Many Voices, One Cause
ACR Government Relations works to effect legislative change.
Over the past year, the ACR Government Relations Department and state radiological societies worked to effect change on a number of fronts.
From state to federal issues, from supporting CT colonography to seeking revisions to the sustainable growth rate, the government relations team, with the support of ACR members, has stepped up to the plate to influence legislation important to radiology.
The ACR chapters engaged legislatures in a number of states during the 2012 legislative session. Understanding the intricacies of the legislative process and lobbying efforts by radiologists resulted in legislative victories for several chapters (see sidebar, "Influencing State-Level Legislation"). Highlighted below are some of the issues states faced during the 2012 legislative session.
States Face Dense Breast Legislation
Bill activity surrounding the topic of reporting breast density to patients took place this year in at least 16 states. Four states — California, New York, Virginia, and Utah — joined Connecticut and Texas by instituting laws related to disclosure of breast density information to patients. The advocate group Are You DENSE? notes on its website (www.areyoudense.org) that efforts to introduce such legislation are underway in Florida, Michigan, Ohio, and Delaware. The number of states with dense breast bill activity will likely increase near the beginning of state legislative sessions in 2013.
For almost 20 years, the ACR BI-RADS® (Breast Imaging Reporting and Data System) lexicon has encouraged radiologists to include breast parenchymal density information in the mammography report, and the ACR would support an FDA mandate that information on breast parenchymal density be included in the mammography report for referring physicians. ACR's Sample Mammography Lay Report Letters have been updated to include optional language for providers to inform the patient if the mammogram shows dense breast tissue. Additionally, the ACR and the Society of Breast Imaging have developed a brochure for patients that describes the significance of breast density and outlines facts about mammography exams. Download the brochure at http://bit.ly/ACRDensityBrochure or visit MammographySavesLives.org today.
Progress on the CT Colonography Screening Front
In addition to dense breast legislation, advancements were made in the area of CT colonography screening. Thanks to the work of the Radiological Society of Connecticut, along with assistance from the ACR's Colon Cancer Committee, Connecticut's law regarding colorectal cancer screening has been revised. The revision, effective Jan. 1, 2013, mandates coverage of colorectal cancer screening (including CT colonography) in accordance with American Cancer Society guidelines. Under prior law, insurers had to follow recommendations established by the American College of Gastroenterology after consultation with the American Cancer Society and the College.
Other State-Level Victories for Radiology
On Aug. 6, Massachusetts Governor Deval Patrick signed The Payment Reform Conference Committee Bill (S. 2400). Among other provisions, the bill requires the formation of the new Massachusetts e-Health Institute. The institute would encourage hospitals, clinics, and health-care networks to implement evidence-based, best practice, clinical decision support tools for providers to order advanced diagnostic imaging services.
The legislation's original language would have made it mandatory for health-care organizations to implement these support resources by Jan. 1, 2017, but the Senate compromised, only requiring the proposed institute to "identify and promote" implementation. Without a mandate, the hope is that a competitive marketplace, in which practices implement new technologies and decision support tools, will persuade more practices to adopt these instruments willingly. Members of the Massachusetts Radiological Society, with the assistance of the group's lobbyist, worked tirelessly to educate the representatives and state senators on the value of such tools.
Massachusetts isn't the only state with a major success story from 2012. North Carolina made progress in promoting adoption of computerized physician order support for imaging this year. During the 2009 budget crunch, the state's government signed a noncompetitive, at-risk contract with a radiology benefits manager (RBM). (Read more about RBMs in the September ACR Bulletin at http://bit.ly/Q2EMJA). By doing so, the state government hoped to achieve $100 million in savings per year. Because of the three-to-one federal matching funds for health-care spending in the state, a decrease in health funding allocation resulted in $400 million in lost revenue for the provider community, made up largely of hospitals and physicians, including many radiologists.
The North Carolina Radiological Society advocated for an alternative to the prior authorization process. More specifically, its members put the emphasis on exploring new technologies and delivery systems such as computerized physician order entry (CPOE). Such a tool assists referring clinicians in delivering the highest quality and most appropriate patient care when placing imaging orders. The first step in adoption of new technologies was to secure inclusion of the language for the secretary of health in North Carolina to have the option of adopting them in the future. Initial targets for implementation were Community Care of North Carolina, a health-care program network that administers health-care benefits for those who are eligible for Medicaid in the state; and the State Employee Health Plan. In the state, CPOE will be an alternative to the prior-authorization process used by the RBM, which is currently administering Medicaid.
In addition to state-level legislation, the government relations team worked diligently to represent radiology at the federal level. The College's 2012 federal legislative agenda predominately focused on five key issues:
• Blocking the 25 percent multiple procedure payment reduction (MPPR) to the professional component (PC) of advanced diagnostic imaging services
• Securing Medicare coverage of CT colonography
• Combating self-referral
• Preventing cuts in physician reimbursement due to Medicare's flawed sustainable growth rate (SGR) formula
• Mitigating attempted reductions to radiologists' technical component reimbursement
Understanding the intricacies of the legislative process and lobbying efforts by radiologists resulted in legislative victories for several chapters.
Professional Component Multiple Procedure Payment Reduction (PC MPPR)
Passing legislation to block CMS' imposed 25 percent PC MPPR serves as the College's principle legislative focus (read more about PC MPPR in the article "Safeguarding Radiology" in the July/August ACR Bulletin at http://bit.ly/SafeguardingRadiology). Following an intense lobbying campaign initiated by ACR's volunteer leaders, members of the U.S. House of Representatives and Senate introduced bipartisan legislation, specifically the Diagnostic Imaging Services Access Protection Act (H.R. 3269/S. 2347) to thwart efforts by CMS to reduce radiologists' professional component reimbursement. Reps. Pete Olson (R-Tex.) and Betty McCollum (D-Minn.) introduced H.R. 3269 in October 2011 followed by Sens. Ben Cardin (D-Md.) and David Vitter (R-La.), who introduced S. 2347 in April 2012. Both pieces of legislation continue to generate bipartisan support in each congressional chamber.
As of press time, 265 bipartisan members of the House of Representatives cosponsored H.R. 3269. The College's lobbying efforts within the Senate also made tremendous progress prior to the August congressional recess. On July 27, Sens. Cardin and Vitter circulated a letter to all members of the Senate urging them to cosponsor S. 2347. This appeal from the two principal sponsors came on the heels of an email distributed by Paul H. Ellenbogen, MD, FACR, chair of the ACR Board of Chancellors, which urged all ACR members to contact their senators about cosponsoring this legislation.
The combination of individual radiologists' grassroots advocacy and direct lobbying by the government relations team members proved fruitful. In fact, the total number of bipartisan cosponsors of S. 2347 doubled from six to 12 in July alone. More importantly, many of the newest supporters of the College's legislation to stop the PC MPPR, specifically Sens. John Kerry (D-Mass.), Ron Wyden (D-Ore.), Debbie Stabenow (D-Mich.), and Richard Burr (R-N.C.), serve on the powerful Senate Finance Committee, which has direct jurisdiction over this crucial bill. As of press time, 17 bipartisan senators are cosponsors of S. 2347.
Despite this success, H.R. 3269/S. 2347 faces considerable obstacles prior to enactment. A condensed legislative calendar following the 2012 election, as well as numerous competing legislative issues, will make it difficult for the Diagnostic Imaging Services Access Protection Act to get a vote. The ACR is hopeful that the high number of bipartisan cosponsors in the House of Representatives makes the PC MPPR bill an ideal candidate for passage using a fast-track legislative maneuver called "suspension of the rules," reserved for noncontroversial bills. Whether the House leadership consents to this tactic remains to be seen. The other likely scenario for enactment of H.R. 3269/S. 2347 is its inclusion in a forthcoming, comprehensive tax or health-care omnibus legislative package that must be passed prior to Jan. 1, 2013.
Mandating Coverage for CT Colonography Screening
The ACR government relations team also focused considerable time and effort on the CT Colonography Screening for Colorectal Cancer Act of 2012 (H.R. 4165/S. 2265). Introduced by Reps. Ralph Hall (R-Texas) and Danny Davis (D-Ill.), this bipartisan House bill mandates Medicare coverage for patient costs associated with CT colonography screening procedures. Referred to the House Committees on Energy and Commerce and Ways and Means, H.R. 4165 currently has 25 bipartisan cosponsors. Sen. James Inhofe's (R-Okla.) Senate companion bill currently has no other democratic or republican support to date.
Since mandating coverage of CT colonography will add costs to the Medicare program, the bill faces an uphill battle, especially in the fiscally conservative, Republican-controlled House of Representatives. To combat potential difficulties, ACR's government relations team circulated calls-to-action to the College's membership in July 2012. Harnessing the specialty's collective grassroots voice has played a key role in securing additional support for this patient-centered legislation. Although the ultimate outcome is difficult to predict, attaching the CT colonography bill to the anticipated large, health-care specific legislative package at the end of the year also represents the best case scenario for enactment of H.R. 4165/S. 2265.
Closing the Self-Referral Loophole
The ACR, in tandem with a coalition of other national medical specialty societies, actively lobbied Congress to close the in-office ancillary services exception (IOASE) to the Ethics in Patient Referrals Act, also known as the Stark self-referral law. The law generally prohibits physicians from referring Medicare patients for "designated health services" — including advanced diagnostic imaging, anatomic pathology, physical therapy, and radiation therapy — to entities in which the physicians have a financial interest.
The Alliance for Integrity in Medicare (AIM) — which includes the ACR, the College of American Pathologists, American Clinical Laboratory Association, the American Society for Radiation Oncology, the American Physical Therapy Association, and the RBMA — focused on securing an analysis of potential savings to the Medicare program gained from closing the IOASE from the nonpartisan Congressional Budget Office. AIM leaders are hopeful that the results of this cost analysis, as well as a healthy dose of political fortitude, will eventually prompt Congress to pass legislation to close this loophole in the self-referral law.
Facing Down Sustainable Growth Rate Cuts
Absent congressional intervention before Jan. 1, 2013, all physicians face a 27 percent reduction in Medicare reimbursement stemming from the flawed SGR formula. Although most congressional representatives oppose continued reliance on the formula, the exorbitant cost of eliminating the policy, currently estimated at $300 billion over 10 years, severely diminishes the odds of a permanent sustainable growth rate repeal in 2012. Thankfully, democratic and republican congressional leaders continue to stress the need to pass legislation to temporarily delay the SGR cuts, and it is likely that legislation will pass before the end of the year to avert these reimbursement reductions.
Riding the Technical Component Cuts Rollercoaster
Another front on which the government relations office has been active is preventing further cuts to radiologists' technical component (TC) reimbursement rates. Defined as the amount of time that an imaging center is open to patients and expensive equipment (priced above $1 million) is actually in use during a 50-hour work week, the equipment utilization rate is one figure in a formula that helps calculate practice expenses reimbursed under Medicare. Higher equipment utilization assumption rates result in lower technical component Medicare reimbursement for individual scans.
Prior to the passage of the Patient Protection and Affordable Care Act (PPACA), CMS, through the 2010 Medicare Physician Fee Schedule, attempted to increase the equipment utilization assumption rate to 90 percent. Preserving the lower 75 percent rate is a de facto victory for the College. Yet the decision to uphold PPACA also ensures that the 50 percent TC MPPR remains in effect. The Supreme Court's June decision to uphold the PPACA has solidified radiologists' TC reimbursement rates. Since the court deemed the law constitutional, it preserved the current equipment utilization assumption rate at 75 percent.
ACR's government relations efforts successfully avoided repeated attempts to cut radiologists' TC reimbursement rates, most noticeably in 2011, when Congress attempted to once again increase the equipment utilization assumption rate to 90 percent through provisions slipped into the South Korea Free Trade Agreement. Although ACR was ultimately successful in removing this specific cut, changes to the equipment utilization assumption rate remain under consideration by numerous spending policy proposals being floated by President Barack Obama and members of the House and Senate. ACR, in conjunction with the ACR-cofounded Access to Medical Imaging Coalition, has met repeatedly with various members of the House and Senate to prevent any further TC reimbursement cuts. Nevertheless, the nation's dire fiscal climate, as well as incorrect perceptions among policymakers that advanced diagnostic imaging spending is excessive, continue to make radiology vulnerable to cuts at the end of 2012.
Radiology Advocacy Network Gets a Reboot
In response to the multitude of issues affecting the specialty, ACR has focused considerable time and energy reforming its grassroots advocacy program, primarily through the creation of the Radiology Advocacy Network (RAN). Created during the fall 2010 BOC meeting, the RAN is designed to alert and motivate ACR members to contact congressional representatives on pressing legislation affecting radiology. In addition, the RAN is dedicated to assisting radiologists in becoming more informed about, as well as more involved in, advocacy for radiology at both the state and national level.
As of press time, 18 states are enrolled in the RAN network and are at various stages of incorporating this new grassroots advocacy model. Five states have completely incorporated the infrastructure, including North Carolina, Arizona, Minnesota, Washington, and South Carolina. These state networks, which involve requesting that members contact their senators or representatives to support various bills, have been tested and proven effective, as indicated in the increased number of those participating in the recent calls-to-action.
Using historical data on the minimal responses to past grassroots advocacy requests, the College government relations office identified a 500 percent increase in the overall membership response rate to recent calls-to-action compared to past rates. Much of this increase is concentrated within the states that have begun to implement the RAN framework. The five states with the most responses to the PC MPPR calls-to-action are as follows:
• New York: 295 responses (8.22 percent of the total response)
• California: 293 responses (8.22 percent of the total response)
• Texas: 282 responses (7.80 percent of the total response)
• Florida: 208 responses (5.78 percent of the total response)
• Pennsylvania: 189 responses (5.30 percent of the total response)
By Chris Sherin and Eugenia Krimer Brandt