AHCA meets BCRA; timeline, context, and future directions

Hirsch, Joshua A; Rosenkrantz, Andrew B.; Allen, Bibb; Nicola, Gregory N.; Klucznik, Richard P.; Manchikanti, Laxmaiah

doi:10.1136/neurintsurg-2017-013478

Cited by 7 publications

(3 citation statements)

References 28 publications

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“…This rate is 3-to 5-fold higher than the current Medicare rates for office payment or even 2-fold higher than the ASC payment. Key words: Medicare, physician payment schedules, HOPD and ASC payment schedule, site-of-service differentials, soft tissue injections, intraarticular injections actment of efforts designed to bend the cost curve downward, the Centers for Medicare & Medicaid Services (CMS) projected that the 2016 total health care spending reached nearly 3.3 trillion dollars, up 4.3% from 2015 with per capita spending increasing to $10,348 in 2016 (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). The agency attributed the increase, in large part, to the aging population and rising prices for health care services in the United States (1).…”

Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

“…With numerous alternate models of payments, and the escalating issues of opioid use, abuse, and deaths (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(21)(22)(23)(24)(25), President Trump has declared the opioid issue as a national health care crisis (26), and is promoting non-opioid interventions. Thus, understanding payment methodology and site of service differentials is critical for interventional pain specialists who are at the forefront of this battle.…”

Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

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Cost Calculation Methodology Exacerbates Site-of-Service Differentials by 10- to 18-Fold for Soft Tissue and Joint Injections in Hospital Outpatient Departments

Manchikanti

2017

PMCR

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In recent years, physicians and facilities have faced a multitude of reforms, regulations, and payment models to reduce health care costs, and to improve access and quality. Despite these measures, total health care cost increased to $3.3 trillion in 2016, up 4.3% from 2015. An aging population and an increase in cost are two of the factors that account for most of the increase in costs. Price intensity from physicians and facilities are influenced by Medicare rate-setting methodology with site-of-service differentials. Site-of-service differentials for payments are increasingly being recognized as a topic that requires discussion. Intraarticular and soft tissue injections are performed in physician offices (90%), ambulatory surgery centers (ASCs) (1%), and hospital outpatient departments (HOPDs) (9%), however, the payment rates differ 10- to 18-fold among these settings with 63% of total payments to HOPDs, 2% to ASCs, and 37% to offices. In this manuscript, we describe significant payment differentials, based on cost calculation methodology that indicate a potential substantial savings of more than $125 million per year if HOPDs are reimbursed at the same rate as ASCS, utilizing any of the formulas, even if the current ASC rate is doubled. This effort would also save significantly when it comes to copayments, which are 27% by patients, instead of the 20% in offices and ASCs. The addition of Medicare Advantage recipients, which constitutes approximately 30% of the overall Medicare population will increase these estimations by 30%. In conclusion, utilizing accurate payment rate calculations for intraarticular and soft tissue injections will result in substantial changes in the payment rates. In fact, just the differences in the copay itself would make the copay $66.06 (which is 27% of $244.68). This rate is 3- to 5-fold higher than the current Medicare rates for office payment or even 2-fold higher than the ASC payment. Key words: Medicare, physician payment schedules, HOPD and ASC payment schedule, site-of-service differentials, soft tissue injections, intraarticular injections

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Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

Cost Calculation Methodology Exacerbates Site-of-Service Differentials by 10- to 18-Fold for Soft Tissue and Joint Injections in Hospital Outpatient Departments

Manchikanti

2017

PMCR

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“…Medicare spending also reached a historic $672.1 billion with a share of 20.36% of total NHEs, while Medicaid spending grew almost as high as Medicare to $565.5 billion in 2016, and a 17.1% share of total NHE (19). The Trump administration started with plans to repeal the ACA, which have not materialized even with multiple legislative attempts through Congress leaving it as the law of the land (20,21). The statistics showing expenditures in the United States reveal that the US spent $87.6 billion on back and neck pain with an additional $95.9 billion on musculoskeletal disorders in 2013 (22).…”

mentioning

confidence: 99%

Reframing Medicare Physician Payment Policy for 2019: A Look at Proposed Policy

Manchikanti

Singh²,

Benyamin

et al. 2018

Pain Phys

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On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2019 Medicare physician fee schedule and quality payment program, combining these 2 rules for the first time. This occurred in a milieu of changing regulations that have been challenging for interventional pain management specialists. The Affordable Care Act (ACA) continuous to be amended by multiple administrative changes. This July 12th rule proposes substantial payment changes for evaluation and management (E&M) services, with documentation requirements, and blending of Level II to V CPT codes for E&M into a single payment. In addition, various changes in the quality payment program with liberalization of some metrics have been published. Recognizing that there are differing impacts based on specialty and practice type, as a whole interventional pain management specialists would likely see favorable reimbursement trends for E&M services as a result of this proposal. Moreover, in comparison with recent CMS final ruling, this proposed rule has relatively limited changes in procedural reimbursement performed in a facility or in-office setting. CMS, in the new rule, has proposed an overhaul of the E&M documentation and coding system ostensibly to reduce the amount of time physicians are required to spend inputting information into patients’ records. The new proposed rule blends Level II to V codes for E&M services into a single payment of $93 for office outpatient visits for established patients and $135 for new patient visits. This will also have an effect with blended payments for services provided in hospital outpatients. CMS also has provided additional codes to increase the reimbursement when prolonged services are provided with total reimbursement coming to Level V payments. Interventional pain managementcentered care has been identified as a specialty with complexity inherent to E&M associated with these services. Among the procedural payments, there exist significant discrepancies for the services performed in hospitals, ambulatory surgery centers (ASCs), and offices. A particularly egregious example is peripheral neurolytic blocks, which is reimbursed at 1,800% higher in hospital outpatient department (HOPD) settings as compared with procedures done in the office. The majority of hospital based procedures have faced relatively small cuts as compared with office based practice. The only significant change noted is for spinal cord stimulator implant leads when performed in office setting with 19.2% increase. However, epidural codes, which have been initiated with a lower payment, continue to face small reductions for physician portion. This review describes the effects of the proposed policy on interventional pain management reimbursement for E&M services, procedural services by physicians and procedures performed in office settings. Key words: Physician payment policy, physician fee schedule, Medicare, Merit-Based Incentive Payment System, interventional pain management, regulatory tsunami, Medicare Access and CHIP Reauthorization Act of 2015

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