AUA Health Policy Basics Course
National Health Policy Organizations
• The RUC meeting, convened by the AMA,
evaluated 4 new CPT 1 codes to determine their
RVU. CMS approved the panel recommendations;
however stated that the GPCI and the PLI portion
of the RVU will be modified. The CY 2012 CF was
calculated at $24.67.
• Studies by the AHRQ and IOM were included in a
MEDPAC report to Congress. A key quality issue
related to Medicare part B was identified. The
AUA, AACU, and LUGPA discussed. The AUA QIPS
committee worked with the SQA and the ACS
through the PCPI to develop a new measure. The
measure was approved by the NQF.
Overview
• Government Health Insurance
– Structure and Reimbursement Process
• Quality Improvement Initiatives and
Organizations
• Physician Organizations
Government Health Insurance
Structure and Reimbursement Process
Medicare
• Health Insurance for the Aged Act
– Johnson Administration 1965
• Health insurance for Seniors
– Nixon Administration 1972
• Patients with renal failure and chronic disability
– Includes 17% of all beneficiaries in 2011
– Seniors qualify for benefits by paying at least 10
years (40 quarters) of payroll taxes
• Premium required for non-qualifiers
Medicare
• Part A
– Hospital Insurance program
• Acute inpatient stays, skilled nursing facilities, hospice, home
health services
• Funded by mandatory payroll taxes (workers and employers)
– Eligible Medicare beneficiaries automatically enrolled
• No co-pay but annual deductible
• Part B
– Supplementary Insurance Program
• Physician services, supplies, outpatient and ambulatory care,
durable medical equipment, and laboratory services
• Voluntary program
– Premium and deductible
Medicare
• Part C
– Medicare Advantage (MMA 2003)
• Private insurance distributes Medicare Part A, Part B,
and an equivalent to Part D with option of “advantage”
– HMO, PPO, PFFS plans
• Part D
– Subsidized prescription medication coverage
• Voluntary
– Variable co-insurance rate drug costs > $310
annually
• “Doughnut hole”
Medicaid
• Title XIX Amendment to Social Security Act 1965
• Means tested health care benefits
– Primarily state managed
• Federal fund distribution based on state needs assessment
and compliance with federal oversight
• Inpatient, outpatient, nursing home, drug benefit
• Special Considerations
– Dual eligible (Medicare and Medicaid eligible)
– Children
• SCHIP or CHIP (Children’s Health Insurance Program)
Medicare Payment Advisory Commission
(MEDPAC)
• Balanced Budget Act of 1997
• Advisory group to Congress on payment and
quality of the Medicare program; makes nonbinding recommendations
– 17 members with staggered three year terms
• 2 practicing physicians
• Broad oversight and mandate
– Access, quality, payments to private insurance,
GME payment recommendations
Center for Medicare and Medicaid
(CMS)
• Previously known as HCFA (Health Care
Financing Administration)
– Changed name to CMS in 2001
• Head of CMS is a presidential appointee
• Administration, coordination, and oversight of
Medicare and Medicaid
– Interprets and implements Congressionally passed
health care law through issuance of regulation for
both programs in the federal register
Common Procedural Terminology
(CPT)
• Descriptive terms and identifying codes for
reporting of provider services and procedures
– Adopted by CMS in 1983 as official Healthcare
Common Procedure Coding System (HCPCS)
• Five digit numeric or alpha numeric codes
– CPT 1
• Well established service or procedure
• Reimbursed for this service or procedure
– CPT 2
• Data collection, measure performance
– CPT 3
• Temporary codes used to assess emerging technology
Common Procedural Terminology
(CPT)
• Evaluation and Management (E&M) codes
– Patient encounters
• Office, hospital, consults (new or established)
• Codes 99201 – 99499
• Procedure codes
– Diagnostic and treatment codes
• Surgical, anesthesia, radiology, laboratory
• Urology specific codes 50010 – 55899
– Cystectomy (51596), Cystoscopy (52000)
• Modifiers
– E&M and Procedure codes
• Lengthy discussion (E&M)
• Two surgeons, need for assistant surgeon (procedure)
• Global period
International Classification of Disease
(ICD)
• First developed by World Health Organization in 1948
– Official use in the United States started in 1989
– ICD – 9 CM (9th revision) (Clinical modification)
• 10th revision planned October 2014
• Codes represent signs, symptoms, complaints, diagnosis
– Justify medical necessity for the patient encounter
• Code specificity
– Three to five digits
• Bladder neck obstruction 596
• Renal mass 593.9
• Urinary frequency 788.41
Relative Value Scale (RVS)
• Links monetary value to a CPT 1 code for
provider reimbursement
– Government reimbursement system
• Resource based relative value scale (RBRVS)
– Developed by statistician William Hsiao (1985)
• Medicare adopted in 1992
– Private insurers begin to use 1995
– Modified RBRVS
• Process where relative value unit (RVU) are updated and
adjusted
CMS Payments Surgery vs. Office Visits 1990-2011*
*US Bureau of Labor Statistics $1.00 in 1990 = $1.68 in 2011
Procedure
1990
2011
1990 Inflated
to 2011
TUR Med BT 52235
$ 689
$ 299
$ 1,158
- 74%
TUR Prostate 52601
$ 949
$ 864
$ 1,594
- 46%
ESWL 50590
$ 967
$ 584
$ 1,625
- 64%
Inf. P. Prosthesis 54405
$ 1,871
$ 838
$ 3,143
- 73%
Radical Neph 50230
$ 1,901
$ 1,325
$ 3,194
- 59%
Rad Ret Prost 55845
$ 2,331
$ 1,695
$ 3,916
- 57%
Rad Cyst/loop 51595
$ 2,882
$ 2,267
$ 4,841
- 53%
E&M New Pt 99203
$
$
$
+ 23%
50
103
84
2011 % Change
from Infl 1990
Medicare Physician Payment Scale
• Work RVU component (52%)
– Time, skill, stress, intensity, risks
• Practice expense RVU component (44%)
• Staff, supplies, rent
• Malpractice RVU component (4%)
– Professional liability insurance (PLI)
• Multiply total RVU by a conversion factor (CF)
for monetary value
Medicare Physician Payment Scale
RVU Work x Geographic Practice Cost Index (GPCI)
+
RVU Practice Expense x PE GPCI
+
RVU Malpractice x PLI GPCI
Total RVU
Dollar amount for service:
Total RVU x CF for CY 2012 ($24.6712) = Payment
Relative Value Scale Update
Committee (RUC)
• Peer review group convened by the AMA
– Payment for service determined by this
committee
• Multispecialty representation – 31 seats
• CMS triggers for RUC review
– New technology
– Volume (billed > 500,000 per year)
– Billed 75% of the time with another code (bundle)
– CMS specific request (fast growing)
Relative Value Scale Update
Committee (RUC)
• Specialty survey data acquisition from membership
– Compile data into a case to retain reimbursement
• Determine physician work and practice expense
component of the RVU
• Specialty presents proposed RVU of the service to
the RUC
• CMS involved in the peer review process
Recovery Audit Contractor (RAC)
• Medicare Modernization Act of 2003
– Recover improper Medicare payment claims
• Initial demonstration program involving five states recovered
nearly 700 million dollars
• Private contractors hired by CMS to “audit”
physician offices or practices
– Medicare Part A and B billing
• Award up to 12.5% of dollars corrected
• FY 2010 - 92.3 million dollars discovered in
improper payments
– 82% overpayment and 18% underpayment
Recovery Audit Contractor (RAC)
• CMS must approve potential issue raised by RAC
– CMS oversight of process through RAC data
warehouse
• Review process
– Automated review
• Analytics used to review claims
– Complex review
• Review medical records on site
• If overpayment is determined a “demand letter”
is sent to the institution
– Appeals process
Quality Improvement Initiatives and
Organizations
Physician Consortium for Performance
Improvement (PCPI)
• National physician led effort to improve health
care quality, patient safety, efficiency
– Over 70 medical specialties involved
• Convened and staffed by the American
Medical Association
– Evidence based physician level measure
development
• Identify areas of quality improvement with specialty
collaboration
• Vote on proposed measures
National Quality Forum (NQF)
• Formed in accordance with National
Technology Transfer and Advancement Act of
1995
– Voluntary, consensus-based organization, formed
to endorse existing measures after expert panel
and member review
– Health care stakeholders
• Eight councils over 300 members
– Professionals, public health, consumers, purchasers, industry
• NQF approved measures “special status”
– PCPI vetted measures
Institute of Medicine (IOM)
• Health arm of National Academy of Sciences
– Independent not for profit organization
– Mission is to “serve as an advisor to the nation to
improve health”
• Provide evidence based “unbiased and
authoritative advice” for private and public
health care sector
• Quality related tasks commissioned and sponsored by
government, industry, independent foundations
• Volunteer members
– Peer review system
Agency for Healthcare Research and
Quality (AHRQ)
• Agency within the Department of Health and
Human Services
– FY 2010 budget 372 million dollars
• 80% of budget supports research grants and contracts
towards improving health care
• Mission is to improve health care quality, improve
safety and outcomes, reduce cost
– Portal for consumer / clinician information
– Health information technology research
• Mandated role to support the US Preventative
Services Task Force
United States Preventative Services
Task Force (USPSTF)
• Independent panel of primary care experts in evidence
based medicine
– Family practice, pediatricians, nurses, behavior specialists
• Review evidence of effectiveness and develop
recommendation statements
– Grades A through D and I
• Recommendations provided for consumption by physicians,
health care systems, and health insurance
– Affordable Care Act 2010
• PSA screening is now a “D”
– Discourage the use of this service
Quality Alliances
• Surgical Quality Alliance (SQA)
– Alliance of surgical specialties and anesthesia
• Quality measurement and improvement initiatives
• Ambulatory Care Quality Alliance (AQA)
– AAFP funded by America’s Health Insurance Plans
• Collaborative of physician groups, health insurance
plans, consumers, AHRQ
• Hospital Quality Alliance (HQA)
– Collaborative of public and private stakeholders
• Data acquisition and reporting, measure development
Physician Organizations
Physician Organizations
• American Medical Association (AMA)
– “Promote the art and science of medicine”
• Political advocacy organization
– Steward organization for the CPT,RUC,PCPI
– Membership
• < 18% of US physicians currently members
– 30% of members are students or residents
• American College of Surgeons (ACS)
– Largest surgical specialty organization
• > 77,000 members (2600 fellows)
– Cancer and trauma care, CME, data registry, SQA steward
– Political advocacy organization
Urology Organizations
• American Urological Association (AUA)
– Founded in 1902
• FY 2010 budget 30 million dollars
– Three entities with one board (2001)
• AUA Education and Research 501(c)(3),
AUA Inc. 501(c)(6), AUA Foundation 501(c)(3)
– Eight geographical sections
• American Board of Urology (ABU)
– “Mission is to act on the behalf of the public to
ensure high quality, safe and efficient practice of
Urology”
Urology Organizations
• American Association of Clinical Urologists (AACU)
– Goal is to protect the professional autonomy of
urologists
• Inform members of issues and create ability to organize
• Work with state societies and specialty coalitions to protect
interests of urology
• Large Urology Group Practice Association (LUGPA)
– Association of groups with > 10 practicing urologists
– Business operations, clinical outcomes benchmarking,
clinical trials, educational programs
• Political advocacy
Urology Organizations
• UROPAC (Urology Political Action Committee)
– Organized in 1992 and since 2003 jointly
sponsored by AUA and AACU
– Support key lawmakers in health policy and
advocates for Urology specific issues
– 2010 election cycle raised over one million dollars