Doctors Ask Congress for Freedom, Not Bigger Reimbursements

/PRNewswire/ -- Once again, the American Medical Association is begging Congress to postpone a fee cut for doctors under Medicare's "sustained growth rate" (SGR) method. Unless Congress acts, doctors' Medicare payments will be slashed 23% on Dec 1, then another 6% on Jan 1. The formula automatically kicks in when Medicare spending exceeds a certain amount.

On what the AMA calls White Coat Wednesday, Nov 17, doctors are urged to call Congress. But the Association of American Physicians and Surgeons (AAPS) advises a different message.

"The AMA and Congress have been playing this game of 'chicken' for more than 8 years," says Dr. Jane Orient, executive director of AAPS. [See: http://www.aapsonline.org/newsoftheday/001097] The AMA threatens doctors will quit seeing Medicare patients unless Congress stops the cuts.

"Meanwhile, the AMA and the government collude on a dictatorial system of price controls."

The values for thousands of medical procedures are set by a secretive 29-member panel called the RUC, the Relative Value Scale Update Committee, convened by the AMA. [See Wall Street Journal, Oct 26, 2010. http://online.wsj.com/article/SB10001424052748704657304575540440173772102.html?KEYWORDS=Relative+Value+Scale+Update] Once the RUC determines the formula for divvying up $60 billion for physician fees, the government accepts most of the recommendations and applies a "conversion factor" to give each fee a dollar amount.

Doctors who charge a different amount are heavily fined or sent to prison. Because of the price controls or ban on "balance billing," if the Medicare-allowed fee doesn't cover the cost, doctors simply can't provide the service. Patients who are willing and able to pay are not permitted to make up the difference. It amounts to a form of covert rationing.

"In a free-market system, patients and doctors decide on the fee," states Dr. Orient. "That is not necessarily the same as the insurance reimbursement."

Doctors who opt out of Medicare set their own fees, but patients cannot collect Medicare reimbursement for their services.

Instead of asking for more taxpayer money, AAPS asks Congress to restore the freedom of patients and physicians to make their own decisions, including the amount of the fee. Without all the expensive Medicare hassles, fees are often lower.

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84% of Physicians Polled will have to Stop Seeing Medicare Patients if Reimbursement Cuts Pass

/PRNewswire/ -- Sermo (http://www.sermo.com/), the world's largest online community for physicians, today announced physician reaction to the Medicare cuts effective March 1st, 2010. Nearly 1,500 physicians participated in an online poll and discussion measuring how they will respond to the reimbursements cuts. Of the respondents, 84% said they will have to stop seeing new Medicare patients, stop seeing all Medicare patients or consider closing their practices altogether.

This cut in reimbursements will dramatically impact both the physicians providing care and the patients. As one Oncologist noted, "Ultimately, it's the patients who will suffer."

Many practices, private and group, will be opting out of Medicare as of March 1st. One Family Practice Physician said, "My primary care group (the largest in our county) will stop accepting new Medicare patients Monday, and if the cuts stick, terminate care for 25-50% of the existing patients and require all new patients with commercial plans to sign up for our retainer offering. We have a leaflet ready explaining the reasons why and how to contact our Congressman and Senators."

Many physicians explained they simply cannot make up for the declining payments by increasing volume of patients seen. For some practices, the bulk of the physician's patients are on Medicare/Medicaid. One Doctor of Osteopathy shares, "Medicare makes up about 50% of my practice. I cannot afford to stop seeing them all together right now. Either way I will have to significantly change my practice to reduce overhead to survive the cut."

Physicians are particularly disillusioned by what they believe is Congress' attempt to control the practice of medicine. One surgeon writes, "The government cannot be allowed to legislate that we take on unprofitable endeavors. It is time for all physicians to take a stand for a fare wage." A Dermatologist added, "Medicare needs to get out of the price-fixing business."

To view the full discussion and polling results, visit the Sermo Blog at http://sermo.com/blog. The Sermo Blog (www.sermo.com/blog) highlights the most vibrant discussions happening. Discussions on Sermo are physician-initiated and cover topics ranging from medical ethics & practice management to challenging clinical cases. All physicians on Sermo are verified as licensed in the US.

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Cancer Community Alarmed at CMS Policy Lumping Life-Saving Cancer Therapy With Diagnostic Testing For Major Funding Cuts

/PRNewswire/ -- The following is being released by US Oncology:

Concerned members of the cancer community, including physicians, patient organizations and other care advocates, spoke out today in opposition to a proposed federal policy under consideration by the Centers for Medicare and Medicaid Services (CMS) that would lump life-saving radiation therapy in with diagnostic testing services in receiving major Medicare funding cuts. In support of their cause, a bipartisan letter led by Reps. Parker Griffith (D-AL), Sue Myrick (R-NC), Lois Capps (D-CA) and Mike Rogers (R-MI), was sent to Health and Human Services Secretary Kathleen Sebelius urging a reversal of this proposal.

"I am very alarmed at the prospect of these dangerous funding cuts being made to radiation therapy, which is a safe and effective treatment proven as a trusted tool in the fight against cancer," said Bernard W. Taylor, M.D., a radiation oncologist at Texas Oncology-Longview Cancer Center in Longview, Texas. "For vulnerable cancer patients like mine, this proposed policy would limit their access to vital radiation treatment through longer wait times and less time spent with their doctors. We must educate policymakers on the radical difference between life-saving, therapeutic radiation therapy and diagnostic testing, and the critical need to spare radiation therapy from these cuts."

At issue is a 19 percent funding cut in Medicare reimbursement to the radiation oncology specialty contained within the CY 2010 Physician Fee Schedule Proposed Rule, equating to cuts of up to 44 percent for certain codes critical to the provision of radiation therapy treatments. Of particular concern in the rule is a proposed policy that raises the utilization rate for medical equipment costing over one million dollars from 50 to 90 percent. The lawmakers and other experts in the industry warn that cuts of this size will result in the closing of many freestanding and community-based cancer centers, particularly in rural areas, harming patient access to care.

"As a radiation oncologist who practiced in the community setting, I am aware of how these severe cuts would limit access to life-saving radiation therapy for cancer patients," said Rep. Griffith. "I am proud to be working on healthcare reform to expand access to high quality, effective care for cancer patients and all Americans, and I look forward to working with both parties as well as the administration to find a solution that averts these cuts and protects patient access to care."

The Congressional letter submitted to Secretary Sebelius, signed by more than 60 Members of Congress, asked CMS to refrain from finalizing the proposed reductions in Medicare payment for radiation oncology services, and to refrain from applying a higher assumed equipment utilization rate to radiation oncology equipment. The letter states:

"We are writing you today to emphasize a clear distinction: Radiation therapy is not diagnostic imaging. . . The therapeutic use of radiation to treat cancer should not be the target of those concerned with volume growth in the area of diagnostic imaging."

The proposal to reduce rates for diagnostic imaging was made by the Medicare Payment Advisory Commission (MedPAC) in their March 2009 report. MedPAC has subsequently stated that it never intended to include radiation therapy in any Medicare reimbursement cuts and yet CMS proposed to extend the cuts to radiation oncology anyway.

According to the National Cancer Institute (NCI), radiation therapy has been found to be under-utilized, with a variety of barriers, including travel time to care, cited as standing between patients and treatment. Following a review of relevant literature, the Agency for Health Care Research and Quality (AHRQ) found evidence of disparities in radiation therapy use among older patients; women; and African Americans, with the exception of care provided in the Veterans' Administration system. In another study of more than 11,000 women in Florida who had undergone breast conserving surgery, the odds of receiving post-surgical radiation therapy decreased by 3 percent for every 5-mile increase in the distance to the nearest radiation therapy facility.

"We support using data to ensure that payment rates for medical procedure are appropriate," said Leonard Kalman, M.D., Chairman of US Oncology's Public Policy Steering Committee. "However, making cuts of this size to radiation therapy - a treatment modality that more than 1 million cancer patients rely upon each year for both curative intent and palliative treatment - without an expressed rationale backed by supporting data is unsound and frankly quite frightening. On behalf of our country's cancer patients, many of whom will rely on radiation therapy at some point in their illness, we must ensure that these cuts are not applied."

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Congress Must Recognize Homecare as Cost-Effective Part of Health Care Reform

/PRNewswire/ -- In their effort to find savings in the healthcare system, the Obama administration and Members of Congress have been eyeing Medicare's home medical equipment (HME) sector for cuts. This sector provides medical oxygen, respiratory therapy, hospital beds, wheelchairs, walkers and other equipment and services that allow people to get the care they need at home instead of in a hospital or nursing home.

Already in 2009, Medicare payments for the most commonly prescribed home medical equipment categories have been cut by 9.5 percent. Medical oxygen reimbursement has been cut by 27 percent so far this year. Another measure aimed at cutting HME costs further is so-called "competitive" bidding.

"The American Association for Homecare urges Congress to recognize that home care is a cost-effective alternative to more expensive forms of care, and should therefore be a critical component -- not a casualty -- of American health care reform. Current and proposed cuts to Medicare's home medical equipment sector are not an effective way to reduce overall Medicare spending. These cuts are likely to increase Medicare costs over time by forcing more seniors into nursing homes and hospitals, blocking preventative care, and causing more frequent visits to emergency rooms.

"Quality home medical equipment and services facilitate hospital discharges, reduce hospital readmissions and emergency room visits, and help to keep seniors and people with disabilities out of more expensive institutional settings. As Congress debates health care reforms, it is important that it keeps these facts in mind and recognizes home care as a partner in improving the quality of American health care and reducing overall health care costs.

"Most home medical equipment costs just dollars a day. The cost of providing the equipment and service for home oxygen, for example, is less than $7 per day under Medicare. Compare that to the average daily cost of about $200 for a nursing facility and more than $5,000 per day for a hospital stay under Medicare.

"According to a recent study in the New England Journal of Medicine, up to one-fifth of all Medicare patients are readmitted to hospitals within one month of being discharged. These unplanned visits cost Medicare an estimated $17 billion in 2004. One reason for the high readmission rates is the lack of continued interaction and guidance once patients are dismissed. Home medical equipment providers help to fill this gap by smoothing the transition from hospital to home with the equipment and services patients need.

"This year, Medicare payments for the most commonly prescribed home medical equipment categories have been cut by 9.5 percent, including complex rehabilitative power wheelchairs. Medical oxygen reimbursement has also been cut by 27 percent so far this year. Home oxygen is a critical, life-sustaining medical treatment prescribed to nearly 1.5 million Medicare patients each year who suffer from respiratory illnesses such as chronic obstructive pulmonary disease.

"Another measure aimed at cutting HME costs further has been labeled 'competitive' acquisition. A regulation enacted in the final hours of the Bush administration would selectively contract with a small number of home care providers based on a race to bid the lowest payment. Even among those who agree to new bid-determined payment rates, Medicare only allows a select few to provide the items, which will have the long-term result of reducing the number of companies competing to offer home care products.

"These cuts in reimbursement are having a negative impact on the quality of equipment and the level of services that providers are able to furnish to consumers who have severe disabilities and who are in greatest need of mobility products and services.

"Home medical equipment and service is already the most cost-effective slowest-growing portion of Medicare spending, increasing only 0.75 percent per year, according to the latest National Health Expenditures data from Medicare. That compares to more than 6 percent annual growth for Medicare spending overall. Moreover, home medical equipment represents only 1.6 percent of the Medicare budget.

"As Congress deliberates cuts to Medicare, they would do well to recognize that cuts to home medical equipment will increase long-term Medicare costs. The home medical equipment sector should be seen as a key element in reducing overall Medicare costs."

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Blue Cross Blue Shield of Georgia Is Skimping on Mental Health Care, Says Georgia Psychological Association

/PRNewswire / -- Late in 2007, Blue Cross Blue Shield of Georgia (BCBSGa) announced that it was cutting its hourly therapy reimbursement rate for clinical psychologists by approximately 19%. This new rate is about the same as you pay your auto mechanic or home handyman per hour.

However, unlike your mechanic, BCBSGa wants to pay licensed psychologists about half of what they were paid 10 years ago by BCBSGa. In 1998 clinical psychologists were reimbursed by BCBSGa nearly one and a half times today's rate for the same therapy hour. Accounting for inflation, today's rate should be nearly double in 2007 dollars (US Bureau of Labor Statistics based on the Consumer Price Index). Unlike medical doctors and dentists, psychologists see only one patient per hour.

As a result, GPA is hearing from its members that more and more licensed psychologists, especially the most experienced, are finding they can no longer see patients insured with BCBSGa insurance because they cannot run a practice, much less make a living, on what BCBSGa, one of Georgia's largest insurers, is willing to reimburse psychologists

Effective treatment requires highly specialized training and experience. Clinical psychologists licensed in the state of Georgia have either a Ph.D. or a Psy.D. including a bachelor's degree, 4-6 years post-graduate work, plus 1 year supervised internship, and at least one year post-doctoral supervision by a licensed psychologist.

"Research has shown again and again that there is a connection between good physical health and good mental health," said Georgia Psychological Association past-president, Dr. Joni Prince. "And taking a pill alone is not usually the most effective way of improving mental health; psychotropic drugs work better when used in conjunction with psychotherapy," she continued.

But clinical psychologists feel pressured to defend themselves if they see their BCBSGa patients for more than the "licensure type average" of 6.0 sessions, even though BCBSGa offers its PPO customers 50 therapy sessions per calendar year. Major depression, can affect almost 9% of the American population (Mann, New England Journal of Medicine, 10/27/05), and is a leading cause of lost productivity and time off from work. "It seems that Blue Cross is basing treatment decisions on statistics rather than clinical information," Prince said.

What else should you know?

In addition to psychotherapy, psychologists are the only mental health professionals who are qualified to administer, score, and interpret psychological testing instruments, including psycho-educational testing (for IQs, learning disabilities, etc.) and neuropsychological testing, among others.

Yet BCBSGa routinely denies coverage to its customers for psychological evaluations. Evaluations and accompanying clinical interviews are the first step in either diagnosing or ruling out learning disabilities, ADHD, Depression, Anxiety, Bi-polar disorder and other psychopathology. Nearly half (45%) of those with any mental disorder meet criteria for two or more disorders (National Institute of Mental Health press release related to a study published in September 2006 issue of the American Journal of Psychiatry).

Without proper evaluation, mental disorders will go undiagnosed and therefore, untreated. For instance, among adults who have an anxiety disorder about half had symptoms of some type of diagnosable mental illness by age 15, an NIMH-funded study showed. The results emphasize the importance of early diagnosis and treatment of anxiety disorders (NIMH Science Update 2/7/07). "In spite of these studies, many of which are publicized, patients are neglecting their mental health in part due to poor coverage and limited access to quality mental health care," Dr. Prince continued.

Once your child is diagnosed, for example, with Autism or Asperger's, his or her treatment may not be covered by BCBSGa, depending on the type of policy. This flies in the face of Georgia Law, which considers both Autism and Asperger's to be neurological conditions, all of which are mandated by law to be covered equally by insurers (GA Code 33-24-59.10).

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