Endobronchial Ultrasonography A Sublime Procedure and a Guide to the Proper Valuation of Health Care Kevin L. Kovitz, MD, FCCP Chicago, IL
Start with the obvious. Endobronchial ultrasonography (EBUS) has revolutionized the diagnosis and staging of lung cancer and other thoracic pathologic conditions. The literature overﬂows with support of its beneﬁts, and the paper by Gildea and Nicolacakis1 in this issue of CHEST alludes to the nearly 1,000 papers published previously. I would go so far as to state that EBUS has had a more profound and practical impact on the care of patients with thoracic cancer and those with benign conditions than all the more recent genetic testing, targeted therapy, high-technology robotics, and other media-worthy treatments of the past 5 years. By properly staging, avoiding unnecessary procedures and risk of complications, directing the patient to the most effective therapy quickly and efﬁciently, outcomes and quality of life cannot help but be positively impacted. This positive impact is tempered by the barrier created by the limited reimbursement for EBUS, which can impact patient access. Bronchoscopy, and by extension EBUS, is the “Calvin Coolidge of procedures,” whereas sexier technologies with less beneﬁt “sell.” No matter how useful a technology is, it will likely not reach the maximal number of patients who need it if it is not FOR RELATED ARTICLE SEE PAGE 1387
AFFILIATIONS: From the Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: K. L. K. is the Chair of the Clinical Practice Committee of the American Thoracic Society and Alternate Member for CHEST to the American Medical Association RUC Committee. CORRESPONDENCE TO: Kevin L. Kovitz, MD, FCCP, 840 S Wood St, Room 920-N CSB, MC 719, Chicago IL 60612; e-mail: [email protected]
Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.06.028
ﬁnancially viable for an institution or practitioner. The fact that ﬁnancially challenging technologies succeed at all in medicine is a testament to the altruism built into the system—speciﬁcally, that of the practitioner. We need to understand the beneﬁts and barriers to EBUS so that we can ﬁnd the optimal way to deploy this very necessary technology. First, we have to understand how reimbursement for a procedure is developed and how that procedure ﬁts into the overall reimbursement environment. Second, we need to step back and decide how best to deploy the procedure for highest quality and efﬁciency. Finally, we should take the lessons learned and use these to prepare for any changes in models of health-care payment. In this area, EBUS deployment can serve as a guide for ﬁnancially challenging times. How are procedures valued? This is not the place for a full discussion of the code development and valuation processes run by the American Medical Association or the subsequent setting of the fee schedule by the Centers for Medicare and Medicaid Services. There are myriad published summaries of the process,2 as well as explanations provided by the American Medical Association.3 The bottom line is that each procedure or encounter is given a relative value multiple or unit (RVU) compared with the value of other procedures or encounters in the system overall. The value of one unit is determined annually by the Centers for Medicare and Medicaid Services and adjusted for region. The pros and cons of the system have been discussed elsewhere. In my view, it is simply the system we currently have and we need to understand it, work within it, and adjust our approach to best survive it until the next system comes along. Gildea and Nicolacakis1 review how EBUS has been used, how a procedure code is valued, and the new Current Procedural Terminology4 codes for EBUS as well as EBUS reimbursement for the practitioner and how that reimbursement is decreasing. It gives one pause when a transformative technology that improves care, yields, safety, time to diagnosis, and treatment is reimbursed less than that which it supplants, beats, or enhances (ie, mediastinosocpy5-7) and is valued even lower once it has gained substantial traction. However, the process has its own internal logic and it is simply the reality. Medicare is a zero sum game. There is a ﬁnite pool of dollars to pay for it. If new technologies and treatments enter the market,
they squeeze in with already-present efforts. If volumes go up for a particular procedure, the pressure is to decrease reimbursement per procedure or for other things, creating a net zero increase. In the current system, a procedure is valued based on the work and risk involved in the procedure itself and not on the value to the patient or system overall. Therefore, how do we deploy a technology in this environment? We need to properly value and evaluate the role of each new technology. If something is introduced, it will not survive only because it is the right new technology. When introducing EBUS to a health-care system or new market, we need to focus on proper training, high yields, and accessibility for patients. However, none of these can take a back seat to the ﬁnancial concerns. Practitioners and the systems they work in have to be able to initially afford and then sustain the technology to offer it. Training and yields are topics for another time. My personal bias as an interventional pulmonologist is that dedicated highvolume practitioners should perform EBUS whether they are pulmonologists, interventional pulmonologists, or thoracic surgeons. Although the qualiﬁcations of who should perform EBUS are the topic for another time, the ﬁnancial reality demonstrated by Gildea and Nicolacakis1 should help inform us about how best to deploy it now. There is opportunity here that must be embraced. The introduction of EBUS is phenomenally positioned as the model for how to adapt to an evolving health-care payment environment. Payment for services will continue to change with a planned emphasis on quality and cost. The Medicare Access and CHIP Reauthorization Act of 2015 includes options for a merit-based incentive payment system and alternative payment models.8 A merit-based incentive payment system will consider quality measures, improvement in electronic health records, clinical practice improvement, and cost to impact physician payment. Alternative payment models take an approach of an at-risk lump sum payment approach. Various models can be created that are targeted at improving quality of care while improving efﬁciency and overall cost to the potential beneﬁt of patient care and provider bottom line. EBUS serves as a model of more efﬁcient care delivery. Its proper use in lung cancer diagnosis and staging can reduce the number of procedures, costs, and complications.9 It is predominantly an outpatient procedure, which means it does not need to be present in each and every institution. It is reimbursed to the institution per procedure in a way that covers the capital
expense over time if done in volume. Its professional reimbursement is such that it does not make sense for all practitioners to shoulder the ﬁnancial burden of performing the procedure. The most cost-effective approach for those who perform the procedure is not to perform it at all, which ﬂies in the face of the basic assumption that procedures pay more. However, as a much needed procedure, some must shoulder the ﬁnancial burden to have it available to many. The practitioners who do it need to be doing so in volume to maximize efﬁciency and in an environment that is not driven on purely ﬁnancial grounds. The RVU can be the enemy of the pulmonary proceduralist if we rely exclusively on total RVUs for compensation. This may actually distort the incentive for proper patient care. In preparing for alternative payment models of care, assessment can be made of the potential volume of patients and geography to be covered to estimate the number of skilled practitioners needed. A regional approach to EBUS and related procedures or care seems prudent and could also be ﬁnancially supported regionally. Signiﬁcant collaboration is needed within and across institutions, and an equitable payment model must be developed. Any model of ﬁnancial distribution based solely on the common RVU model will have the same pitfalls as the current system. Efforts directed at incorporation of EBUS into a program can serve as a guide for building an all-encompassing, high-quality, more cost-efﬁcient system of care delivery for the patient undergoing thoracic procedures. Such a care model can serve as a guide to valuing care by more than the dollars and cents of a procedure but rather by the value provided to the patient in care and to the system in cost and efﬁciency. Such efforts ﬁt with the goals of the newer payment models. I know this is challenging. I have worked in enough settings, academic and community as well as public and private, and have been through enough hospital mergers and acquisitions to know that it is difﬁcult to get collaboration even within groups, divisions, or departments, let alone between competing practices, multiple hospitals within a network, and competing institutions. However, we must adapt. We must collaborate to survive!
References 1. Gildea TR, Nicolacakis K. Endobronchial ultrasound: clinical uses and professional reimbursements. Chest. 2016;150(6):1387-1393. 2. National Health Policy Forum. The Basics: Relative Value Units (RVUs). Washington, DC, January 12, 2105. http://www.nhpf.org/ library/the-basics/Basics_RVUs_01-12-15.pdf. Accessed June 6, 2016.
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3. American Medical Association. The Medicare Physician Payment Schedule. http://www.ama-assn.org/ama/pub/physician-resources/ solutions-managing-your-practice/coding-billing-insurance/ medicare/the-medicare-physician-payment-schedule.page. Accessed June 6, 2016. 4. CPT - Current Procedural Terminology CPT is registered trademark of the American Medical Association. http://www.ama-assn.org/ ama/pub/physician-resources/solutions-managing-your-practice/ coding-billing-insurance/cpt/about-cpt/cpt-process.page? Accessed September 8, 2016. 5. Vilmann P, Clementsen PF, Colella S, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Endoscopy. 2015;47(6):545-559.
6. Um SW, Kim HK, Jung SH, et al. Endobronchial ultrasound versus mediastinoscopy for mediastinal nodal staging of non-small-cell lung cancer. J Thorac Oncol. 2015;10(2):331-337. 7. Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer. JAMA. 2010;304(20):2245-2252. 8. Centers for Medicare and Medicaid Services. Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA. https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/Value-Based-Programs/MACRAMIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed June 6, 2016. 9. Almeida FA, Casal RF, Jimenez CA, et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782.