Organized urology reiterates Independent Payment Advisory Board concerns

Washington-For urologists who strongly oppose key provisions of the Patient Protection & Affordable Care Act (ACA), upheld by the U.S. Supreme Court in late June, the best hope for change may lie in the ballot box rather than in the halls of Congress.

The ruling also means that the ACA's "value-based modifier" provisions, intended to tie physician Medicare payments to the quality and cost of care they provide, will go forward.

"Since the [ACA] was passed in 2010, organizations representing urologists nationwide have been working with lawmakers and regulators to demonstrate how certain provisions-including the establishment of the Independent Payment Advisory Board and the value-based modifier-will negatively impact physicians' ability to provide quality care to patients. Though we applaud the altruistic motives behind the legislation, it is a disservice to millions to provide health care without also providing a strong infrastructure through which care can be provided."

"There are parts of the law that we like," said David F. Penson, MD, MPH, the AUA's health policy chair, "like those assuring that more Americans will have health care coverage and those banning restrictions based on pre-existing conditions. But there are things that need to be changed." The IPAB, he said, "is effectively a rationing panel" whose decisions, designed to contain cost, will be directed essentially at physician Medicare payments.

The Alliance of Specialty Medicine, of which the AUA is a member, warns that the IPAB's authority is such that it will be extremely difficult for Congress to reject its recommendations, subjecting physicians to fee payment cuts without the opportunity for redress.

Regarding the value-based modifier, the ACA requires the Department of Health and Human Services to establish a separate, budget-neutral payment modifier to the Medicare fee schedule that is based on the relative quality and costs of care physicians or physician groups provide. The modifier is to be implemented in the 2013 rulemaking process and will become effective on Jan. 1, 2015, when the modifier will affect payments based on 2014 performance data.

Dr. Penson expressed concern that the payment modifier could adversely affect the ability of many patients to have access to appropriate medical services if Medicare implements value-based purchasing in such a way that providers are penalized for ordering these often-appropriate services.

"We need to take a good look at value-based purchasing," he said. "That gets to the concept of obtaining the best value for health care dollars, more appropriate use of health care services, and paying in a capitated manner. The payer agrees to pay 'x' amount of dollars for the episode of care-no more, no less-and it must meet certain quality standards. Urologists have to be sure their patients have access to appropriate medical services when needed. We want to make sure that patients have access to high-quality care. I worry that the value-based modifier may negatively affect this if not done properly."

Under the provision, physicians who provide quality care at lower cost to Medicare will receive higher payments, while those who increase Medicare costs without better results will see their payments reduced.

Dr. Penson said he is optimistic that change can be achieved through Congress.

"We are working with elected officials who understand our position and think the same way we do, and want to see high-quality health care maintained for Americans," said Dr. Penson.

That means putting the AUA's political action committee, UROPAC, to work, supporting candidates and lawmakers who agree with the organization's views on those key issues.

Change in Oval Office called crucial

"We are optimistic that we may be able to succeed," Dr. Penson said, "particularly if there is change in November. If Gov. Romney becomes president, he would be much more likely to sign a bill that would change the IPAB. That is a top priority for us."

The IPAB, Dr. Penson asserted, will affect all urologists, regardless of their practices.

"If that comes to pass in 2014, it will reduce reimbursement for health care providers," he warned. "It takes away Congress' responsibility and puts it in the hands of unelected individuals."

All of that is in addition to the Medicare fee schedule cuts that loom once again in January, unless a solution to the sustainable growth rate formula is found or unless Congress, once again, provides a reprieve.

If history is instructive, at least a temporary reprieve likely will occur during a lame duck session following the election, running up into the Christmas holidays. According to the published congressional schedule, the target date for the House to adjourn for the year is Dec. 14. The Senate has not set a date-no doubt a wise decision.

Bob Gatty, a former congressional aide, covers news from Washington for Urology Times.