CMS Payment Policy Update:
AAHKS Efforts to Avert Cuts
November 10, 2013
Mark Froimson, MD, MBA
AAHKS, Health Policy
Committee Chair
What is happening with Medicare
Payment for TKA, THA?
•
•
•
•
The RUC, In brief
Current Threats for cuts to payment
AAHKS Response
Potential Scenarios/Future
Directions
Medicare RBRVS
• Medicare implemented the Resource-Based
Relative Value Scale (RBRVS) on January 1, 1992
• Payments determined by the resource costs
needed to provide them
• Most public and private payers utilize the
Medicare RBRVS
• AMA RUC has been delegated by CMS to advise
on appropriate relative values for procedures
The RUC: a secret society
American Medical Association
CPT Editorial Panel
American Osteopathic Association
Practice Expense Review Committee
Health Care Professionals Advisory Committee
Anesthesiology
Cardiology
Dermatology
Emergency
Medicine
Family Medicine
General Surgery
Geriatric Medicine
Infectious Diseases*
Internal Medicine
* indicates rotating seatt
Neurology
Neurosurgery
Obstetrics/Gynecol
ogy
Ophthalmology
Orthopaedic
Surgery
Otolaryngology
Pathology
Pediatrics
Plastic Surgery
Primary Care*
Psychiatry
Radiology
Rheumatology*
Thoracic Surgery
Urology
Vascular Surgery*
RUC Cycle
CPT Editorial
Panel or CMS
Requests
Level of Interest
Medicare Payment
Schedule
Specialty Society
Survey
Specialty RVS
Committee
CMS
The RUC
Medicare RBRVS
•
The cost of providing each
service is divided into three
components
1. Physician Work
2. Practice Expense
3. Professional Liability
Insurance
Professional
Liability
Insurance, 4.3%
Practice
Expense, 47.4%
With geographic modifiers to
reflect costs associated with
different regions
Physician
Work, 48.3%
Physician Work
• Determined by:
- The time it takes to perform the service
• Prep/positioning time
• OR time
• Post op in hospital and office visits
- IWPUT (intensity)= RVU/time
- The technical skill and physical effort
- The required mental effort and judgment
- Stress due to the potential risk to the
patient
The Survey
• Sent by specialty society (AAOS) to wide
array of surgeons
- Specialists, generalists
• Standardized instrument with Vignette/patient
• Surgeons are to self report
- How much time they spend during
- Prep for surgery
- Surgical time—the entire case
- Waiting time/positioning
- Post op discussion with family/Dictation
- Hospital and Office visits
• What procedures can it be compared to?
CPT Editorial
Panel or CMS
Requests
RUC Cycle
Level of Interest
Medicare Payment
Schedule
Specialty Society
Survey
Specialty RVS
Committee
CMS
The RUC
Confidentiality
• All RUC materials are
confidential
• Cannot publish RVU
recommendations until CMS
publishes Federal Register
• CMS publishes in interim final
Rule (November 27th) and
goes into effect for one year
with comment period
• CMS issues an interim
proposed rule in June
- did not include TJR values
Medicare High Expediture
Procedures trigger review: 2011
• TKA > $3.5 billion
- the largest CMS expenditure for
a single procedure.
• Heart Failure $3.4 billion
• PCI with stent $2.0 billion
• Spinal fusion $3.2 billion
CMS targets TJR, tasks RUC to
review codes
• CMS identified four key orthopedic codes for RUC review
- Review of the 70 most high expenditure non-E/M
services billed to Medicare, considered outside the
normal 5 year cycle
CPT
CODE
DESCRIPTION
27236
Hip Hemiarthroplasty
27446
Single Compartment Knee
Arthroplasty
27447
Total Knee Arthroplasty
27130
Total Hip Arthroplasty
• Combined Medicare volume: 450,000
• Significant cost to CMS
TJR Review timeline
• 2011 Identified as High Expenditure Procedures
• 2012 Sent to RUC for review
• AAHKS, AAOS advocate delay in consideration
- need to establish values for TSA, TEA as
comparators
• 2012 TSA, TEA, Hemiarthroplasty codes valued
- All increased in value
• 2012 Surveys sent to members for THA, TKA
• 2013 TKA, UKA, THA values debated by RUC
• January 2013 RUC recommends significant cuts
RUC Review
• AAHKS and AAOS surveyed family of codes and
presented at the January 2013 RUC meeting*
CPT
CODE
27236
AAHKS/
AAOS
REC.
RUC
REC.
DIFFERENCE
Between current
values and RUC
17.61
17.61
17.61
0
16.38
17.48
17.48
+1.1
(+6.7%)
23.25
22.13
19.6
-3.65
(-16%)
21.79
21.79
19.6
-2.19
(-10%)
CURRENT
VALUE
Hip
Hemiarthroplasty
27446
Uni Knee
Arthroplasty
27447
Total Knee
Arthroplasty
27130
Total Hip
Arthroplasty
*27236 presented at October 2012 RUC meeting
RUC rationale
• Surgical time on surveys for TKA and THA
showed significant reduction from historic
- 100 minutes from 135 of surgical time in RUC
database from 2005
• Hospital LOS reduced
- 3 days from 4
• Post operative office visits reduced
- 3 visits in 90 days, from 4
• Intensity of procedure not increased
significantly to make up for reduced time
AAHKS Concerns with
RUC Recommendations
• RUC’s recommended times and RVUs
incorrectly undervalued these procedures
• RUC values create rank-order anomalies
- Only 10 minutes more for THA vs. hemi
• AAHKS/AAOS recommended times and RVUs
more appropriate relative to other
musculoskeletal codes
- TSA
AAHKS/AAOS argument
• Surgical time on surveys showed significant
reduction from historic
- 100 minutes from 135 of surgical time
- But historic RUC value based on NSQIP data,
not survey
• Survey data from 2005 was identical
• NSQIP data identical
• Anesthesia data showed only 2% decrease
• There has been no real change in
operative work
CMS anesthesia data
Year
Validate trends with anesthesia payment
deflated by anesthesia conversion factor
Calculate mean anesthesia time
5%
sample
claim
count
Anesthesi Allowed
Mean
a CF
charge /
anesthe
Mean (median conversi
sia time Time in allowed of locality on
units
minutes charge rates)
factor
Anesthesia for total hip (CPT 01214)
2005
8,793
9.92
148.8
2008
8,162
9.55
143.3
2011
8,719
9.73
146.0
$
$
221.42 17.76
$
$
242.60 19.92
$
$
261.92 21.04
12.47
12.18
12.45
-2%
% change, 2011 versus 2005
0%
Anesthesia for total knee (CPT 01402)
2005
19,218
9.89
148.3
2008
19,004
9.55
143.2
2011
20,047
9.50
142.5
% change, 2011 versus 2005
-4%
$
$
209.20 17.76
$
$
231.60 19.92
$
$
242.85 21.04
11.78
11.63
11.54
-2%
AAHKS/AAOS argument
• Hospital LOS reduced
- 3 days from 4
- But intensity of services increases
- 99231 to 99232
• Post operative office visits reduced
- 3 visits in 90 days, from 4
- But intensity of service increased
- 99212 to 99213
• Patients have more comorbidities, obesity,
chronic disease and intensity of care is higher
AAHKS Advocacy
• Meeting with key CMS staff with AAOS
- June and August
- Presentation on RUC valuation flaws
- Written description of better methods
for valuation
• “Leave behind”
• An alternative method for valuation
• “building block methodology”
- Ongoing dialogue with CMS
AAHKS Advocacy:
Key Messages
• No or minimal change in work of procedure
- “a mature procedure by 2005”
• Request release of proposed values in
interim proposed rule in July
• Surgeons need to know what to expect well
in advance of the effective date
- (July vs. November for 2014 go live date)
• Access to care may be in jeopardy
Decrease in RVUs May Impact
Medicare Beneficiary Access:
AAHKS Survey by EBM committee
• If Medicare cuts payment 15%-20%
• Negative impact on beneficiary access
- Surgeons will increasingly provide
care to non-Medicare patients first
- 57% will decrease # of Medicare
patients they see
- 22% will leave Medicare
- 6% will quit doing joints
- 7% will retire early
Summary Recommendations
• AAOS & AAHKS support the RUC recommendations
for codes 27236 and 27446 and these should be
maintained by CMS
• AAOS & AAHKS believe the RUC recommendations
for Total Hip Arthroplasty (27130) and Total Knee
Arthroplasty (27447) are incorrect
• We urge CMS to accept the AAOS/AAHKS
recommended times and RVUs for these codes to
maintain the appropriate relativity and rank order
CMS Meetings
• Left CMS with lack of promise that they would
consider our recommendation vs. RUC
CPT
CODE
27236
AAHKS/
AAOS
REC.
RUC
REC.
DIFFERENCE
Between
AAHKS/AAOS
and RUC
17.61
17.61
17.61
0
16.38
17.48
17.49
+1.1
(+6.7%)
23.25
22.13
19.6
-3.65
(-16%)
21.79
21.79
19.6
-2.19
(-10%)
CURRENT
VALUE
Hip
Hemiarthroplasty
27446
Uni Knee
Arthroplasty
27447
Total Knee
Arthroplasty
27130
Total Hip
Arthroplasty
Advocacy Efforts: The Message
• Members, BOTG, Patients, Lobbyists contact:
• CMS
• No valid reason for decrease
• Alternative methods proposed more valid
- Congress
• CMS is threatening access to care
• Through non validated method to revalue/
reduce physician payment for TJA
• CMS needs to be transparent as a public
agency
Advocacy Efforts
• Letters to CMS from patients
• Letters from Congress to Director
Tavenner
- Congressman Price, GA
- Congressman Ruppersberger, MD
- Congressman Buchanan, FL
- Congressman Stutzman, IN
- Congressman, Kind, WI
- Congressman, Neugeberger, TX
Advocacy Efforts
• Letters to congress, visits and calls from
from members and patients
• Letters from Senate to Director Tavenner
• Senators Kaine and Cantor, VA
• Senators Pryor and Boozman, AK
• Senator Cardin, MD
• Senator Burr, NC
• Senator Cornyn, TX
• Calls to Director Tavenner
• Georgia congressman Tom Price
• Arkansas Senators Pryor and Boozman
Advocacy Efforts
•
•
•
•
•
•
•
•
CQ Roll Call
Easy method to generate letters
Database of prepopulated letters
Database of legislative contacts
Accessible to Members
Available from link on new AAHKS website
Industry Support: Biomet letter campaign
AARP, AHA—not helpful
Will the RUC change?
• Significant negative Press
• Recent article in Washington Post
• Recent press release from AMA
• Secretive nature of process under fire
• Survey methodology questioned
• Proposal to use extant databases and
other methods
• Promise to allow public disclosure
What’s Next?
• CMS will come out with Interim Final Rule on
or by November 27, 2013
• It may:
• Include cuts at RUC recommended level
• Include more modest cuts between RUC
and AAOS/AAHKS recommended
• Accept AAOS/AAHKS recommended
levels
• Be silent on THA, TKA
• CMS may or may not return this to RUC
or other method for further review
Future Directions
•
•
•
•
Continued erosion based on FFS payment
SGR repeal with VBP modifiers
?opt out or reduce medicare patients?
Alternate Payment models
• BPCI
• ACO
• Shared Savings
- Pursue strategies to align compensation
with true value of surgeon’s contribution to
the value chain
Thank You