A Fiscal Cliffhanger

Don't let political shenanigans distract you from what's truly important — your patients.a fiscal cliffhanger

I was lucky that in the aftermath of Hurricane Sandy, I only lost my car. So many others' lives were devestated, and many are still recovering.

When I think back over those days, I remember an overwhelming feeling of anxiety at the uncertainty over restoration of power to homes and offices, at the need to try to contact patients while phone lines were still down, and at the question of how my practice would make it through the significant financial challenges the disaster posed. I remember being surprised at how much anxiety can impact one's ability to function.

Similar feelings of anxiety probably hit many of you as the nation waited with bated breath to learn whether there would be a deal to avoid a headlong plunge over the so-called fiscal cliff, the combination of automatic tax increases and spending cuts that threatened to go into effect January 2013 if Congress and the White House failed to pass a national budget. For physicians, a major concern was whether there would be any fix for the looming Sustainable Growth Rate (SGR) deficit.

SGR Basics

The SGR was established as a way to manage Medicare costs and was part of the Balanced Budget Act of 1997. The act prescribed that if Medicare costs outstripped GDP growth, then an adjustment would be made to the conversion factor, which is used to multiply the RVUs for a procedure into an actual payment amount. Because Medicare spending has grown faster than GDP ever since 2002, a series of potential conversion-factor decreases have been pulled back at the last minute by a matching set of temporary SGR fixes. Many attempts have been made to institute a permanent fix for this unsustainable process, with no success so far.

So we found ourselves last December once again looking at a yawning chasm in Medicare reimbursements: a projected 27 percent rate cut unless Congress acted to institute at least another temporary fix. Negotiations around the imminent plunge over the fiscal cliff complicated the process. Lawmakers looking to use savings from the Medicare program to fund the SGR fix were rumored to be looking at utilization-rate increases for imaging. Nail biting times indeed. Those of us with staff to pay and equipment payments to make certainly found it hard to focus on our main priority — our patients — while wondering if we were going to be able to pay our bills.

Par for the Course

Unfortunately, this not a new phenomenon. As I mentioned, this has happened multiple times. And while there has always been a fix at the last minute, it is no way to treat our Medicare beneficiaries and the physicians who care for them. Add to that the arbitrary cascading reductions in reimbursement imposed on imaging since the Deficit Reduction Act, with the most recent egregious application of a multiple procedure reduction across group practices, and it's no wonder we are all feeling anxious and uncertain.

Unfortunately, when the resolution came on New Year's Day, the rumors of "pay-fors" (spending cuts or tax hikes that cover the costs associated with a piece of legislation) proved to be true, at least for radiologists. With projected savings of $800 millions over 10 years, an increase from 75 to 90 percent in the utilization rate assumption (which is used to recongize equipment expenses for Medicare payments) proved irresistible, and Congress opted to include this in the final bill. Recall that the tradition assumption was that our equipment is, on average, in use about 50 percent of the time. It is disappointing that Congress chose a path that is based on flawed data and will undoubtedly limit innovation and even access for beneficiaries in rural areas by reducing reimbursement.

Maintaining Focus

As we think about how we as radiologists can most effectively contribute to integrated high-value care, it seems counterintuitive to continually distract us with scare tactics and arbitrary cuts that lead us to wonder whether we will be able to afford to continue participating in the Medicare program. I believe we are all committed to providing the best care for our Medicare beneficiaries, but this can only happen if we are allowed to focus on the care and not fight the same reimbursement battles over and over again.

The ACR is looking at ways to effectively prevent further arbitrary cuts to Medicare reimbursement. We are also continuing to advocate for a permanent and real fix for the SGR. Our letters to CMS on the 2013 Final Rule for the Medicare Physician Fee Schedule reiterated our position that a professional component multiple procedure reduction (MPPR) is specious and its application across group practices even more egregious and without merit than the application of a professional component MPPR for a single physician. At the same time, we are looking at ways to mandate a transparent and reproducible approach to payment policy that is accountable to both beneficiaries and providers. CMS has never been able to demonstrate a factual basis for the efficiencies that it states are inherent when a provider interprets more than one study on a patient, probably because it doesn't have to. Mounting a response to these fallacious policies costs time and money for the provider community and, once again, takes us away from the most important thing that we do: take care of our patients.

As always, I'd love to hear your feedback at This email address is being protected from spambots. You need JavaScript enabled to view it.. You can also follow me on Twitter (@gmcginty).

geraldine mcgintyBy Geraldine B. McGinty, MD, MBA, Chair

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