In many circles, the discussion of health care reform overshadows discussion about the economy. In others, the two topics are intertwined: the cost of health care is being blamed for the condition of the economy. In any case, President Obama has placed health care reform front and center on his agenda, and he’s told Congress he wants a bill on his desk this fall.
Both houses of Congress have agreed and were pushing for passage of bills by the end of July. If successful, the bills will need to be reconciled, and you will have the opportunity to contact your representatives while Congress is in recess. The current direction will not just affect the amount you are paid, but the way you practice.
The question is no longer if health care reform will occur, but when and what it will look like. It will take time, perhaps years, to implement any reform. For urologists, the real question is:
How will health care reform impact your practice next year and beyond? This article will discuss the likely near- and long-term changes you can expect.
Changes in 2010
Hopefully, Congress will act to avoid the approximately 20% scheduled decrease in Medicare payment. There is a chance that the flawed sustainable growth rate formula will be replaced. Watch this issue carefully.
There is a possibility that the political process will push passage of a bill to late in 2009 or early next year. If this occurs, we may face a situation in which the year begins with a reduced conversion factor, only to have a retroactive fix in place in early 2010. This, coupled with the beginning of the year deductible requirement, could create a cash flow problem in January and February.
We also expect continued downward pressure on “profit centers.” Each time there is an increased use of a code in a specialty, Medicare reviews the reasons for such an occurrence to be sure excess payment is not being made. For example, when urologists started setting up pathology labs, the Centers for Medicare & Medicaid Services recognized the labs as “profit centers,” and they moved to not only decrease the profit gained from pathology procedures, but also to decrease the opportunities for ownership.
Also keep an eye on these reimbursement scenarios in 2010:
Office procedures that are frequently billed together (eg, urodynamics) are being reviewed, and payment will probably decrease.
Changes in payment for imaging may occur. Potential exists for both a decrease in and restriction of payment for in-office services. Congress is concerned that the increase in the number of services results from “self referral” for profit.
The same is true for intensity-modulated radiation therapy.
In 2010, imaging is at the highest risk for lost reimbursement. In addition to the government and private payers being fully aware that imaging is the fastest growing cost in health care, there are data suggesting that physicians who own imaging centers order imaging tests more frequently. Radiologists are in an all-out war with other specialties to prevent the loss of “their” profit centers. We are not sure how it will occur, but we can anticipate a decrease in income from those services. That decrease will continue over the next several years.
Changes in 2011 and beyond
Initially, we don’t expect to see changes in the way physicians are paid in 2011. We think physicians can anticipate a continued decrease in fee-for-service payments and an increase in incentive payments for either practicing in a certain way or performing additional reporting for payment, eg, through Physician Quality Reporting Initiative participation and electronic prescription writing.
As with electronic prescriptions, bonus payments may be replaced in the near term with payment reductions assessed for non-participation in these programs.
In the long run, we will be seeing an increasing amount of income through incentive pay and a decreasing amount through fee for service. We would anticipate that Medicare will begin to make good on its promise to become a “value purchaser”, rather than a passive payer of health care services. This means physicians will be paid more for practicing “quality, cost-efficient care,” as opposed to being paid for providing services.
Other possible changes to watch for in 2011 and beyond:
There will be a push to force physicians into larger treatment “groups” with bundled payments. Some argue that this should be done by specialty. Unfortunately, the more likely scenario is that aggregation will occur among much bigger groups based on hospital systems, and hospitals will be responsible for managing the health care dollar—a big mistake, in our opinion. In addition, hospitals will be responsible for trying to coerce physicians into managing health care more efficiently, which will further strain physician-hospital relations.
The medical home.
The medical home places a provider at the center of care required for chronic disease management. The common thinking is to force all patients into the medical home for “coordination” of care. Urologists will need to provide additional management of patients who require greater care in order to be a participant in a medical home.
Your practice is going to be an open book. Payers are now publishing physicians’ fees, and different entities will be researching the number of procedures we do, the complications we have, etc. The single most important thing you can do to prepare for the future is make sure your office data attests to the cost efficiency of your practice. In addition, organize your practice so you can access and fully utilize available shared data from other urology practices, which will allow you to understand how you compare to your colleagues and the “standard” of care.
In summary, quality and data are going to be at the forefront of all of the discussions, but the real issue is cost. Prepare to change the way you practice as the rules change. Strongly consider becoming politically active by contacting your senator or representative. Reform is taking place in the public eye, but the real decisions are being made by the politicians. Other players will try to influence the system. If urologists do not bring pressure through direct or indirect lobbying efforts, decisions will be made for you.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Mark Painter is CEO of PRS Urology SC in Denver.
