LAS VEGAS – A coalition working to address dual-energy X-ray absorptiometry access issues is developing draft legislation that would establish a geographically adjusted national minimum payment for DXA, according to Dr. Michael Schweitz.
Under the draft legislation – a response to a series of reimbursement cuts over the past several years – DXA CPT codes 77080 and 77082 would be paid at $98 and $35, respectively, and a bundled code or bundled payment for bone density and vertebral fracture assessment studies would result in a national minimum payment of $133, Dr. Schweitz, president of the Coalition of State Rheumatology Organizations, said at Perspectives in Rheumatic Diseases 2013 during an update on federal legislative and regulatory issues facing rheumatologists.
Restoring reimbursement is an issue on the "front burner," he said, noting that studies have demonstrated an increase in hip fracture rates in the wake of declining reimbursement as some practices have abandoned DXA.
The DXA draft legislation is just one of a number of current legislative initiatives and issues that should be on rheumatologists’ radar, Dr. Schweitz said.
Sequestration
Under sequestration – a "heavy hammer" proposed as a way to push for agreement on a deficit-reduction plan and implemented when that agreement didn’t materialize – Medicare provider reductions are limited to 2% per year. Claims are reduced by 2% after beneficiary coinsurance or deductible. H.R. 1416, the Cancer Patient Protection Act of 2013, would terminate sequester cuts for all part B drugs, not just cancer drugs.
Medicare physician payment
Based on the formula for the Medicare sustainable growth rate, or SGR, physician payments will be cut by 24.4% if Congress does not intervene by Jan. 1, 2014. The latest cost estimate by the Congressional Budget Office for repeal of the SGR is $176 billion – far less than previous estimates and far less than the combined cost of prior short-term patches. President Barack Obama’s 2014 budget, as well as Congressional budgets and recent federal rulemakings, all assume that Congress will fix the SGR this year. Draft legislation released in July based on a replacement proposal from the bipartisan House Energy & Commerce Committee calls for a two-phase approach. Phase I would repeal the SGR entirely and replace it with a 5-year period of stable payments, including a 0.5% increase across-the-board, and phase II would involve implementation of an enhanced "PQRS-like Update Incentive Program." This would maintain fee-for-service as an option, allow providers to move into other models at any time, and would involve physician-driven quality measurement.
"This is something all of us should be aware of ... you can be sure that this whole system of reimbursement for what we do is going to change in the future," said Dr. Schweitz, who has a private practice in West Palm Beach, Fla.
How the changes would be paid for has not been defined, but there is a proposal from the House Ways & Means Committee that involves entitlement reform with increased part B/D deductibles and an increased age for eligibility.
Part B drug payments
A new bill (H.R. 800) that would affect physicians who provide in-office drug infusion excludes prompt pay discounts from manufacturers to wholesalers from the average sales price (ASP) calculation for part B drugs. This would improve payment for physicians who do not receive the discounts. However, the president’s 2014 budget assumes part B drugs are overpaid and proposes reducing Medicare payment from ASP plus 6% to ASP plus 3%.
This would require legislation to enact. The House and Senate budgets do not include any assumption regarding ASP.
"There’s very little chance, I think, that either side is going to be successful with this," Dr. Schweitz said.
The Independent Payment Advisory Board
The IPAB, a 15-member board created as part of the Affordable Care Act to make recommendations to cut spending when costs exceed growth targets, has been a contentious issue.
"There is a huge outcry in Congress against this IPAB," Dr. Schweitz said, explaining that there is a sense that the IPAB represents a usurping of the authority of Congress in controlling this part of Medicare activity.
A bipartisan repeal effort is underway in the form of H.R. 351/S. 351, the Protecting Seniors’ Access to Medicare Act. This has a chance of moving forward, but opposition in the Senate could hold it back, Dr. Schweitz said.
Of note, the president’s 2014 budget would lower the target rate that triggers IPAB recommendations from gross domestic product plus 1% to GDP plus 0.5%. Also, House Speaker John Boehner (R-Ohio) and Senate Minority Leader Mitch McConnell (R-Ky.) are on record saying that they will not nominate members to the IPAB, he said.