economics 101: an overview of general terminology and concepts katie keysor director, economics...
TRANSCRIPT
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Economics 101: An Overview of General Terminology and Concepts
Katie Keysor
Director, Economics & Health Policy
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Economics & Health Policy Department Staff
Angela Kim, Senior Director Pamela Kassing Diane Hayek Katie Keysor Gloria Garcia Stephanie Le
Anita McGlothlin Laura Pattie Gloria Bland Evelyn Gilbert Rynzelle Spraggs 2 Vacant Positions
Cindy Moran, Assistant Executive Director
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ACR Commission on Economics
Geraldine McGinty, MD, MBA, Chair Katie Keysor, Staff Pam Kassing, Staff
19 Committees/Subcommittees
4 Networks
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Committee Staff Chair(s)
Body Imaging Committee Gloria Garcia David Paushter
Breast Imaging Committee Laura Pattie Ellen Mendelson
Coding & Nomenclature Committee Diane Hayek, Gloria Garcia, Laura PattieDaniel Picus (Chair) Timothy Crummy (Vice Chair)
Economic Issues in Academic Radiology Committee Pam Kassing James V. Rawson
Future Trends Committee Pam KassingDavid C. LevinFrank J. Lexa (Co-Chair)
GSR Committee Kathryn Keysor Robert S. Pyatt
HOPPS/APC Committee Pam Kassing James V. Rawson
Interventional & Cardiovascular Radiology Committee Gloria Garcia Sean Tutton
Managed Care Committee Kathryn Keysor Mark O. Bernardy
Medical Physics Committee Anita McGlothlin Michael D. Mills
Neuroradiology Committee Laura PattieRobert M. Barr William Donovan (Co-Chair)
Nuclear Medicine Committee Laurie Pattie Gary Dillehay
Pediatric Radiology Committee Anita McGlothlin Richard M. Benator
Practice Expense Committee Stephanie Le/Angela Kim Ezequiel Silva
Radiation Oncology Committee Anita McGlothlin Louis Potters
Reimbursement Committee Stephanie Le/Angela Kim William Donovan
Ultrasound Committee Stephanie Le John S. Pellerito
Utilization Management Committee Kathryn Keysor Christopher Ullrich
Value Added Sub Committee Stephanie Le/Angela Kim Ezequiel Silva
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ACR Commission on Economics - Networks
Carrier Advisory Committee (CAC) Network Radiology
Robert Zeman, MD (Chair) Shawn Conwell, MD (Vice-Chair)
Radiation Oncology Richard Hudes, MD Donald Schwartz, MD
Managed Care Network Mark Bernardy, MD (Chair)
Medicaid Network Raymond Tu, MD (Chair)
Radiology Integrated Care (RIC) Network David Rosman, MD (Chair) Jack Farinhas, MD (Vice-Chair)
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Alphabet Soup
ACO – Accountable Care Organization ADIS – Advanced Diagnostic Imaging Services APC – Ambulatory Payment Classification CAC – Carrier Advisory Committee CPT – Current Procedural Terminology CERT – Comprehensive Error Rate Testing CF – Conversion Factor CMD – Contractor Medical Director CMS – Centers for Medicare and Medicaid
Services
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More Alphabet Soup
DOS – Date of Service DRA – Deficit Reduction Act EHR – Electronic Health Record E/M – Evaluation and Management GPCI – Geographic Practice Cost Index HCPCS – Healthcare Common Procedural Coding System HHS – Health and Human Services HIT – Health Information Technology HOPPS – Hospital Outpatient Prospective Payment
System IPAB – Independent Payment Advisory Board
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…And More
ICD-9,10 – International Classification of Diseases IDTF – Independent Diagnostic Testing Facility LCD – Local Coverage Determination MAC – Medicare Administrative Contractor MCC – Managed Care Committee MCN – Managed Care Network MedCAC – Medicare Evidence Development and Coverage
Advisory Committee MedPAC – Medicare Payment Advisory Commission MFS – Medicare Fee Schedule MEI – Medicare Economic Index
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…And More Still
MPPR – Multiple Procedure Payment Reduction NCD – National Coverage Determination NCCI – National Correct Coding Initiative NPI – National Provider Identifier PC, -26 – Professional Component POS – Place of Service PPACA – Patient Protection and Affordable Care Act of 2010 PPIS – Physician Practice Information Survey PPS – Prospective Payment System PQRI – Physician Quality Reporting Initiative
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…Last one
RAC – Recovery Audit Contractor RBM – Radiology Business Management Company RBMA – Radiology Business Management Association RCCB – Radiology Coding Certification Board RVU – Relative Value Unit RUC – Relative Value Update Committee SGR – Sustainable Growth Rate TC – Technical Component
And many others…
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Economics: From New Technology to Coverage
New Technology (published evidence)
CPT Code Code Valuation Coverage
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CPT Coding Background
CPT = Current Procedural Terminology “Codes” Number assigned to services provided to patients Evolve over time (new, revised, eliminated) Developed, owned, and copyrighted by AMA
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CPT Editorial Panel (17 members)
Blue Cross and Blue Shield Association (1) American Hospital Association (1) American’s Health Insurance Plans (1) Centers for Medicare and Medicaid Services (1) Health Care Professionals Advisory Committee (2) Physicians (11)
Appointed by AMA Board of Trustees Radiology is NOT guaranteed a seat!
Source: Duszak, “The CPT Process and How It Influences Our Economic Future”
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Types of CPT Codes
Category III “Emerging Technology” Intended to be used for data collection to substantiate
widespread use
Category I – high evidence threshold Distinct service/procedure FDA approved Widely performed (in USA) Substantial US peer reviewed literature
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How to Choose a CPT Code
Pre- 2001 CPT Instructions: Select the code that most accurately identifies the
service performed
2002 CPT Instructions: Select the code that accurately identifies the service
performed Do not select a code that merely approximates the
service provided If no accurate code exists, then use an unlisted code
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Once FDA approved, and modest clinical trial data exists…
Level III CPT code is likely to be approved… Once there’s level III code, Medicare Administrative
Contractors (MACs) may choose to develop local coverage determinations (LCDs) and private payers may offer some limited coverage
This may precede CMS consideration of whether or not a national policy is needed Example: coronary CTA, diagnostic CTC
Level III codes are valued locally
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ACR Coding Products
ACR Coding Guides
Ultrasound (2013)
Nuclear Medicine (2013)
Radiation Oncology (ASTRO/ACR - 2013)
Interventional Radiology Update (SIR/ACR - 2013)
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ACR Coding Products
Newsletters: ACR Radiology Coding SourceTM
Bimonthly electronic newsletter on coding & reimbursement
Feature article Medicare and third party payer issues Q&A CEUs available toward RCCB certification
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ACR Coding Products
Clinical Examples in Radiology AMA-ACR Coding Publication (2005) Published quarterly
Real dictations with expert analysis Documentation challenge Test case Q&A Semi-annual bulletin articles to address timely topics
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American Medical Association Specialty Society
R
RelativeValue Scale
U
Update
C
Committee
R
Resource
B
Based
R
Relative
V
Value
S
Scale
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Total RVU
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Practice Expense (TC)
+
Work (PC)
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ACRRefine-ment Panel
RUC CMS CMS FINAL
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Medicare Physician Fee Schedule (MFS)
How radiologists get paid for their work and practice expense for their offices
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Medicare Physician Fee Schedule
Proposed Rule published in late June/early July
Final Rule published in late October/early November
Monitor the impacts of adjustments to the MFS for increases and decreases in physician work, practice expense and malpractice RVUs
Other CMS payment policy decisions (e.g. MPPR, interest rate, utilization rate, etc.)
Analyze these effects and write formal comments to CMS on areas of concern
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Multiple Procedure Payment Reduction
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No credible data justifies these proposals Permanently devalues Radiology relative to
other physician services 2013 CMS rule: 25% PC MPPR reduction across
group practices $100 Mil savings – redistributed to others Independent of any other “adjustments”
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Hospital Outpatient Prospective Payment System (HOPPS)
HOPPS mandated by Balanced Budget Act (BBA) of 1997
April 7, 2000 CMS issued final rule on HOPPS
HOPPS went into effect August 2000
Previously Medicare paid for services performed in
hospital in a variety of methodologies based on
reasonable costs
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Prospective Payment System
Less granular than Medicare Physician Fee Schedule
Belief that prospective payments incent efficiency
Other examples: DRG payments to hospitals for inpatient admission
Payments calculated annually based on hospital charges
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Ambulatory Payment Classifications
Service divided into ambulatory payment classifications
(APC)
Each APC encompasses services that are clinically
similar and require similar resources
All services within an APC are generally paid at same
prospectively-fixed rate.
Payment determined by hospital charges submitted to
CMS
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2 Times Rule
CMS considers the items and services within a
group as NOT comparable if the highest median
cost for an item or service within a group is more
than two times greater than the lowest median
cost
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Proactive Work with CMS
Work with The Moran Company to analyze new bundled
CPT codes based on predecessor codes
Meet with CMS staff in person to provide
recommendations prior to publication of Final Rule
CMS is appreciative of the information and generally
accepts recommendations
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CMS COVERAGE
DECISION
LCD NCD (CAC)
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What is a MAC? Medicare Administrative Contractor
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15 Jurisdictions
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Local Coverage Determination (LCD)
Most Medicare coverage decisions are made at the local level through LCDs No LCD does not mean there is no coverage
MACs are required to post draft coverage policies for comment and hold Carrier Advisory Committee (CAC) meetings to discuss the policies ACR CAC Networks
Screening coverage must be through a National Coverage Determination
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National Coverage Determination - NCD
“reasonable and necessary for the diagnosis or treatment of an illness or injury within the scope of a Medicare benefit. “NCD’s are made through evidence-based process… with public participation. In some cases CMS’ own research is supplemented with an outside technology assessment and/or consultation with MEDCAC” (eg internal decision cardiac flow add-on code for cardiac MRI)
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MedCAC
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Provide independent, expert guidance…“Up to 100 experts in clinical and administrative medicine, biological and physical sciences, public health administration, patient advocacy, health care data management and information analysis, health care economics,and medical ethics…”
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US Preventive Services Task Force
“...independent panel of private sector experts in prevention and primary care…conducts rigorous impartial assessments of the scientific evidence… for effectiveness of screening, counseling, and preventative medications”
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Private Payer Coverage – Influences
Medicare Often, Medicare coverage or non-coverage equals private payer
coverage or non-coverage, but not always
Blue Cross Blue Shield Association Technology Evaluation Center (TEC)
United States Preventative Services Task Force (USPSTF) Increasing influence on Medicare coverage decisions Some payers now cite the USPSTF in their coverage decisions
Radiology Benefits Management Companies (RBMs) Most say that they use ACR Practice Guidelines and
Appropriateness Criteria, but do not have transparent processes
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The TEC uses five criteria to evaluate new technologies The technology must have final approval from the
appropriate governmental regulatory bodies. The scientific evidence must permit conclusions concerning
the effect of the technology on health outcomes. The technology must improve the net health outcome. The technology must be as beneficial as any established
alternatives. The improvement must be attainable outside the
investigational settings.
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Blue Cross Blue Shield Association Technology Evaluation Center (TEC)
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Little to no transparency
Not required to publish draft policies for public comment
Relationships are key!
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Private Payer Decisions
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ACR Networks
CAC Managed Care Medicaid Radiology Integrated Care (RIC) General, Small, and Rural Practices
The Networks are the eyes and ears of the ACR!
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James Moorefield Economics Fellowship Two week program
Learn about activities of the College, and specifically about economics.
Provide clinical feedback on various projects
Two interns per year
Applications accepted February-April