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President's Column

How the College is working to resolve differences with subspecialists

From the March 2000 ACP–ASIM Observer, copyright © 2000 by the American College of Physicians–American Society of Internal Medicine.

Through this column, I have enjoyed the opportunity to report news from the College and my views on issues affecting internal medicine. I am grateful to those who responded to my columns, and I have enjoyed communicating with you by e-mail.

In my final column, I would like to review how the College is working to resolve differences over Medicare reimbursement with several subspecialist organizations. Our differences stem largely from HCFA's implementation of a resource-based practice expense system, which will reimburse physicians for their practice expenses based on costs instead of historic charges. While the move will help generalists, it will cut into the income of a number of subspecialties.

The College has supported HCFA's move to resource-based reimbursement for practice expenses because it will benefit all internists. Several subspecialty groups representing cardiologists and gastroenterologists, however, have expressed concern about our support for several key measures of HCFA's plan.

Taking action

In December, College leaders met with representatives of the American College of Cardiology (ACC), the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA) and the American Society for Gastrointestinal Endoscopy (ASGE). As a result of that meeting, ACP­ASIM's Medical Services Committee recommended seven specific actions to improve key aspects of HCFA's plan. Those recommendations were approved by the Board of Regents in January.

The College is prepared to address the following areas to resolve our differences and keep internal medicine united:

  • Site-of-service pay. The College has agreed to consider a proposal from the AGA, ACG and ASGE to eliminate HCFA's site-of-service differential for procedures. Gastroenterologists are understandably concerned that the site-of-service policy pays more for office endoscopies than for those done in a hospital. We agree that the policy may create inappropriate financial incentives for physicians to perform endoscopies in the office setting.

While one proposal offered last year would correct this problem, it would have raised HCFA payments for practice expenses for a large number of procedures (including surgical procedures). While it's true that the proposal would have helped correct the reimbursement problem for endoscopies, it would have also eliminated years of progress in implementing resource-based reimbursement for practice expenses.

We have invited the AGA, ACG and ASGE to present a solution that we can support. We ask only that any proposal to resolve the site-of-service problem be consistent with the principle of basing Medicare payments on the relative costs of providing services instead of historic charges. We also ask that any proposal narrowly target endoscopies and other procedures that are done infrequently in the office.

  • Non-physician staff costs. The College will continue to work to persuade HCFA to include the costs of non-physician clinical office staff in practice expense payments for services provided in a hospital or other health care facility, including endoscopies. ACP­ASIM recognizes that HCFA's arbitrary decision to exclude these costs hurts gastroenterologists and cardiologists, and we have strongly objected to the policy. If necessary, the College will support legislation to force HCFA to reimburse physicians for these costs when supported by data.
  • Cost averaging. ACP­ASIM will urge HCFA to base reimbursement for practice expenses on the average—rather than typical—costs of treating a patient. Under HCFA's current approach, no payment is allowed for overhead costs that exceed what is considered "typical" for a given procedure. This financially punishes physicians, including many subspecialists, who see a significant number of patients who may be more expensive to treat. Basing practice expense reimbursement on average costs would allow for atypical costs to be averaged into payments.
  • The down payment lawsuit. The College will not be involved in further litigation over a lawsuit filed over HCFA's implementation of resource-based practice expenses—as long as internists do not have to refund any payments to Medicare as a result of the final decision.

In December, 1998, several groups representing cardiologists, gastroenterologists and surgeons sued HCFA over its implementation of what has come to be known as the primary care "down payment." Under the Balanced Budget Act (BBA) of 1997, HCFA was directed to increase reimbursement for practice expenses resulting from office visits. To pay for the increase, HCFA was to reduce payments for procedures that were scheduled to be cut once HCFA had fully implemented resource-based reimbursements for practice expenses.

At issue was exactly how long HCFA was supposed to continue increasing those reimbursements. The subspecialty groups suing HCFA maintain that HCFA was supposed to increase those payments for only one year, 1998. A number of other medical societies, including the College, have argued that the new payments were intended to remain in effect until HCFA has completely phased in resource-based practice expense reimbursements. ACP­ASIM got involved in the lawsuit by filing an amicus brief supporting HCFA's position.

Although the lawsuit raises important philosophical and policy issues, the impact in terms of physician fees is extremely modest. Payments to gastroenterologists and cardiologists were reduced by approximately 1%, while internal medicine as a whole gained slightly more than 1%. We have concluded that it is in the best interests of internal medicine to put this conflict behind us.

Therefore, if the court rules in favor of the subspecialty societies, the College will not get involved in any appeal by the government. If the court rules against the subspecialty societies and they appeal, ACP­ASIM will not file a second amicus brief supporting the government. Although we still believe that the position we took on the lawsuit was the right one for both patients and internists, we have agreed to accept the decision of the court, regardless of the outcome.

  • Publication of RVUs. We will urge HCFA to publish the practice expense relative value units (PE-RVUs) as interim PE-RVUs for another three-year period. By subjecting the PE-RVU interim values to public comment for another three years, groups like the ACC, ACG, AGA and ASGE will have time to refine the data and make changes before the PE-RVUs are finalized.
  • Practice expense work group. We have offered to establish a practice expense joint work group including representatives of ACP­ASIM, ACC, ACG, AGA, ASGE and other subspecialty organizations to coordinate our future positions on resource-based practice expenses. A joint work group would allow our organizations to discuss concerns about HCFA's methodology and explore "win-win" solutions for all our members.
  • Pay for screening endoscopies. We support the intent of legislation proposed by ACG, AGA and ASGE to increase Medicare payments for endoscopies provided under Medicare's colorectal screening benefit. ACP­ASIM worked closely with all three organizations in persuading Congress to enact the colorectal screening benefit in 1997, and we remain committed to making sure that the payments for this benefit are adequate.

Working together

The Regents have reaffirmed ACP­ASIM's long-standing support for resource-based payments and the principle that payments should be based on the relative costs of providing services. The vast majority of College members will gain under a resource-based practice expense methodology.

The College remains committed to aggressive public policy and Medicare advocacy and will continue to pursue reimbursement rules that encourage superior medical care for patients and adequate compensation for all internists. Notwithstanding our recent differences on a few issues, we have a strong record of working with our subspecialty colleagues to improve Medicare payments.

Because of ACP­ASIM's leadership—with the support of the AGA, ACG, ASGE and ACC—Congress agreed to enact legislation in 1997 to establish a single dollar conversion factor for the Medicare fee schedule, instead of continuing to pay for surgical procedures at a higher dollar rate than everything else. All internists are receiving substantially higher Medicare payments as a result. As the chart on page 14 shows, cardiologists and gastroenterologists benefited the most from this College-initiated change.

We propose an ongoing process for reaching a consensus rather than engaging in conflict after the fact. Differences of opinion will occasionally arise, and we may not always be able to resolve them. But general internists and subspecialists must remember that we are stronger as a group than as individual societies. The College will continue to work to improve the dialogue between all medical professionals and strive to keep the channels of communication open.

Our profession and our patients demand no less.

I welcome your comments on this or any other topic at waddingt@rsh.net.

—Whitney W. Addington, FACP

P.S. Next month you will see a new face within this column, as Sandra Adamson Fryhofer, FACP, takes over her duties as President of the College. Like you, I eagerly await her views on the challenges and the joys of the practice of internal medicine.

Dr. Addington

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