AUA protests proposed CMS payment caps

Washington-While it is still unclear whether and how Congress will reform the Medicare sustainable growth rate (SGR) formula in time to avoid a 25% payment cut beginning in January, many physician groups, including the AUA, are adamantly opposed to another key component of the proposed 2014 Medicare Physician Fee Schedule.

Although Congress is almost completely absorbed with its ongoing budget battles and ideological differences over the Patient Protection & Affordable Care Act, there are signs that key lawmakers in both the House and Senate have been working to develop a workable SGR plan. Whether that will materialize given the budget fight that has angered legislators on both sides of the aisle remains to be seen.

Meanwhile, the AUA and other physician groups find themselves grappling with a proposal from the Centers for Medicare & Medicaid Services to cap payment rates for some 211 in-office physician services at outpatient or ambulatory surgery center (ASC) rates. According to the AUA, 15 urology-related codes would be affected, and the organization has submitted a detailed letter to CMS explaining why the proposal is misguided and should be withdrawn.

In addition, the AUA joined the American Medical Association and 40 other medical organizations in signing a letter warning that the proposal would reduce payments for some services by 50% or more, potentially driving them out of physician offices and requiring patients to obtain the services in a more costly, less convenient setting.

“An AMA analysis found that, for 82% of the codes with proposed reductions, the direct expenses alone (ie, clinical labor, supplies, and equipment employed in the service as adopted and implemented by CMS) exceed the proposed payment rate,” the AMA’s letter said. Moreover, it argued that 78 of the 211 services proposed for reductions are already paid less than the outpatient rate, so if they were removed from physician offices and transferred to hospital outpatient departments, the cost would actually be higher.

15 urology-related codes affected

According to the AUA, 15 urology-related codes would be affected, with CMS proposing to cap the payment amounts at the ASC rate, “which would not cover the supply costs for these services in the nonfacility setting,” the AUA explained in its letter signed by David F. Penson, MD, MPH, chair of the AUA’s Health Policy Council.

As an example, the AUA cited the current direct practice expense (PE) cost with the proposed ASC payment rate for CPT code 51729: Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique.

“This service requires a sophisticated urodynamic system to precisely measure filling and emptying of the bladder, pressure inside the bladder, and record muscle and nerve activity. The use of special catheters, transducers, and tubing also are required during this procedure,” the AUA said in the letter.

Dr. Penson said the total payment for the code in the nonfacility setting is $347.37. The direct PE cost is $186, including payment for supplies, equipment, and clinical staff. CMS has proposed paying $130.36 for the service in 2014, substantially less than the costs incurred by the physician’s office.

Dr. Penson pointed out that preliminary analysis of several other codes indicate that the procedures were “almost entirely” performed in the office in 2012, not in ASCs or hospital outpatient departments. The AUA letter went on to take issue with other specific codes and the payment rates that would result from CMS’s proposal.

The AUA also argued that CMS did not provide sufficient information to allow medical societies to comment within the 60-day comment period.

“To introduce a proposal with ambiguous policy exemptions, inconsistent data payment rates, and a truncated comment period is both premature and ill advised,” Dr. Penson wrote.

The AUA said the codes it identified should be removed from the list of those covered, adding that CMS should withdraw its entire proposal until a comprehensive review has been completed.

AUA urges SGR fix

Meanwhile, focusing on the SGR controversy, the AUA co-signed a letter from the Alliance of Specialty Medicine to congressional leaders urging them to include a permanent replacement for the SGR on their list of priority provisions to be acted on by the end of the year.

“As you know, physicians treating Medicare beneficiaries face an insurmountable 25% payment cut beginning in 2014, as well as the multitude of other financial penalties related to Medicare’s quality improvement initiatives and an additional 2% sequestration pay cut,” the letter said.

“As a result, physicians are reconsidering their participation in the Medicare program, limiting the number of Medicare patients they see, or leaving the practice of medicine altogether,” it added. “Those who may remain in practice, or in Medicare, will not be able to make critical investments in their practice’s infrastructure to support new models of delivery that aim to improve quality and efficiency, including the adoption of health information technology.”

Thus, the Alliance and its members said, beneficiary access to high-quality health care will be jeopardized, with patients experiencing longer waiting time for appointments and lengthy travel to see a physician, especially specialists.UT

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