014 and to prohibit "evergreening" – the securing of additional periods of exclusivity for brand biologics because of minor changes in product formulations.
Additionally, the Coalition of State Rheumatology Organizations is lobbying state legislatures to ensure that biosimilars legislation includes appropriate patient protections, such as physician notification of any substitution, appropriate record keeping, and "dispense as written" requirements. To date, five such bills have passed, with North Dakota, Utah, Virginia, and Oregon including all of these measures and Florida including all but notification.
Graduate medical education
Workforce shortages aren’t just a primary care issue. They also affect multiple specialties, including rheumatology. Though not unique in this regard, rheumatology is representative of an aging specialty, with more physicians reaching the end of their careers than young physicians entering the field. Coupled with the aging population, this raises concerns. The coalition and the Alliance of Specialty Medicine Policy Roundtable on Workforce sought cosponsors for H.R. 1180 and S. 577, the Resident Physician Shortage Reduction Act of 2013, and H.R. 1201, the Training Tomorrow’s Doctor Today Act. These legislative initiatives seek to address the problem of residency-slot shortages.
Dr. Schweitz reported having no disclosures.
AT PERSPECTIVES IN RHEUMATIC DISEASES 2013