Happy Birthday,Medicare and Medicaid!
Fifty years after their inception, both programs continue to evolve with the shifting health care landscape. Where do radiologists fit in?
This summer retired U.S. Senator Bill Frist, who (as most of you know) was a practicing physician before entering politics, and Drew Altman, president and CEO of the Kaiser Family Foundation, wrote an excellent overview of the Medicare and Medicaid programs in JAMA.
Even if you are not a health policy nerd like me and don’t read the whole article, you may enjoy the video that accompanies it. It includes a clip of President Lyndon B. Johnson signing the bill into law on July 30, 1965, with former President Harry S. Truman (“The real daddy of Medicare,” quipped Johnson) by his side. It’s a fascinating story and included significant opposition from the physician community.
Meanwhile, as the two programs celebrate their half-century, they cover one in three Americans and cost a combined trillion dollars. Medicare and Medicaid are extremely popular with beneficiaries even as both programs have seen fundamental changes in how care is delivered and paid for. The future of the programs is a subject of extensive debate, and both were integral to the Affordable Care Act’s intention to reform health care delivery and payment.
So as Medicare and Medicaid continue to evolve, how do we in radiology interact with these programs? And how does the ACR represent you in dealing with the body that administers them (the Centers for Medicare and Medicaid Services, or CMS)?
Let’s start with Medicare. Most of us in radiology participate in the Medicare program, and for many of us it is a significant portion of our overall revenue. Medicare has chosen to significantly decrease payments for imaging services over the last several years, contending that inappropriately high payments have led to over-utilization.
Your ACR economics team has fought that misperception tirelessly. We dedicate a team of our best and brightest volunteers to responding to Medicare’s rules and participating in the CPT and Relative Value Scale Update Committee (RUC) processes that develop codes and valuations for the services we provide. Not only do these volunteers spend at least nine days each year away from their practices attending CPT and RUC meetings, but they answer countless emails and, at least once a year, travel to CMS headquarters in Baltimore to make the case for the value of the services we provide.
We may not always agree with Medicare’s decisions, but we engage with the team at CMS in a way that respects its perspectives and constraints while clearly putting the needs of our patients in the forefront. We believe that this strategy of active engagement has been instrumental in CMS’ decision to cover lung cancer screening and in the agency’s thoughtful approach to the Protecting Access to Medicare Act legislation as it relates to clinical decision support. Our crack team of ACR staff experts is available at all times to help you understand Medicare’s rules and regulations. You’ll also find great resources on the ACR Medicare Payment Systems page.
We also engage with the lawmakers whose legislation affects the future of Medicare. This year was a clear example of the effectiveness of our Government Relations team as the flawed SGR payment formula was repealed by a huge bipartisan majority. This legislation provides us in radiology with a major challenge and a significant opportunity to not only participate but also take the lead in the transition from volume to value about which we have heard so much. I’ve written about the College-wide effort to respond to this new payment policy, and you’ll be hearing much more about it in the future.
Moving on to Medicaid, this joint state and federal program covers the poor, especially poor children. It has been a focus recently because expansion of Medicaid eligibility was a key factor in the ACA. This provision was subsequently derailed in part when the Supreme Court ruled in 2012 that states could choose whether or not to expand their Medicaid coverage. Far more physicians participate in Medicare than in Medicaid, whose payment rates have traditionally been lower with confusing rules about which services are covered. The ACR’s task of tracking and influencing this program is made much more daunting than our work with Medicare because Medicaid programs vary by state and many states have transitioned to managed care programs to control costs.
Despite the obstacles, we decided to engage actively because we believe that all our patients deserve the best care possible and we saw some real opportunities. Our Medicaid network, chaired by Raymond K. Tu, MD, FACR, now includes representatives from almost every state. We have chosen to frame our conversation around quality and appropriateness, and we have made contact with the leaders of several of the managed care organizations that are contracted with states to administer benefits. We have been concerned to see imaging utilization controlled by radiology benefit managers and have advocated strongly for clinical decision support instead.
We have also collaborated with the Society for Pediatric Radiology. Although CMS, recognizing that low payment rates may result in reduced access, made payment rates for primary care services to Medicaid beneficiaries equal to Medicare’s in 2013 and 2014, it did not extend that parity to imaging services. We are always looking for new volunteers to help us with our Medicaid team, so please email me if you are interested.
By Geraldine B. McGinty, MD, MBA, FACR, Chair