The great healthcare reform bill has passed—great as in size, and not necessarily in content, given the continued threats of massive reimbursement cuts. Although many provisions in the bill were important changes the ACR supported, we were unable to fully support the overall bill because it is missing the crucial fix to appropriately reimburse physicians without jeopardizing healthcare access for Medicare patients.
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Explore This IssueMay 2010
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That said, in this month’s column I will recap the key provisions of the new healthcare reform bill and how they will affect you and your patients. While healthcare reform missed the mark on Medicare and physician reimbursement, there are some provisions in the new law that will help our patients.
Some Positive News for Rheumatologists
The ACR has been going to Capitol Hill to educate members of Congress on a variety of issues. Two of these issues—improved reimbursement for dual-energy X-ray absorptiometry (DXA) and the authorization of a pediatric loan repayment program—became law as part of the healthcare reform bill. One provision will restore payments for DXA services furnished during 2010 and 2011 to 70% of the 2006 Medicare rate. The rates will be retroactive to January 1, 2010. The Secretary of Health and Human Services is authorized to request a study on the ramifications of Medicare payment reductions from the previous year and to submit the study to Congress.
The pediatric loan repayment program authorizes the establishment of a loan repayment program for pediatric subspecialists who agree to work in medically underserved areas. This provision was a part of the Arthritis Prevention Control and Cure Act (H.R. 1210/S.984) that the ACR and the Arthritis Foundation lobbied Congress to pass. Physicians, health professionals, and patients should be proud of their hard work. These two provisions were included in the bill because of our work through Advocates for Arthritis, the ACR’s annual Capitol Hill fly-in, and thousands of visits, telephone calls, and e-mails over the past few years.
I urge rheumatologists to start using the ACR Rheumatology Clinical Registry today because it can be used to satisfy the PQRI requirements.
Quality continues to be the buzzword in healthcare, and several provisions related to improving quality were included in the legislation. The law creates a national strategy for quality improvement to better health outcomes, efficiency, and the patient-centeredness of healthcare for all populations.
President Barack Obama took a vital first step in implementing the strategy by nominating Donald Berwick, MD, MPP, to become the new administrator for the Centers for Medicare and Medicaid Services (CMS). Dr. Berwick is the current president of the Institute for Healthcare Improvement, which works to accelerate healthcare advances by cultivating promising concepts to improve patient care.
The Physician Quality Reporting Initiative (PQRI) will continue to pay bonuses for participation in its reporting program, with a 1% bonus in 2011 and 0.5% bonus in each of the years 2012–2014. There will be a 1.5% penalty in 2015 for unsuccessful participation, which will increase to 2.0% in subsequent years. Essentially, physicians will be forced to participate in PQRI by 2015 or they will see a reduction in reimbursement. With this mandate, I urge rheumatologists to start using the ACR Rheumatology Clinical Registry today because it can be used to satisfy the PQRI requirements.
Fraud and Abuse
One of the ways Congress and President Obama have said that the law will save money is by cracking down on fraud and abuse in the Medicare system. The law now extends the Recovery Audit Contractor (RAC) program to Medicaid and Medicare Parts C (Medicare Advantage) and D (Prescription Drug). The ACR has expressed to legislators and CMS our serious concern over the reimbursement of RACs, which have been tasked to recover revenue through detecting waste, fraud, and abuse in the Medicare system. Presently the RACs are paid a percentage of what they recover from the physicians and hospitals they audit. This methodology is unethical and dangerous, and could foster potentially overzealous reviews in hopes of greater revenue for the contractors. We will continue to closely monitor this process and how it affects rheumatology healthcare professionals.
Three Changes for Patients
Many patients with rheumatic disease have difficulty acquiring insurance in the individual market because some rheumatic diseases were considered pre-existing conditions. With the new law, patients will no longer be excluded because of a pre-existing condition. In addition, patients will no longer have lifetime or annual limits on their health insurance, which will eliminate many out-of-pocket expenses for individuals. Finally, for those on Medicare, the new law will slowly fill the Medicare Part D prescription drug coverage donut hole. Currently, patients who spend over $2,700 enter a coverage gap until their out-of-pocket costs exceed $6,150. This gap will slowly close until it is eliminated in 2020.
Creation of New Government Programs
The new law introduces a variety of new government programs, including the Independent Payment Advisory Board, which will annually determine if the projected per capita growth rate under Medicare exceeds the target rate. With this information, recommendations will be made to reduce the Medicare per capita growth rate. The ACR opposes the creation of an independent commission that has the authority to mandate physician payment cuts, and will work with other medical specialties to include the removal of this commission in a corrections bill.
The law also creates an approval pathway for biosimilar biologics. The ACR believes that, while cost savings are highly desirable, the approval process for biosimilars needs to place safety and efficacy, supported by scientific sound evidence, as its highest priorities.
The law hopes to increase the number of primary care physicians by increasing reimbursement to physicians who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine. These physicians, along with nurse practitioners and physician assistants working in those areas, will see a 10% increase in their reimbursement if at least 60% of their services are provided as primary care services. Subspecialists have not been named in this section and therefore will not receive the increase.
Access for Medicare patients continues to falter as Congress continues to ignore the flawed sustainable growth rate (SGR) formula and costs for a permanent fix increase dramatically. Unfortunately, a fix for the SGR formula was not addressed in the new law. Physicians have had uncertainty throughout the year because Congress refuses to permanently repeal the flawed formula and continues to pass short-term fixes to Medicare reimbursement rates. This has made it impossible for physicians to run a practice with any certainty of their monthly gross income from Medicare patients. Several times CMS has held payments to physicians, allowing Congress more time to pass another band-aid. The time for band-aid fixes is now over. Physicians, health professionals, and patients must contact Congress to ensure that Medicare patients have access to care. With the baby boomers reaching Medicare eligibility, Congress cannot ignore the flawed formula and leave millions of Medicare patients without access to healthcare. Congress must fix the flawed SGR formula and guarantee appropriate reimbursement for physicians.
Healthcare reform is really just beginning. The law has been passed, but now the law must be implemented. The ACR will continue to advocate for physicians and our patients. We are staying abreast of the bill and know that as it unfolds we all will be trying to find access to care for the 32 million Americans who will now have healthcare insurance. To keep current on healthcare reform, I recommend you visit www.rheumatology.org.
Dr. Cohen is president of the ACR. Contact him via e-mail at firstname.lastname@example.org.