Medicare’s Proposed Rule for 2016

Changes are just around the corner.


July 2015

Medicare published the Proposed Rule for 2016 later than usual. Typically it’s issued just before the July 4th holiday, but this year it dropped almost a week later.

Although we all enjoyed a weekend off with our families (which we’d

usually spend poring over the legislation), we started to worry that its late appearance might bode ill for us. We heaved a sigh of relief when we saw that for the first time in many years Medicare calculate the overall reduction for radiology at 0 percent. Interventional radiology will, in fact, see a small overall increase of 1 percent.

Now, we all know that this comes on the heels of several years of drastic reductions. And, as you’ll read, many codes are at risk that have to date escaped the arbitrary cuts, especially on the practice expense side, about which we’ve protested so vigorously. But let’s start with the good news.

Just the PACS

For 2015, CMS had decided to transition from inputs based on film for the payment formula to inputs that reflect the digital environment in which we all practice nowadays. However, citing lack of available invoices for the equipment involved in a PACS, CMS defaulted to a desktop computer as a proxy and estimated the price as $2,501. Anyone who has installed a PACS in recent times knows that figure grossly understates the costs involved. We took a collaborative, data-driven approach to our response to CMS. A PACS workgroup was formed led by our Economics Commission Vice Chair Ezequiel Silva III, MD, FACR . The group comprised informatics experts like Christoph Wald, MD, PhD, FACR, and Paul Nagy, PhD; representatives from the Radiology Business Managers Association; industry representation; and members of the private practice community from Strategic Radiology. We thank all the workgroup members for their time and dedication in patiently tracking down and compiling redacted invoices and developing a rationale that convinced CMS to more than double the amount it will recognize for the PACS workstation. Effective January 2016, the $2,501 PACS workstation will be replaced by one costing $5,557. Does this roll back the entire cut? Alas, no, but it is a significant achievement by this dedicated group of folks, and we thank not only Zeke for his leadership but also Stephanie Le, ACR staff, who so ably staffed and managed the project.

AUC Goes to Washington

As you have read many times, the Protecting Access to Medicare Act of 2014 mandated that CMS implement clinical decision support for advanced imaging studies effective in 2017. CMS has significant milestones to clear between now and then, including deciding which appropriate use use criteria it will approve for use, how it will actually implement the regulation, and which clinical decision support mechanism it will use.

We in radiology of course recognize the evidence-based and multispecialty nature of the ACR’s appropriateness use criteria (AUC) — and the fact that the electronic version of those AUC, ACR Select, is effectively making the AUC available either embedded in the electronic health record or on a free web portal. However, the CMS coverage group tasked with implementing this legislation was not nearly as familiar with our efforts. Again we took a collaborative and data-driven approach and engaged early and often with the CMS team to ensure that they knew all about the 20 years of volunteer efforts by radiologists as well as the collaboration with other specialties that have gone into developing the largest guideline set in the National Guideline Clearinghouse. We also travelled to the HHS headquarters in Washington, D.C., and the CMS offices in Baltimore to demonstrate how the AUC could be incorporated into clinical practice without burdening the referring physician.

Recognizing that CMS will inevitably want to make sure that there is room for more than one alternative delivery vehicle for CDS, we collaborated with other stakeholders, including Intermountain Healthcare as well as other specialty societies like the American Academy of Orthopedic Surgeons, to maintain the original legislative intent of using AUC to improve care and reduce costs. We are very encouraged by the thoughtful approach that CMS has taken in the Proposed Rule. Although we have some questions on certain elements, we are optimistic that we can continue our positive interactions going forward.

Leaving Us Breathless

All good so far, but there are some stings in the tail. The ACR worked with a broad range of stakeholders to persuade Medicare to cover lung cancer screening, and we were very happy with CMS’ decision to do so in February of this year. The next question, of course, was how much CMS would pay for this life-saving service. Even though screening services are typically paid at a lower rate than diagnostic procedures, we argued and presented data to support the rationale that this particular screening service was in fact more intense and required more resources than its diagnostic equivalent (71250 non contrast chest CT). Unfortunately, CMS did not agree with us in the Proposed Rule and plans to pay the same amount for a screening CT as for a non-contract chest CT. We are puzzled as to why CMS does not recognize the additional effort involved in the robust quality program we have built around this new service, and we will be vigorously reiterating our position in our comments as well as re-engaging our stakeholder group for support.

Cutting Cuts

As you’ve heard me say many times, it is important to maintain fair reimbursement for our services in the current fee-for-service world, even as we explore new payment models. The savage cuts that we’ve seen imposed on many of the services we provide, breast biopsy for example, threaten access for our patients and represent a “double jeopardy” for services that have already saved the delivery system significant amounts because they replaced more invasive surgical procedures. Yet CMS continues to shine a spotlight on services that we provide and once again has identified a long list of procedures, many of them imaging services, that must be reviewed as “potentially misvalued.” We are fully supportive of a process that ensures fair valuation and reimbursement, but too often arbitrary cuts have been imposed on our services. You should know that our reimbursement team is incredibly skilled and hardworking and will do its best to prevent further cuts. Our patients deserve nothing less than our best effort.

I’ve only given you the highlights of this more-than-1,000-page document. We have issued a more detailed summary and will be diligently digging through the language to produce a comprehensive comment letter to CMS, which will be due on September 8th.

Please don’t hesitate to be in touch with your thoughts and questions. As always, you can reach me at This email address is being protected from spambots. You need JavaScript enabled to view it., and I encourage you to follow me on Twitter at @DrGMcGinty.

McGintyHeadshotBy Geraldine B. McGinty, MD, MBA, FACR, Chair


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