On Thursday, November 19th, the House of Representatives passed HR 3961, The Medicare Physician Payment Reform Act of 2009. This legislation will repeal the flawed Sustainable Growth Rate (SGR) formula, eliminate all SGR debt, and provide an MEI (Medicare Economic Index) update for 2010 instead of a 21.2 percent Medicare physician payment cut.

The American Association of Clinical Urologists (AACU) have maintained our position that a permanent repeal of the SGR is one our top priorities. With the help of our grassroots, we have feverishly voiced our concerns to Congress of the consequences in not repairing the flawed system, and continuing these unsustainable, short term “fixes.”

The AACU thanks the Members of the House and encourages their colleagues in the Senate to move quickly before the payment cut is instituted in January 2010.

Please feel free to contact the AACU at info@aacuweb.org or call 847.517.1050 if you have any questions or would like any additional information or assistance on this legislative matter.

SGR Bill Expected on The House Floor This Week

The Medicare physician payment formula, The Sustainable Growth Rate (SGR), is seriously flawed and has been producing severe cuts that have required Congress to intervene and attempt to “Fix” repeatedly for the last several years.

Once again, physicians are looking at another round of cuts. In less than two months Medicare physician payments will be slashed by more than 21 percent!

The House of Representatives is expected to vote on HR 3961, The Medicare Physician Payment Reform Act of 2009,sometime this week. This legislation will work to fix this issue once and for all by:

• Repealing the SGR and providing an MEI (Medicare Economic Index) update for 2010 instead of a 21.2% Medicare physician payment cut.

• Eliminate all SGR debt accumulated after years of temporary, unfunded fixes.

• For 2011 and subsequent years, establish updates based on two new targets with significantly higher utilization growth allowances than the SGR.

• Re-set the new targets after five years to help reduce the likelihood of accumulated debt and future steep cuts under the new targets.

If you have not done so already, please visit AACU’s Legislative Action Center and allow your voice to be heard on Capitol Hill. Click here to send a message to your elected officials directly through the AACU website.

Please feel free to contact the AACU at info@aacuweb.org or call 847.517.1050 if you have any questions or would like any additional information or assistance on this legislative matter. 

Senate Finance Passes Health Reform Legislation

The Senate Finance Committee passed their version of health care reform legislation this afternoon by a vote of 14-9. Republican Senator Olympia Snowe (ME) joined all of the committee’s Democrats in voting for the legislation. All other Republicans voted no.

“Is this bill all that I want? Far from it. Is it all that it could be? No,” Snowe said. “But when history calls, history calls. And I happen to think the consequences of inaction dictate the urgency of Congress to take every opportunity to demonstrate its capacity to solve the monumental issues of our time.” (www.ThePolitico.com)

The legislation still has to be merged with the Senate HELP committee’s bill passed earlier this summer. There are still many unresolved issues and the final outcome still has to be decided. One of those questions is whether or not Senate Majority leader Harry Reid (D-NV) will include some version of a “Public Insurance Option” in the bill.

UPDATE - Weiner/Braley Self Referral Amendment Offered, then Withdrawn

During the House Energy and Commerce Committee’s markup of H.R. 3200, America’s Affordable Health Choices Act of 2009, Representatives Anthony Weiner (D-NY) and Representative Bruce Braley (D-IA) offered, then withdrew, an amendment to eliminate the in-office ancillary services exception for advanced medical imaging under the Stark law.

The American Association of Clinical Urologists (AACU) has been vehemently opposing this amendment, and aggressively educating lawmakers and staff on the ramifications to patient care if it would pass. The amendment would i ncrease inefficiencies and present significant barriersto appropriate screenings and treatments.

AACU will continue to advocate on behalf of our members and work with Congress to develop a health care reform bill that is beneficial to all stakeholders involved. If you have any questions about AACU efforts you can contact Joe Arite, AACU Federal Affairs Manager, at info@aacuweb.org.

Senator Baucus Releases Long Awaited Bill

Senator Max Baucus (D-MT), Chairman of the Senate Finance Committee, released his committee’s version of the health care reform bill on Wednesday. Baucus went ahead with the $856 billion bill without the bipartisan support he had sought. After months of closed-door talks, not one of the three Republicans involved in the bipartisan “Gang of Six” talks have endorsed the legislation.

The Committee is set to begin marking-up the bill on September 22 nd.

Click here to read the Chairman’s Mark

What’s included?

• People who earn as much as 133 percent of the federal poverty level ($14,440 for an individual, $29,400 for a family of four) would be eligible for Medicaid

• The measure includes a health insurance ‘exchange’ where people could buy insurance and a system of health care “co-ops” rather than a government-run health insurance plan.

• Paid for with an excise tax on high-end health insurance policies, lower payments to the Medicare Advantage program and with fees on medical device manufacturers, clinical labs, drug makers and health insurance companies.

• Imaging utilization rate would be increased from 50 percent to 65 percent for 2010-2013. The rate would be further increased to 75 percent beginning 2014.

• The Chairman‘s Mark would establish an independent Medicare Commission (hereafter the Commission) that would develop and submit proposals to Congress aimed at extending the solvency of Medicare, slowing Medicare cost-growth, and improving the quality of care delivered to Medicare beneficiaries.

• The Chairman‘s Mark would increase Comparative Effectiveness Research (CER) being done at the Agency for Healthcare Research and Quality ( AHRQ ), and establish a private, non-profit corporation that would be known as the ―”Patient-Centered Outcomes Research Institute.”

AACU will continue to provide updates on the proposed legislation in the Senate. If you have any questions about AACU efforts you can contact Joe Arite, AACU Federal Affairs Manager, at info@aacuweb.org.

AACU Submits Comments to CMS

The American Association of Clinical Urologists (AACU) along with the Rocky Mountain Urological Society, Sexual Medicine Society of North America, Indiana Urologic Association, Florida Urological Society, Oklahoma State Urological Association, Society for the Study of Male Reproduction, Society for University Urologists, Society for Urodynamics & Female Urology and the Society of Urologic Prosthetic Surgeons, submitted comments to the Centers for Medicare and Medicaid Services (CMS) in opposition of their propose rule on the 2010 Physician Fee Schedule. Click here to read our comments.

AACU Disappointed in Proposed Cuts to the 2010 Physician Fee Schedule

In Early July, the Centers for Medicare and Medicaid Services (CMS) released its proposed physician fee schedule for 2010, which includes a scheduled 21.5 percent reduction to Medicare physician payments due to the flawed sustainable growth rate (SGR) formula. In addition to the 21.5 percent cut, CMS projects that other proposed changes in this rule would reduce total Medicare payments to urology by 7 percent.

AACU is very concerned with these cuts and is actively working with CMS and Congress to remedy the situation.

CMS is allowing for public comments on this proposed rule. AACU is asking for all members to submit their comments online. Comments will be accepted until 5 P.M. Eastern on August 31, 2009.

AACU will continue to provide updates on the proposed physician fee schedule over the upcoming months. If you have any questions about AACU efforts to counter these proposed payment cuts you can contact Joe Arite, Federal Affairs Manager for AACU at 847-264-5930.

Statement from American Association of Clinical Urologist (AACU) President Dr. Jeffrey Frankel in Response to President Obama’s Comments Last Week

During President Obama's press conference on July 22, he stated that a surgeon would base a decision on how to treat a sore throat on the amount of reimbursement he/she would receive. It was quite disconcerting to hear physicians represented in this matter. Medical decisions are based on what is best for the patient. Doctors treat patients to the best of their ability and in the manner that their training and ethics require. The Hippocratic oath states that, "doctors will follow that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful." To infer, even indirectly, that physician are going to operate on a patient simply because of better reimbursement is an insult to the thousands of hard working surgeons of every specialty in the US.

The AACU, as does the administration, supports better coverage for millions of Americans while reducing the overall cost of healthcare in the country. It is clear that the inequities and inefficiencies in the medical malpractice system negatively affect the cost and quality of healthcare in America. More importantly, I hope the President and congress recognize that the practice of "defensive medicine" as a means of avoiding a legal action is a major contributor to healthcare cost. A federally mandated reform of the current medical tort system must be included in any final health reform package.

Urology, which takes care of millions of Medicare beneficiaries, has been heavily involved in a cooperative fashion to help formulate true healthcare initiatives that allow us to better care for our patients. The AACU, which represents 4,000 Urological specialists, wants to reaffirm its commitment to high quality, patient centered care that is based on the ethical practice of medicine. We hope the President will rethink his misplaced comment and continue to work with physicians in a positive and constructive fashion.

Senate HELP Committee Sends HealthCare Reform to Full Senate
The Senate Health, Education, Labor and Pensions Committee successfully passed a $600 billion healthcare bill that includes a public option plan. By a 13-10 vote along party lines, members endorsed the bill crafted by Sen. Ted Kennedy. It included 16 GOP amendments. The committee was the first congressional committee to approve any health bill, but how to pay for it still remains undetermined. The Senate Finance Committee, chaired by Senator Max Baucus (D-Montana), has yet to complete its work coming up for a way to pay for the plan.

Physician-Owned Hospitals Restrictions
In the first week of July, Senate Finance Chairman Senator Max Baucus (D-Montana) and the hospital lobby struck a deal to restrict physician’s ownership in hospitals. The hospital lobbying groups, represented by the American Hospital Association, the Catholic Health Association and the Federation of American Hospitals, agreed to reduce $155 billion in federal healthcare reimbursement over the next 10 years. In exchange, Senator Baucus would place restrictions on physician self-referral to hospitals in which they have an ownership interest and place strict limits on any further expansion of physician-owned hospitals. Specifically, this deal could include language not allowing new facilities to treat Medicare and Medicaid patients, unless they were already able to as of January 1, 2009. These restrictions are also present in House Democrats’ health reform proposal contained in House Resolution 3200, the America’s Affordable Health Choices Act.

As you might remember, similar language, regarding physician-owned hospitals, was included in House Resolution 2, the extension of the State Children’s Health Insurance Program (SCHIP) back in January. The section would have limited referrals to hospitals owned by the physician to only those facilities that had physician owners or inves­tors on January 1, 2009 and were eligible for Medicare reimbursement through a provider agreement on that date, much like this deal indicates.

House Democrats Release Full HealthCare Plan
The House Democrats formally introduced their Health Care Reform legislation on Wednesday called America’s Affordable Health Choices Act . It creates a government-run insurance plan to operate alongside private plans, it would require most employers to provide insurance for their employees, and it would still require individuals to purchase insurance. It also overhauls the SGR formula that the government uses to calculate payments to physicians. It replaces the sustainable growth rate (SGR) with a new system that calculates payments based on care coordination and efficiency. There are also some additional changes to Medicare, including reworking Medicare's Part D drug benefit, eliminating overpayments to private Medicare Advantage plans, and bundling payments to providers.

Originally, recommendations suggested raising the imaging utilization from the current assumption of 50% up to 90% or 95% for advanced imaging such as MRI and CT. The final House Bill increases this assumption to 75%. When calculating its reimbursement formula for diagnostic imaging services, the Centers for Medicare and Medicaid Services (CMS) currently assumes that imaging equipment is in use, on average, 50 % of the available time. This utilization rate is similar to the actual rate at which advanced imaging equipment operates. If this bill is enacted, it will then be 75%. Original proposals did not group ultrasound with other more advanced imaging services like CT and MRI, nor does this.

To pay for their healthcare legislation, House Democrats proposed tax increase on wealthy households, aiming to raise $540 billion over the next ten years with a package of taxes on families making $350,000 or more.

It passed both the House Ways and Means and Education and Labor Committees late last week.

Senate Leaders Release Healthcare Delivery Proposals

Senate Finance Committee Chair Max Baucus (D-MT) and Ranking Member Chuck Grassley (R-IA) released their proposal for reform of the current healthcare delivery system. This policy proposal document is the first of three such policy proposals that are scheduled to be released within the next month. Proposals regarding access to healthcare and financing will be released by the end of May. The document is divided into five sections: payment reform, long-term payment reforms, infrastructure investments, Medicare Advantage, and fraud/waste reduction.

In addition to changes to the value-based purchasing programs for hospitals, nursing homes, Medicare Advantage plan changes, and changes to payments for rehabilitation facilities, some of the major policy proposals in the document include:

• Extending the Physician Quality Reporting Initiative (PQRI) to include payments for participating in a qualified Maintenance of Certification (MOC) or completion of a MOC practice assessment;
• Requiring disclosure of financial interests in services provided through the in-office ancillary services exception to the Stark Law and to notify patients of other providers in their area, although it does not propose changes to any of the services currently allowed under the exception;
• Development of appropriateness criteria for the use of imaging services;
• Instituting primary care and certain general surgeon services bonus payments. If these payments are made “budget neutral,” the cost of these payments could be set by reductions in payments to specialty providers.
• Bundling of payments for treatments requiring hospital stays;
• Changing the Sustained Growth Rate formula. Two policy options are considered here, although the document states that others are under consideration as well. The first would update the fee schedule by 1% in both 2010 and 2011 and 0% in 2012. It would then go back to the current law in 2013. The second option would be the same, except that, beginning in 2012, a floor of –3% would be set. Beginning in 2014, for those rates with an average growth rate of at least 110% would have a floor of –6%;
• Creating Accountable Care Organizations, which would allow provider groups to opt to share in any cost savings they generate for Medicare if they meet certain quality thresholds; and
• Considering the inclusion of comparative clinical effectiveness research priorities;
• Ending the physician-owned hospital exceptions in the current Medicare provisions, with some limited exceptions for facilities that have both physician ownership and a Medicare provider agreement in effect as of July 1, 2009. There would also be increased reporting requirements for these grandfathered hospitals.

Please click here to read the full proposal.

PQRI Update

With all of the attention on the broader health reform topic, pay for performance has become an increasingly larger part of the discussion.  As such, it will likely be an important component of any final agreement that may occur in this area as it is likely that health care reimbursements would move to a quality-based payment system under a healthcare reform proposal, although no specific proposals have been yet been advanced.  One small issue that has been discussed would be to extend the Physician Quality Reporting Initiative (PQRI) to include payments for providers who are participating in a qualified Maintenance of Certification (MOC) or completion of an MOC practice assessment. 

Please click here for more information on legislative initiatives on quality initiatives and pay for performance and also for information on the 2009 updates for the PQRI process.

An article from Dr. Michael Rapp, the head of the CMS PQRI system, on implementation advice for 2009 PQRI and e-prescribing incentive payments can be found by clicking here.

MedPAC Releases March Annual Report for 2009

MedPAC has released its March 2009 Annual Report in which it makes its recommendations for Medicare payment policy. In its report to Congress, presented to the House Ways & Means Subcommittee on Health during a hearing on March 17th, the Commission announced that the report focuses on furthering sustainability by modifying the current payment systems. Recommendations included changes in Part D drug payments, Medicare Advantage plan reimbursements, and hospice care payments. For physician payments, MedPAC recommends that Congress update payments for physician services by 1.1 percent, which is the same percentage increase as was set by Congress for 2009.

Of particular importance and concern for urology, the report made recommendations for changing payments for both imaging services and ambulatory surgical centers. The imaging proposal recommends that Medicare adopt a standard by which providers are assumed to use imaging equipment at 45 hours per week, or 90 percent of the time that providers are assumed to be open. The recommendations ask that HHS begin by applying this standard to all diagnostic imaging machines that cost more than $1 million. For ASCs, MedPAC recommends that ASCs receive a payment update of 0.6 percent for calendar year 2010 and that the facilities be required to submit cost and quality data to the department in order to study the future adequacy of payment rates for these facilities.

Please click here for a copy of the report.

Red Flag Rules Scheduled to Go Into Effect

UPDATE: Late on April 30th, the FTC postponed the implementation date for the Red Flag Rules to August 1, 2009, less than 12 hours before they were due to go into effect. Affected parties, including physicians, will now have an additional three months to adopt policies implementing the rule. Physician groups, including the AACU, will use this additional time to work to convince the FTC that physicians are not "creditors" and should therefore not be subject to these rules.

In late 2007, Congress passed legislation that required all “creditors” to adopt procedures for how to deal with suspected cases of identity theft and fraud in their businesses. At that time, the Federal Trade Commission (FTC) interpreted “creditor” unnecessarily broadly to include physicians if they issue invoices, allow payments in installments, or in any way defer payment for services, even if payments are deferred while waiting for insurance reimbursement. Despite repeated advocacy efforts by several provider groups, including the AACU, they have not yet changed this position.

AACU believes strongly that the FTC failed to consider the totality of circumstances regarding application of these rules to physicians, who are already subject to strict legal and administrative burdens to ensure that patient information is kept private and secure. Their decision to include physicians in the definition of creditor is also contrary to all other interpretations of the statute and was quite obviously not the intent of Congress when passing this law. AACU will continue to advocate against this extreme piece of legislation.

In the meantime, the AMA has developed a policy template that practices can use as the basis for their own policies. Please contact your legal representative before adopting any policy to ensure that it meets your particular needs.

Please click here for the policy template.

White House Forum on Healthcare Reform

The President’s White House Forum on Healthcare Reform met on Thursday, March 05, 2009 to discuss ideas for healthcare reform. Over 120 participants were at the event and included Members of Congress, as well as representatives from physician, consumer, labor, insurance, and employer groups. This meeting was an initial gathering of key participants in the health care debate and was meant to start the process toward a reform bill expected to be introduced this summer. The White House also announced that regional meetings in California, Iowa, Michigan, North Carolina, and Vermont will be held in the upcoming months, although specific dates have not been released.

A list of the participants in the forum can be found here.

Comments to CMS on the 2009 Medicare Physician Fee Schedule

AACU has submitted comment to CMS on the proposed regulatory changes in the 2009 Medicare Physician Fee Schedule. In addition to provisions affecting physician payment, there are numerous proposed changes to requirements relating to in-office imaging, application of anti-markup rules, nonpayment for Hospital Acquired Conditions beyond the hospital setting, drug acquisition and pricing, and many other issues. See the comments submitted by AACU to CMS as well as a summary of the 2009 Medicare Physician Fee Schedule from CMS here.

A copy of the court’s opinion can be found by clicking here.

Urologists United Against Payment Cuts

Update: On Tuesday, July 15, the President vetoed HR 6331, legislation to prevent the scheduled 10.6% cuts to Medicare payment to physicians for 18 months. The House and Senate immediately passed a veto override, and HR 6331 is now the law of the land.

While this remarkable victory for medicine should be celebrated, this issue is not truly resolved. Urologists will face cuts in Medicare payment of greater than 20% in 18 months. Congress must now act to seek lasting changes to the physician payment formula.

The flawed Sustainable Growth Rate (SGR) formula must be reformed more broadly. Not only has the SGR formula generated pay cuts - it has kept current Medicare physician payment rates about the same as they were in 2001. As a result, physicians are prevented from investing in the staff, equipment, and health information technology needed to provide optimal care. The Medicare program’s own predictions are that by 2016, total payment cuts to physicians under the SGR will equal about 40%, while over the same period, physician practice costs will increase nearly 20% - at least a 60% shortfall to the average urology practice.

It is essential that urologists – who, as a whole, bill Medicare for at least half of their total gross charges – demand that Congress use the time afforded by this 18 month reprieve to act on the guidance previously provided by MedPAC to seek lasting reform to the physician payment formula, and replace payment cuts with positive updates based on expected increases in practice costs.

For updates on the effort to reform Medicare payment, please contact the AACU at any time by sending an email to info@aacuweb.org.

Federal Trade Commission and the U.S. Department of Justice Release Statement Opposing Certificate of Need Laws

In response to a request for comment from the Illinois Task Force on Health Planning Reform, the Federal Trade Commission and the Antitrust Division of the U.S. Department of Justice recently entered a joint statement in which they called on states to abolish their Certificate of Need (CON) laws for health care services.

The Department of Justice originally undertook a detailed investigation of CON laws in 2004 that ultimately found that these laws do not reduce health care costs and, to the contrary, impose additional costs and may lead to anti-competitive actions. The report notes that the federal mandate that was the original impetus behind the creation of CON laws has since been repealed because of changes in government and private insurance reimbursement processes.

Finally, the statement lists several instances where the CON process itself has been exploited to encourage non-competitive behaviors by both current certificate holders and regulators themselves. Most notable was in Illinois when a member of the planning commission charged with administering the CON process in the state pled guilty to a kickback scheme using his position on the board to secure CON approval for a particular hospital.

Currently, thirty-six states have CON laws in place. Several states, including Illinois, are examining their laws, however, to determine if they should be changed or abolished. In addition to the statement in Illinois, similar statements have been issued by the agencies to Georgia in 2007, and to Alaska and Florida earlier this year.

Please click HERE for a copy of the statement issued to the Illinois Task Force. A copy of the original Department of Justice report can be found here.

For more information, please contact Bonnie Shadid, State Affairs Manager, at statesociety@aacuweb.org.

2008 AACU State and Federal Legislative Priorities

AACU has made available its legislative priorities for 2008. Physician payment, eliminating excessive regulation on the practice of Urology, promoting men's health, defending effective medical liability reform, and supporting practice management are among the issues that AACU will be focusing its efforts on this year. The 2008 priorities can be seen in their entirety here.

Recovery Audit Contractor (RAC) Expansion

Update: Last November, Congresswoman Lois Capps (D-CA 23rd) introduced legislation to place a moratorium on expansion of the RAC program. This legislation has gained momentum following the 2008 Urology Joint Advocacy Conference, as advocates for urology used their visits to Capitol Hill to urge co-sponsorship of the bill. The Medicare Recovery Audit Contractor Program Moratorium Act of 2007 (HR 4105) would place a one-year moratorium on the RAC demonstration program, prevent it from beginning in any other states, require CMS to detail the number and nature of claims as well as the outcomes of all appeals, and require GAO to evaluate the RAC program for efficiency, integrity and compliance. The legislation is concurrently being considered by the House Ways and Means and Energy and Commerce Committees, and as of this writing, has 97 co-sponsors.

Background: As part of the Medicare Modernization Act of 2003, Congress authorized the Medicare Recovery Audit Contract (RAC) Program, beginning with a demonstration project in three states (California, Florida, and New York). The program provides contingency payments to auditing firms that identify improper payments from Medicare.

The goal of seeking cost savings in Medicare is laudable. However, the methods used by auditors in the program have been very questionable. Auditors participating in the program are allowed to retain their 30% contingency fee even in the case of denials that are overturned on appeal. These audits place an enormous and unanticipated burden on physician practices, with some offices receiving 50-100 letters asking for multiple patient records on previously paid charges reaching as far back as 3 years to be submitted in a matter of weeks. The egregious nature of these audits potentially threatens the financial solvency of practices subjected to them, with obvious implications not only for the professional lives of urologists, but for their patients who may face shuttered office doors.

The RAC program is now set to expand to more states. In the Tax Relief and Health Care Act of 2006, Congress authorized the Centers for Medicare and Medicaid Services (CMS) to expand the demonstration program to all fifty states by 2010. CMS has already expanded the RAC program to include Arizona, Massachusetts, and South Carolina, and the program is on schedule to be rolled out across the entire country. This will essentially implement an incomplete program without any opportunity for evaluation, or solve the problems it currently poses to physicians. Congress should place a moratorium on the program, and seek a review of the program and the practices of RAC contractors in order to ensure that the problems faced by urologists in the demonstration states are not allowed to expand nationwide.