Rhode Island Chapter of
Over the past six months RICC and MCI practices have been filing out both the MedSolutions (MSI) pre authorization and the ACC FOCUS protocols for each myocardial perfusion study. We are asking the question: Can a self regulated pre authorization tool perform as well or better than the Radiology Benefit Manager (RBM) tool?
The results are currently being analyzed. We know that for cardiologists in particular the number of denials from MSI is very low and, as such, we expect the FOCUS data will demonstrate a high percentage of 'appropriate' studies. We also anticipate that FOCUS will be more robust at identifying uncertain or inappropriate studies. Confirmation of this would indicate FOCUS is actually a more robust filter and will provide the basis for further discussions with Blue Cross Blue Shield of Rhode Island.
Our goal is to replace the RBM with the FOCUS tool. Such a step would result in financial relief for both provider and payer and would remove an important barrier to care for our patients.
Interestingly the whole RBM issue has a new head of steam on the national stage after the recent decision by the Delaware Insurance Commissioner. BCBS of Delaware was fined for an illegal contract with MedSolutions which indirectly resulted in denial of appropriate testing and delay of a lifesaving bypass operation for a 46 year old man with multi vessel disease. BCBS Delaware has been mandated to use FOCUS for all nuclear testing pre authorization for the next three years.
The annual ACC Legislative Conference was held September 11-13 in Washington DC. Representing Rhode Island were Peter Tilkemeier, myself and THREE cardiology fellows; Gabe Delgado, Antonio Fernandez and Taz Mansour. (The was modest consternation about flying into Reagan National airport on the 10th anniversary of 9/11 but happily this proved a non event).
The line up of hot issues was familiar: the SGR, Imaging reimbursement, RBMs, Tort Reform and Payment Reform.
The SGR is getting ridiculous. The amount now stands at $300 Billion.
(For those of you not familiar with the arcane derivation of the Sustainable Growth Ratio this is the story: As part of the Balanced Budget Act of 1997, the SGR was introduced as a way of tying Medicare provider payments to the Gross Domestic Product. In other words, growth in that sector of Medicare costs could not exceed growth of the GDP. This would ensure Medicare payments to providers remained sustainable. Trouble is growth in Medicare provider payments has exceeded growth in the GDP for 9 of the last 10 years. Therefore, as mandated by the SGR rules, Medicare owes money back to the government in exponentially increasing amounts. That means WE (the providers) have been paid too much over the last decade to the tune of $300 billion (that includes interest).
To put that in perspective, total Medicare payments to providers in any given year is about $100 billion (16 percent of total dollars). It would take 3 years of physicians working for free to catch up with the SGR).
Everyone wants the SGR fixed. No one knows how to do it. The Joint Select Committee for Deficit Reduction (the 'Super Committee') may look at the SGR, or part of it, as a potential way to make up $1.2 trillion in cuts it must generate by November 2, 2011. As such it is not unlikely that we will see some SGR related reimbursement reductions on Jan 1, 2012.
So with great optimism we all hit 'The Hill' on Tuesday September 13. We visited with aides to Senators Reed and Whitehouse and met with Representative Cicilline and an aide. Admittedly nothing substantive came from discussions about issues so great in magnitude other than a general agreement that we are in a pickle. Nonetheless there was general agreement that RBMs are a bad way to effect resource control and all were interested in the outcome of our discussions with BCBS of RI.
The Cardiology for Primary Care Providers conference is coming up on September 28th at the Providence Marriott. The conference is always well attended and the talks always interesting. We are also developing plans for a January RIACC educational conference. The concept involves presentation of the most interesting and instructive clinical cases managed by the cardiology fellows over the past year. The exact format is being developed. There is more to come about this.
Proceeds from the new conference in addition to private contributions will be ear marked to support a travel grant for one FIT to attend the Legislative conference annually.
Steve Berkowitz PA has accepted the CCA position on the ACC Council. Welcome Steve!
Elections for the next RI ACC Governor are coming up. Two excellent candidates are on the ballot: Brian Abbott and Robert Schwengel. Please cast your vote!
We all owe a big Thank you to Mike Paolino for his work on the new website. He donated expertise and a lot of time to create a much more attractive and user friendly site. We hope it will take root as the standard for communication and education within our chapter. Please let us know if you have suggestions about design, use or content. (mpaolino@riacc.org, ckinney@riacc.org, mgilson@lifespan.org)
Michael
Michael Gilson M.D.
Governor, Rhode Island Chapter of the American College of Cardiology