ACR and RBMA Update on Congressional Activities and Medicare Payment Policies
On December 16, 2008, the RBMA hosted a Webinar to update members on ACR congressional activities and Medicare's payment policies for 2009. The first of the three presenters was Joshua Cooper, senior director of government relations for the ACR. According to Cooper, the ACR was able to achieve all of its legislative goals with the passage and enactment of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) on July 15, 2008. It should be noted that the legislation passed after both the House and Senate voted to override a presidential veto. The ACR may wield significantly more clout with this Congress due, in part, to its sizable campaign contributions. The ACR was the third-highest health professional political action committee contributor to federal candidates, and almost 90% of the candidates that it supported won their elections. The goals for 2008 were:
  • avoiding a 10.6% Medicare conversion-factor (sustainable growth rate) cut for physicians;
  • implementing mandatory imaging accreditation standards for advanced modalities (MRI, CT, PET, and nuclear medicine);
  • funding the Appropriateness Criteria Demonstration Project; and
  • avoiding additional technical-component reductions to pay for the delay in physician-payment cuts.
The MIPPA legislation that accomplished these feats barely halfway into the year reversed a scheduled midyear 2008 Medicare Physician Fee Schedule (MPFS) conversion-factor rate of –10.6%, with a 0.5% update (retroactive to July 1, 2008) through the end of 2008. It set a 1.1% increase in the MPFS conversion-factor rate for 2009, and it required medical imaging providers to be accredited by January 1, 2012, to receive payments from Medicare for MRI, CT, PET and nuclear-medicine procedures. MIPPA also established the Appropriateness Criteria Demonstration Project to test the use of physician-developed appropriateness criteria. There were no further imaging cuts. Reviewing these achievements, Cooper adds, “This legislative victory was made possible by the intense advocacy and educational efforts of ACR and RBMA members and staff.” The ACR may wield significantly more clout with this Congress due, in part, to its sizable campaign contributions: Cooper reported that the ACR was the third highest health professional political action committee (PAC) contributor to federal candidates, and almost 90% of the candidates that it supported won their elections. ACR PAC contributions totaled $1.05 million, of which $583,000 went to Democrats. Cooper concluded his portion of the Webinar by renewing a call for ACR members to be active and to work closely with the RBMA. Following Cooper, Bibb Allen, Jr, MD, RCC, FACR, chair of the ACR Economics Commission, discussed economic issues for 2009. Allen opened his section with the question, “Did you know 95% of coverage and payment decisions occur at the local level?” The question set the stage for the ACR’s focus on local coverage determinations. In his recap of 2008 accomplishments, Bibb cited three positive developments. First, the CMS Carrier Advisory Committee Network continues to review and comment on draft local coverage determinations. Second, all states now have local coverage determinations for cardiac CT and coronary CT angiography (CCTA) and for CT colonography (CTC) for incomplete colonoscopy. Third, 24 states cover CTC when diagnostic colonoscopy is contraindicated. The emphasis on the effort to improve local coverage determinations is due to handicaps within the national coverage determinations (NCDs) that could severely affect patient care. According to Allen, NCDs can be “extremely restrictive” and “deny coverage completely.” Allen then discussed the status of three specific areas of care: cardiac CTA, CTC, and cardiac MRI. For cardiac CTA, Allen noted that all 50 states and Washington, DC, have adopted final and draft local coverage determinations, the majority of which contain language from the ACR/American College of Cardiology models. The cardiac CTA process presents a separate set of challenges, and an NCD decision will probably take a year. Allen referred to CTC coverage status as “déjà vu all over again,” and listed the top concerns and extracolonic findings (and associated costs) and radiation exposure. For IDTF proposals, one of the most visible subjects for 2009, Allen provided an update on the ACR’s efforts to standardize protocols. CMS proposed that IDTF standards apply to all sites that provide any type of imaging and that physicians’ offices must enroll as IDTFs. ACR agreed with CMS, and suggested initially applying regulation only to advanced imaging. CMS stated that because of MIPPA provisions and accreditation for all in 2012, it would delay implementation, but would finalize the proposal in the future if needed. Pamela Kassing, MPA, RCC, senior director of economics and health policy for the ACR, highlighted the top 2009 Ambulatory Payment Classification (APC) topics for hospital-based outpatient imaging. Five new APC groups were created: ultrasound, CT/CTA with contrast, CT/CTA without contrast, MRI/MRA with contrast, and MRI/MRA without contrast. These groups are meant to address the Medicare Payment Advisory Commission’s continued comments that the multiple-procedure reduction rule should be applied in the hospital outpatient setting (the ACR has argued, in the past, that this rule should not apply because hospitals already report their actual costs). When two or more of these studies are done in the same session, hospitals report one claim and one bundled payment is made. The presenters concluded that continued physician involvement in legislative and economic issues is key to the successful representation of the specialty on national and local levels.