- Email: [email protected]
Tales from the Table
REIMBURSEMENT ROUNDS KURT A. SCHOPPE, MD
Tales from the Table Kurt A. Schoppe, MD, Lauren Golding, MD “Everything is complicated if no one explains it to you” [1]. The mechanics of reimbursement in health care are important. We achieve powerful insight into the practice of radiology and medicine when we choose to explore and understand the mechanics of how we are paid as physicians. In this column, I have heretofore taken a more philosophical approach to the issue of reimbursement, choosing to look at the big picture. I think it is critical to understand trends in the business of medicine and politics. Nevertheless, we cannot ignore the details. There are many reasons to invest time in understanding the reimbursement process, which involves a degree of personal and professional advocacy. Perhaps the most important is that it helps us control our emotions. As leaders in our practices or departments, we can avoid reacting with fear or frustration to decreases in reimbursement when we understand the context for these changes. For instance, the reimbursements for certain interventional radiology procedures were decreased significantly in the past 5 years, but the value of many pathology and radiation oncology procedures were decreased even more. When we engage in strategic planning and long-term goal setting, we must also temper unrealistic expectations. It is ill advised to presume flat or rising reimbursement levels, especially compared with inflation, given what we know about the mandates for containing
spending within Medicare. In this way, our understanding of the reimbursement process helps us preserve our sense of agency in a climate where it is easy to feel lost. So, let us look more deeply into one of the controversial aspects of the reimbursement process, the Relative Value Scale Update Committee (RUC). This body debates the relative value units for each medical procedure and recommends a final value to Medicare. As the RUC Advisor for the ACR, I lead the team when presenting codes at the RUC meeting. My perspective on the process may have merit, but I think an introduction is better achieved through the eyes of a newcomer. Dr Lauren Golding attended the most recent RUC meeting for the first time and agreed to write about her experience. The following is her account.
TALES FROM THE TABLE I had the privilege of attending the AMA/Specialty RUC meeting for 4 days at the end of April. In the months leading up to the meeting, I kept hearing references to what I gathered had to be a very venerable piece of furniture central to the valuation process: “The Table.” I learned that most people attended years of RUC meetings before approaching The Table. That you better have your act together when presenting at The Table. The description of the imposing characters seated at The Table reminded me of the grilling one might have received at a certain Louisville hotel during oral
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.06.009
boards. Although intrigued, I wasn’t entirely sure what to expect. By the end of the meeting, my introduction to this literal table revealed new ways the ACR advocates for the value radiologists bring to the proverbial health care table.
Setting the Table In the months leading up to the April RUC session, I was copied on 79 emails regarding the 30 codes that would be presented. (Schoppe: My e-mail count shows 271.) I interloped on five conference calls lasting up to 2 hours, many of which were coordinated with other specialty societies. (Schoppe: My calendar shows 13.) These are not superfluous communications, but spreadsheet-laden messages of generous complexity, with language requiring a secret decoder pen for translation. Acronyms and jargon proliferate to an extent that rivals the most convoluted bureaucratic endeavor; understanding the language is a sizable hurdle before one could ever hope to comprehend the nuances of presenting codes. I am still waiting for my decoder pen. One of the central components to effectively translating our value into reimbursement (by way of relative value units) is data. Massive amounts of data. Charts and calculators and databases and countless hours spent by staff and ACR volunteers acquiring and understanding how best to use these data to demonstrate the real work invested
1
by radiologists to nonradiologists who are neither inclined to appreciate nor reward it. The ACR is so adept at processing and presenting data that other specialty societies look to us as leaders when presenting codes for which we are not the primary provider. Through the dedication and behind-the-scenes effort invested by our RUC team, the ACR skillfully and effectively sets The Table.
Table Manners Immediately upon my arrival, I was struck by the respect with which the ACR is viewed by CMS, the AMA, and other specialty societies, both as advisors presenting at The Table and as RUC members seated at The Table. This is a direct testament to years spent establishing credibility through hard work, diligence, and integrity. The legacy of RUC advisors is one of brilliance, collaboration, and character; in the end, this is undoubtedly our greatest strategic strength. I quickly learned that the reputation of the ACR is built on a certain etiquette, a few core table manners that govern our approach to what can be thorny and contentious endeavors. The most important of these recurred throughout the meeting as we saw the success or failure of other presenters hinge on their ability to master it: The importance of brevity or silence cannot be overstated. Although this is a solid life lesson in general, it is imperative to success at the RUC. Resisting the urge to argue one more
point, bristle against one more slight, respond indignantly to one more misconception is not for the faint of heart, but an inability to do so at The Table is a recipe for disaster. The second salient table manner I came away with is the concept that strategic concessions and compromise can be advantageous when the time comes to fight for what really matters. Yet another critical life lesson, mastering the ability to pick your battles is essential to success at the RUC and another skill that the ACR has historically brandished with expertise.
A Seat at the Table Maintaining a seat at The Table is critical for radiology. This is unquestionably accomplished at the literal table of the RUC. At the very same time, the ACR is also ensuring that we have a figurative seat at The Table in a value-based payment system. With RUC proceedings in the background, a fledgling model for a radiology-specific alternative payment model was born from scrawled diagrams and whispered conversation among the ACR team. How Does This Help Me? I would like to highlight a few things from Dr Golding’s dispatch. The valuation process is undeniably human. Although there are data and some quantitative rigor, there is also psychology, and emotion, and all the messiness therein. As such, advocacy plays an important role in the
process, especially for our patients. No one approaches the valuation process with malice, but we all bring our own perspective on how best to serve our patients, including Medicare. Although we as physicians naturally focus on the patient right in front of us, Medicare is concerned with caring for all their beneficiaries; they numbered approximately 55 million in 2015 [2]. The weight of responsibility hangs heavily at The Table. Therefore, the valuation process is at best unpredictable. Maybe even capricious. But before convicting the current process of malfeasance, you must consider the alternatives, and so far, I haven’t been presented with one I would prefer. Several years ago, I chose to involve myself in the health care reimbursement process. What I learned then informs decisions I make now in how I provide care to my patients and manage challenges with my group. I choose not to approach changes in reimbursement from a fatalistic point of view, but with a realistic optimism. The people that make the decisions in the trenches, at the RUC and at Medicare, do share a common goal. We all want to care for our patients.
REFERENCES 1. Backman F. My grandmother asked me to tell you she’s sorry. New York, NY: Atria Books; 2015. 2. The Henry J. Kaiser Family Foundation. Total number of Medicare beneficiaries. Available at:. http://kff.org/medicare/state-indicator/totalmedicare-beneficiaries/. Accessed May 30, 2017.
Kurt A. Schoppe, MD, Lauren Golding, MD, are from Radiology Associates of North Texas, PA, Fort Worth, Texas. The authors have no conflicts of interest related to the material discussed in this article. Kurt A. Schoppe, MD: Radiology Associates of North Texas, PA, 816 W Cannon St, Fort Worth, TX 76104; e-mail: kschoppe@ radntx.com.
2
Journal of the American College of Radiology Volume - n Number - n - 2017
Tales from the Table Kurt A. Schoppe, MD, Lauren Golding, MD “Everything is complicated if no one explains it to you” [1]. The mechanics of reimbursement in health care are important. We achieve powerful insight into the practice of radiology and medicine when we choose to explore and understand the mechanics of how we are paid as physicians. In this column, I have heretofore taken a more philosophical approach to the issue of reimbursement, choosing to look at the big picture. I think it is critical to understand trends in the business of medicine and politics. Nevertheless, we cannot ignore the details. There are many reasons to invest time in understanding the reimbursement process, which involves a degree of personal and professional advocacy. Perhaps the most important is that it helps us control our emotions. As leaders in our practices or departments, we can avoid reacting with fear or frustration to decreases in reimbursement when we understand the context for these changes. For instance, the reimbursements for certain interventional radiology procedures were decreased significantly in the past 5 years, but the value of many pathology and radiation oncology procedures were decreased even more. When we engage in strategic planning and long-term goal setting, we must also temper unrealistic expectations. It is ill advised to presume flat or rising reimbursement levels, especially compared with inflation, given what we know about the mandates for containing
spending within Medicare. In this way, our understanding of the reimbursement process helps us preserve our sense of agency in a climate where it is easy to feel lost. So, let us look more deeply into one of the controversial aspects of the reimbursement process, the Relative Value Scale Update Committee (RUC). This body debates the relative value units for each medical procedure and recommends a final value to Medicare. As the RUC Advisor for the ACR, I lead the team when presenting codes at the RUC meeting. My perspective on the process may have merit, but I think an introduction is better achieved through the eyes of a newcomer. Dr Lauren Golding attended the most recent RUC meeting for the first time and agreed to write about her experience. The following is her account.
TALES FROM THE TABLE I had the privilege of attending the AMA/Specialty RUC meeting for 4 days at the end of April. In the months leading up to the meeting, I kept hearing references to what I gathered had to be a very venerable piece of furniture central to the valuation process: “The Table.” I learned that most people attended years of RUC meetings before approaching The Table. That you better have your act together when presenting at The Table. The description of the imposing characters seated at The Table reminded me of the grilling one might have received at a certain Louisville hotel during oral
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.06.009
boards. Although intrigued, I wasn’t entirely sure what to expect. By the end of the meeting, my introduction to this literal table revealed new ways the ACR advocates for the value radiologists bring to the proverbial health care table.
Setting the Table In the months leading up to the April RUC session, I was copied on 79 emails regarding the 30 codes that would be presented. (Schoppe: My e-mail count shows 271.) I interloped on five conference calls lasting up to 2 hours, many of which were coordinated with other specialty societies. (Schoppe: My calendar shows 13.) These are not superfluous communications, but spreadsheet-laden messages of generous complexity, with language requiring a secret decoder pen for translation. Acronyms and jargon proliferate to an extent that rivals the most convoluted bureaucratic endeavor; understanding the language is a sizable hurdle before one could ever hope to comprehend the nuances of presenting codes. I am still waiting for my decoder pen. One of the central components to effectively translating our value into reimbursement (by way of relative value units) is data. Massive amounts of data. Charts and calculators and databases and countless hours spent by staff and ACR volunteers acquiring and understanding how best to use these data to demonstrate the real work invested
1
by radiologists to nonradiologists who are neither inclined to appreciate nor reward it. The ACR is so adept at processing and presenting data that other specialty societies look to us as leaders when presenting codes for which we are not the primary provider. Through the dedication and behind-the-scenes effort invested by our RUC team, the ACR skillfully and effectively sets The Table.
Table Manners Immediately upon my arrival, I was struck by the respect with which the ACR is viewed by CMS, the AMA, and other specialty societies, both as advisors presenting at The Table and as RUC members seated at The Table. This is a direct testament to years spent establishing credibility through hard work, diligence, and integrity. The legacy of RUC advisors is one of brilliance, collaboration, and character; in the end, this is undoubtedly our greatest strategic strength. I quickly learned that the reputation of the ACR is built on a certain etiquette, a few core table manners that govern our approach to what can be thorny and contentious endeavors. The most important of these recurred throughout the meeting as we saw the success or failure of other presenters hinge on their ability to master it: The importance of brevity or silence cannot be overstated. Although this is a solid life lesson in general, it is imperative to success at the RUC. Resisting the urge to argue one more
point, bristle against one more slight, respond indignantly to one more misconception is not for the faint of heart, but an inability to do so at The Table is a recipe for disaster. The second salient table manner I came away with is the concept that strategic concessions and compromise can be advantageous when the time comes to fight for what really matters. Yet another critical life lesson, mastering the ability to pick your battles is essential to success at the RUC and another skill that the ACR has historically brandished with expertise.
A Seat at the Table Maintaining a seat at The Table is critical for radiology. This is unquestionably accomplished at the literal table of the RUC. At the very same time, the ACR is also ensuring that we have a figurative seat at The Table in a value-based payment system. With RUC proceedings in the background, a fledgling model for a radiology-specific alternative payment model was born from scrawled diagrams and whispered conversation among the ACR team. How Does This Help Me? I would like to highlight a few things from Dr Golding’s dispatch. The valuation process is undeniably human. Although there are data and some quantitative rigor, there is also psychology, and emotion, and all the messiness therein. As such, advocacy plays an important role in the
process, especially for our patients. No one approaches the valuation process with malice, but we all bring our own perspective on how best to serve our patients, including Medicare. Although we as physicians naturally focus on the patient right in front of us, Medicare is concerned with caring for all their beneficiaries; they numbered approximately 55 million in 2015 [2]. The weight of responsibility hangs heavily at The Table. Therefore, the valuation process is at best unpredictable. Maybe even capricious. But before convicting the current process of malfeasance, you must consider the alternatives, and so far, I haven’t been presented with one I would prefer. Several years ago, I chose to involve myself in the health care reimbursement process. What I learned then informs decisions I make now in how I provide care to my patients and manage challenges with my group. I choose not to approach changes in reimbursement from a fatalistic point of view, but with a realistic optimism. The people that make the decisions in the trenches, at the RUC and at Medicare, do share a common goal. We all want to care for our patients.
REFERENCES 1. Backman F. My grandmother asked me to tell you she’s sorry. New York, NY: Atria Books; 2015. 2. The Henry J. Kaiser Family Foundation. Total number of Medicare beneficiaries. Available at:. http://kff.org/medicare/state-indicator/totalmedicare-beneficiaries/. Accessed May 30, 2017.
Kurt A. Schoppe, MD, Lauren Golding, MD, are from Radiology Associates of North Texas, PA, Fort Worth, Texas. The authors have no conflicts of interest related to the material discussed in this article. Kurt A. Schoppe, MD: Radiology Associates of North Texas, PA, 816 W Cannon St, Fort Worth, TX 76104; e-mail: kschoppe@ radntx.com.
2
Journal of the American College of Radiology Volume - n Number - n - 2017