- Email: [email protected]
Advancing the ACR's Agenda in Washington
ACR CHAIR’S MEMO
JAMES H. THRALL, MD, BOC Chair
Advancing the ACR’s Agenda in Washington Drama is never far away when Congress is in session. This summer was no exception with physicians from all specialties, including radiology, watching the machinations in the House and Senate with great care and interest and much trepidation. The source of this summer’s drama was caused by the annually recurring problem of threatened decreases in Medicare reimbursement to physicians. The threat arises from a flaw in the formula used each year to calculate a so-called “sustainable growth rate” (SGR) that in turn is used to calculate the level of reimbursement to physicians from Medicare. The flaw originated in the 1997 Medicare Modernization Act and has not been corrected fundamentally in the ensuing decade. For this calendar year, the projected cut in payments to physicians was particularly large, equaling 10.6%, so interest and concern throughout the medical community were especially high. For many years now, Congress has faced the need to pass special legislation to block physician payment cuts that would otherwise ensue from application of the flawed SGR formula. Congress and the President could not agree on a full-year solution to the problem last fall and consequently a six-month “fix” was put in place covering the period from January 1 – June 30, 2008. Some referred to this waggishly as “kicking the can down the road.” Other cynical observers noted that it also guaranteed that every medically oriented political action committee (PAC) would feel obligated to continue contributing to congressional campaign coffers. The two challenging aspects of this year’s legislative initiative were the unusually large size of the projected cut—10.6% vs circa 5% in most years—and the need to find
money from elsewhere in the federal budget to pay for or offset the funds required to keep physician reimbursements whole. Everyone will recall the unhappy circumstance in 2005 when the authors of the Deficit Reduction Act (DRA) used cuts to the technical reimbursement for non-hospital outpatient imaging procedures as the “pay for.” Rumblings from certain quarters of Congress through the spring suggested the possibility that imaging was being looked at again in 2008 as a source of offset funds to pay for reversing the calculated physician payment reductions resulting from the SGR process. During the deliberations leading to the six-month fix, President Bush had blocked the pathway of adjusting over payments to private Medicare HMO companies as a source of the offset funds, so more cuts to reimbursement for imaging services were clearly a real possibility and a major concern for College members. Against this background, the ACR undertook a two-pronged approach. The ensuing story is an exemplar for how our political system works and how a dedicated group of people with a strong agenda that is in the public’s interests can impact the legislative process. First, the ACR legislative team of government relations staff and member volunteers made the case with key congressional leaders that imaging had already been tapped for more than its fair share as a result of the DRA. The team pointed out that the actual savings to Medicare have turned out to be over twice the originally projected savings. Moreover, there have been substantial negative consequences for industry and for many outpatient imaging practices from the DRA as well—with the po-
© 2008 American College of Radiology 0091-2182/08/$34.00 ● DOI 10.1016/j.jacr.2008.08.008
tential for reduced access to imaging services for Medicare beneficiaries if the cuts were deepened. The background information provided and the framing of issues related to imaging were well received, and imaging cuts were kept out of the legislation. At the same time, the ACR lobbied strongly in its second pincer that the SGR legislation should include requirements for practice accreditation for providers of imaging services and support for demonstration projects of imaging appropriateness criteria. The ACR argued that accreditation speaks directly to the quality of care delivered. Accreditation requires that imaging providers meet quality and safety standards that encompass overall practice, including personnel, equipment, quality assessment activities and ultimately the quality of patient care. Accreditation raises the bar and culls out substandard providers. We have seen this with the Mammography Quality Standards Act (MQSA), and MQSA served as a model for discussion. The ACR further pointed out that properly applying appropriateness criteria should limit utilization to those care situations where imaging is truly needed, thereby saving money through elimination of unnecessary procedures. The magnitude of potential savings appears substantial based on research documenting excessive use of imaging by self-referring physicians. Better, more objective utilization of imaging also improves safety—radiation exposure is avoided whenever an unnecessary procedure that involves ionizing radiation can be eliminated. We now know, of course, that Congress overrode the President’s veto on July 15, 2008 to pass the Medicare Improvement for Patients and Providers Act of 2008 1021
1022 ACR Chair’s Memo
(H.R.6331). The act blocked the impending 10.6% payment cut. The legislation extended for all of 2008 what had been a temporary 0.5% increase for the first six months of 2008 and added another 1.1% increase that will take effect for calendar year 2009 giving physicians 18 months of relief. In parallel with its financial provisions, the Medicare Improvement for Patients and Providers Act of 2008 includes the two high priority issues sought by the ACR—requirements for accreditation and support for demonstration projects of appropriateness criteria. The College succeeded in keeping these two highly important, long-term goals literally completely intact in the legislation and including timelines for implementation. I believe these provisions in the legislation constitute a victory for the American public as much as for the ACR, because the public will be better served by our health system as a result. It is often difficult to assess the role of any one organization in shaping and stewarding congressional legislation, especially when many groups have the same aligned interests. In this case, there can be no doubt between cause and effect, because there is a clear one-to-one relationship between what the College undertook to support in terms of accreditation and appropriateness and what ensued legislatively. It has been a true milestone achievement. Congratulations to all involved. While it is extremely gratifying that Congress acted as it did to repeal the cuts in Medicare reimbursement and also to support the ACR legislative provisions, the process that we have gone through highlighted something that may be even more important to the College and all of us as
members going forward—we have received broad-based feedback during the legislative process that the College is highly regarded in Washington—this increases our effectiveness with Congress and the Centers for Medicare & Medicaid Services. The high regard appears to be based on several factors. First, the unique agenda specific to the ACR throughout this legislative process was fundamentally aimed at improving the quality of care delivered to and received by patients in the United States and was further aimed at ensuring the appropriateness of that care. This posture of the College agenda is in sharp contrast to that of many—perhaps most— organizations that approach Congress. Most agendas are clearly about the special interests of respective interest groups and are not aimed at the welfare of the American public at large. I believe this is an incredibly important lesson for us—if we can first and foremost take our patients’ interests and those of the health system into consideration and then develop our agenda to coalign with those interests, we are likely to be successful in the long run. We may not always find issues that are as well aligned with the public’s interests as accreditation and appropriateness, but the point is, we should always look for them and when we find them, act accordingly. Another factor contributing to the strong reputation of the College in Washington is recognition of our level of commitment and the willingness of knowledgeable members of the College to come to Capital Hill to meet with their representatives and to tellthewonderfulstoryofradiology— over three hundred radiologists visited Capitol Hill as part of the ACR
Annual Meeting and Chapter Leadership Conference. Member volunteers are supported by an outstanding government relations staff that has earned the trust of members of Congress and their staffs, and through that trust our staff has built important and effective relationships on Capital Hill. All physicians won an important victory with the recent legislation, and we have once more dodged the bullet of substantial Medicare reimbursement cuts. However, the victory is more of a reprieve than a definitive solution. The cumulative balance related to the SGR process is now estimated at well over $50 billion. These dollars must be “paid back” if Congress fails to extend its annual overrides of the SGR calculations. The ensuing chaos in the health care system would be overwhelming, so this is unlikely to happen, but the risk and threat are still there. Because of the foregoing considerations, no one should declare the SGR battle over and strike the props. It is my anticipation that as soon as we have a new Congress and a new administration in place, we will need to go back to work as hard as ever. The ACR will work toward a permanent fix for the flawed SGR formula and development of a physician payment system that keeps up with the increasing costs of medical practice. We will continue to work toward widespread adoption of appropriateness criteria and other policies that promote objective evidence based utilization of imaging. We will undoubtedly need to respond to other health care reforms that are likely to be proposed after the election. We are ready.
James H. Thrall, MD, Massachusetts General Hospital, Dept of Radiology Rm 216; 32 Fruit St, Boston MA; e-mail: [email protected].
JAMES H. THRALL, MD, BOC Chair
Advancing the ACR’s Agenda in Washington Drama is never far away when Congress is in session. This summer was no exception with physicians from all specialties, including radiology, watching the machinations in the House and Senate with great care and interest and much trepidation. The source of this summer’s drama was caused by the annually recurring problem of threatened decreases in Medicare reimbursement to physicians. The threat arises from a flaw in the formula used each year to calculate a so-called “sustainable growth rate” (SGR) that in turn is used to calculate the level of reimbursement to physicians from Medicare. The flaw originated in the 1997 Medicare Modernization Act and has not been corrected fundamentally in the ensuing decade. For this calendar year, the projected cut in payments to physicians was particularly large, equaling 10.6%, so interest and concern throughout the medical community were especially high. For many years now, Congress has faced the need to pass special legislation to block physician payment cuts that would otherwise ensue from application of the flawed SGR formula. Congress and the President could not agree on a full-year solution to the problem last fall and consequently a six-month “fix” was put in place covering the period from January 1 – June 30, 2008. Some referred to this waggishly as “kicking the can down the road.” Other cynical observers noted that it also guaranteed that every medically oriented political action committee (PAC) would feel obligated to continue contributing to congressional campaign coffers. The two challenging aspects of this year’s legislative initiative were the unusually large size of the projected cut—10.6% vs circa 5% in most years—and the need to find
money from elsewhere in the federal budget to pay for or offset the funds required to keep physician reimbursements whole. Everyone will recall the unhappy circumstance in 2005 when the authors of the Deficit Reduction Act (DRA) used cuts to the technical reimbursement for non-hospital outpatient imaging procedures as the “pay for.” Rumblings from certain quarters of Congress through the spring suggested the possibility that imaging was being looked at again in 2008 as a source of offset funds to pay for reversing the calculated physician payment reductions resulting from the SGR process. During the deliberations leading to the six-month fix, President Bush had blocked the pathway of adjusting over payments to private Medicare HMO companies as a source of the offset funds, so more cuts to reimbursement for imaging services were clearly a real possibility and a major concern for College members. Against this background, the ACR undertook a two-pronged approach. The ensuing story is an exemplar for how our political system works and how a dedicated group of people with a strong agenda that is in the public’s interests can impact the legislative process. First, the ACR legislative team of government relations staff and member volunteers made the case with key congressional leaders that imaging had already been tapped for more than its fair share as a result of the DRA. The team pointed out that the actual savings to Medicare have turned out to be over twice the originally projected savings. Moreover, there have been substantial negative consequences for industry and for many outpatient imaging practices from the DRA as well—with the po-
© 2008 American College of Radiology 0091-2182/08/$34.00 ● DOI 10.1016/j.jacr.2008.08.008
tential for reduced access to imaging services for Medicare beneficiaries if the cuts were deepened. The background information provided and the framing of issues related to imaging were well received, and imaging cuts were kept out of the legislation. At the same time, the ACR lobbied strongly in its second pincer that the SGR legislation should include requirements for practice accreditation for providers of imaging services and support for demonstration projects of imaging appropriateness criteria. The ACR argued that accreditation speaks directly to the quality of care delivered. Accreditation requires that imaging providers meet quality and safety standards that encompass overall practice, including personnel, equipment, quality assessment activities and ultimately the quality of patient care. Accreditation raises the bar and culls out substandard providers. We have seen this with the Mammography Quality Standards Act (MQSA), and MQSA served as a model for discussion. The ACR further pointed out that properly applying appropriateness criteria should limit utilization to those care situations where imaging is truly needed, thereby saving money through elimination of unnecessary procedures. The magnitude of potential savings appears substantial based on research documenting excessive use of imaging by self-referring physicians. Better, more objective utilization of imaging also improves safety—radiation exposure is avoided whenever an unnecessary procedure that involves ionizing radiation can be eliminated. We now know, of course, that Congress overrode the President’s veto on July 15, 2008 to pass the Medicare Improvement for Patients and Providers Act of 2008 1021
1022 ACR Chair’s Memo
(H.R.6331). The act blocked the impending 10.6% payment cut. The legislation extended for all of 2008 what had been a temporary 0.5% increase for the first six months of 2008 and added another 1.1% increase that will take effect for calendar year 2009 giving physicians 18 months of relief. In parallel with its financial provisions, the Medicare Improvement for Patients and Providers Act of 2008 includes the two high priority issues sought by the ACR—requirements for accreditation and support for demonstration projects of appropriateness criteria. The College succeeded in keeping these two highly important, long-term goals literally completely intact in the legislation and including timelines for implementation. I believe these provisions in the legislation constitute a victory for the American public as much as for the ACR, because the public will be better served by our health system as a result. It is often difficult to assess the role of any one organization in shaping and stewarding congressional legislation, especially when many groups have the same aligned interests. In this case, there can be no doubt between cause and effect, because there is a clear one-to-one relationship between what the College undertook to support in terms of accreditation and appropriateness and what ensued legislatively. It has been a true milestone achievement. Congratulations to all involved. While it is extremely gratifying that Congress acted as it did to repeal the cuts in Medicare reimbursement and also to support the ACR legislative provisions, the process that we have gone through highlighted something that may be even more important to the College and all of us as
members going forward—we have received broad-based feedback during the legislative process that the College is highly regarded in Washington—this increases our effectiveness with Congress and the Centers for Medicare & Medicaid Services. The high regard appears to be based on several factors. First, the unique agenda specific to the ACR throughout this legislative process was fundamentally aimed at improving the quality of care delivered to and received by patients in the United States and was further aimed at ensuring the appropriateness of that care. This posture of the College agenda is in sharp contrast to that of many—perhaps most— organizations that approach Congress. Most agendas are clearly about the special interests of respective interest groups and are not aimed at the welfare of the American public at large. I believe this is an incredibly important lesson for us—if we can first and foremost take our patients’ interests and those of the health system into consideration and then develop our agenda to coalign with those interests, we are likely to be successful in the long run. We may not always find issues that are as well aligned with the public’s interests as accreditation and appropriateness, but the point is, we should always look for them and when we find them, act accordingly. Another factor contributing to the strong reputation of the College in Washington is recognition of our level of commitment and the willingness of knowledgeable members of the College to come to Capital Hill to meet with their representatives and to tellthewonderfulstoryofradiology— over three hundred radiologists visited Capitol Hill as part of the ACR
Annual Meeting and Chapter Leadership Conference. Member volunteers are supported by an outstanding government relations staff that has earned the trust of members of Congress and their staffs, and through that trust our staff has built important and effective relationships on Capital Hill. All physicians won an important victory with the recent legislation, and we have once more dodged the bullet of substantial Medicare reimbursement cuts. However, the victory is more of a reprieve than a definitive solution. The cumulative balance related to the SGR process is now estimated at well over $50 billion. These dollars must be “paid back” if Congress fails to extend its annual overrides of the SGR calculations. The ensuing chaos in the health care system would be overwhelming, so this is unlikely to happen, but the risk and threat are still there. Because of the foregoing considerations, no one should declare the SGR battle over and strike the props. It is my anticipation that as soon as we have a new Congress and a new administration in place, we will need to go back to work as hard as ever. The ACR will work toward a permanent fix for the flawed SGR formula and development of a physician payment system that keeps up with the increasing costs of medical practice. We will continue to work toward widespread adoption of appropriateness criteria and other policies that promote objective evidence based utilization of imaging. We will undoubtedly need to respond to other health care reforms that are likely to be proposed after the election. We are ready.
James H. Thrall, MD, Massachusetts General Hospital, Dept of Radiology Rm 216; 32 Fruit St, Boston MA; e-mail: [email protected].