Cardiologists React Badly to Proposed Medicare Payment Cuts
Posted on July 6, 2009
Filed Under Cardiology Topics, Primary Care in America |
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The Obama administration has used its executive authority to begin redistributing wealth among doctors, and in so doing has taken an important step toward achieving two of its oft-expressed healthcare goals: a) supporting primary care medicine; and b) stifling greedy specialists who habitually use all that expensive technology.
In particular, the proposed new rule (which was published on July 1 and which masochists can read here) from Centers for Medicare and Medicaid Services (CMS) offers to increase payments to primary care practitioners by between 6 - 8%, and offers to pay for that well-deserved increase largely by cutting payments to specialists. The specialists who will be particularly effected by this first major foray into redistribution will be those who make their living by providing diagnostic imaging services - mainly, radiologists and cardiologists. The plan, if finally approved, will be implemented next year.
According to TheHeart.org, the American College of Cardiology is “aghast” (one of DrRich’s favorite words) at the proposed cuts to cardiologists. Dr. Bove, the ACC President, is quoted as saying, “The ACC is shocked.” He goes on to point out that, because of payment cuts ranging between 25% and 42%, there will be “very important issues of access” to “services that have saved countless lives.” (DrRich, a cardiologist himself, is certain that Dr. Bove did not mean this as an actual threat, but merely as some sort of “prediction.”)
Others from the ACC complain that the proposed major cuts in reimbursement to cardiologists resulted from jiggering the data that CMS applies to the extremely complex reimbursement formulas it uses to determine how much doctors should be paid for various services. In particular, the ACC asserts that CMS (with the complicity of the American Medical Association) deviated from its own policy standards in obtaining the data to plug in to those formulas. It is almost (the ACC implies) as if CMS knew the results they wanted to obtain ahead of time, then went out to dig up the “right” data to use that would achieve those desired results.
To summarize the ACC’s conclusions: “It’s not fair.”
The ACC is calling upon its membership - and upon the sense of fair play (and a desire to avoid “important issues of access”) inherent in all citizens - for support, specifically, it urges all right-thinking people to lobby CMS not to promulgate this “grave threat to cardiology practices and the patients they serve.”
And now, DrRich will simply make two observations.
First, if the ACC’s leadership is actually “aghast” and “shocked” by the Obama administration’s first attempt to redistribute payments away from high-priced specialists, then DrRich can only bow his head in dismay. Just where have they been, and what have they been thinking? And if they really believe anyone (aside from cardiologists themselves) are the least, tiny little bit disturbed by the proposed pay cuts, and that their threat (rather, their prediction) of reducing the number of procedures they perform should these cuts be implemented will trouble the authorities, why, they are more dilusional than Sarah Palin thinking that resigning as governor will prove she’s no quitter.
The only question here is whether the cardiologists themselves, as a stand-alone special interest, a special interest which is regarded by most of the medical community and non-medical community alike (and not without reason), as over-enthusiastic purveyors of high-cost procedures, prone to err perhaps just a bit on the avaricious side, are powerful enough to get the Obama administration to pull back on this rule.
DrRich believes that the Obama administration has made a judgment on the strength of the cardiology lobby, and (while it may have to compromise a bit on the magnitude of the pay cuts) is pretty certain it will prevail, thus establishing a vital precedent against one of the strongest medical specialties on the planet. DrRich would not bet against the administration here.
Second, while primary care doctors are understandably in a celebratory mood over this new proposed rule, DrRich prays they will sober up quickly. Primary care has suffered low reimbursement rates for decades, largely at the hands of specialist interests. The secretive RUC process was rigged against primary care physicians from the outset, and the powerful specialists were set up to completely overwhelm the relatively weak voice of primary care physicians, much to the detriment of not only the PCPs, but also of patients, the healthcare system, and the healthcare budget itself.
Revenge, and more money, are powerfully innervating. But DrRich’s abiding faith in the human spirit will suffer a major blow if the prospect of an 8% pay raise plus a modicum of revenge would suddenly make primary care medicine an attractive option for American doctors. The depredations that have been visited upon primary care in America (which are summarized here) are so deeply odious and demeaning, and so fundamentally destructive to the doctor-patient relationship, to the profession of medicine, and to American patients, that it is simply too terrible to contemplate that a modest increase in payment would suddenly render primary care (as it is now constituted) a perfectly acceptable pursuit. While it is entirely understandable and appropriate for primary care doctors to celebrate this rare fiscal victory, it should not change their basic outlook on what is being done to them.
Primary care physicians ought to be fighting primarily for their professional souls, and only secondarily for their pocketbooks.
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28 Responses to “Cardiologists React Badly to Proposed Medicare Payment Cuts”
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An 8% raise is not going to make much of a dent in the financial black hole of primary care.
The Obama administration once this pay change goes into affect will have done something different (This will finally be an increase in pay for primary care). However this falls short of the desperate expectations that many in primary care had with the changes we expected from a dynamic new leader. That he has looked to reduce healthcare costs by squeezing doctors and hospitals (the drug companies will still be making stellar profits) while leaving the malpractice sharks out of the equation seems to me shameful.
I have to say I am disappointed and will now look at the only option which looks viable for the primary care physician, concierge medicine.
Call it “retainer medicine” please to avoid the snobby connotations. I’m all for it and repeatedly ask my PCP to adopt the business model to try to decrease the likelihood that he will close shop or join some Dark Side HMO to survive.
Dr. Rich, what is the process for approval of the reimbursement changes proposed by CMS? Does this require affirmative approval from Congress? Or is this the sort of thing that gets rolled back by Congress every year as with the annual DRA cuts?
Or are we to believe that Medicare is actually allowed to make such a cut without interference? Surely that can’t be the case, or else reimbursements might already be more balanced.
Praveen,
I don’t think Congress is involved at all in this one. This is an executive branch endeavor.
However, the proposed rule is open for public comment until August 31. The ACC is gearing up to flood DHHS with a volume of negativity they will not be able to ignore. This is a test case (in my opinion), and if the cuts go through, a lot more will be coming.
Rich
There is no question that Family Physicians, as well a Pediatricians and general Internists have been severly underpaid for decades. The situation must be corrected if necessary access to basic health care services will remain available into the future. It is difficult for me to accept that one group of physicians is greatly more important than any other. We need Family Physicians and we need Cardiologists, Gastroenterologists, Radiologists etc. We are all, I would venture to say, equally important. Several other societies have ended debate on this issue by paying all physicians basically the same base salary, and perhaps allowing for increases based on quality performance and efficiency. If there were not the huge gaps in income between primary care physicians and specialists perhaps more physicians would choose their specialty based on personal preference and aptitude rather than income potential. We might then have more satisfied physicians and patients. In all fairness, the transition process toward more equitable income would have to occur with some moderate pace; but, certainly it should start now.
Dr. Hartz,
I don’t disagree with you. I just can’t help marveling that physicians have gotten themselves into a position where their pay is determined by Acts of Congress (or, in the present case, by Executive Fiat), just like the doctors in the old Soviet collectives. Once you end up there, the pay you get tends to be determined by whatever influence you can bring to bear on the decisionmakers (who are professional politicians) rather than by your training, skill, importance, experience, or other such factors that determine the remuneration received by, say, lawyers.
Rich
Primary care should stick together and get a seat at the table. What they can offer can bend the curve of health care costs unlike specialists who drive costs up. Giving some incentives will bring pride back to this field that so deserves uplifting. Never have I seen any “aghast” all these years while specialists esp cardiogists were drawing 3-4 times income of primary physician and they were being kicked in the mouth. Now suddenly it is don’t rob Peter to pay Paul, which was what was happening all these years at the cost of Primary care and spiraling costs. More in the health overhaul by congress also will address this as well. Finally it is the underdog’s day ( maybe).
Remember, everyone who does E&M will get a raise in their E&M fees. For inpatient visits it’s anywhere from 5-8%. For the outpatient clinic visits, it’s as high as 10%. That includes the cardiologists. Some how, I don’t think they will be hurting as much as they want to believe they are.
Happy,
Yes, some cardiologists (small “c”), the ones who do clinical evaluations on patients and bother to bill for them, will actually see a modest improvement in their reimbursement. But the real Cardiologists, the ones who first meet their patients 90 seconds before numbing the skin, don’t do clinical evaluations. They have people for that. And on those rare occasions when they do, they don’t bother billing for them (for the same reason they don’t stop to pick up a penny on the street when they are late for their tee-off time). So they wouldn’t know E&M from S&M, and (thinking you must mean S&M) would be scandalized at your suggestion. Which requires me to say on behalf of my Cardiology colleagues, you should try to be more sensitive.
Rich
Goverment intervention dictating physician income is not the answer. Cheering physicians cut in some subspecialist is pathetic. As a cardiologist a long time ago I recognize the value of echos and stress testing in complementing my patients assesment. Often my partnerts are called in the middle of the night to evaluate a patient who is hemodynamically unstable or to perform an intervention in someone having a heart attack (a large number of these patients do not have health insurance). We will not be able to provide these services to Medicare patients and we’ll move to cash only as the only available alternative. Without doubt patients with money we’ll end up receiving better care as cardiologist all over the country are unable to provide appropiate care for our patients (I guess we’ll save money)
My, my Dr. Rich, bitter aren’t you?
It does not make sense that different physicians train longer than others, work longer hours, put themselves at greater risk by providing invasive procedures, pay higher malpractice and overhead (full time staff with time spent in the OR) and have more involved call responsibility yet they are greedy for making more money.
The only way for the American public to truly understand what cardiology care in the US will be like if Obama’s changes are made is to visit a VA hospital. VA Cardiologists are actually quite good clincally and don’t do unnecessary procedures since they don’t get paid more for doing lots of them. However, acute, emergent cardiology care at the VA is very poor if it is needed after 5 pm and on weekends. Would you want thrombolytics for your mother? She’s gonna get them if she has a MI on Sunday night…at least she’ll get an echo by next Wednesday I guess…
When President Obama experiences his first emergency need for bypass or a stent I wonder if there will be any cardiologists left to take care of him. You can’t cut reimbursement 40% over three years and increase malpractice costs 125% since 1998 and expect anyone to be still in business especially when the starving malpractice attorneys are circling the few cardiologists who are left treading water.
Stop allowing cardiologists and other specialists to house imaging equipment. That will cut down costs tremendously!!!!
I meant non-radiology specialists.
I would rather my cardiologist has imaging equipment in office so the test can be run quickly and interpreted by the cardiologist (the true specialist for the heart). It saves me time, gets my results faster and I would argue results that are clinically definitive. Unlike the mostly vague results of a radiologist. I would say if radiologists want non-radiology specialists not to “house” equipment then radiology should add significantly to their education and actually become able to manage patients! Then I would never need to see a disclaimer along the lines of “clinical correlation is needed” on a radiology report. I find it a waste of money to be sent to a radiologist for an imaging test, wait for both the test appointment and the report, then have to return to the ordering physician to have the report not only read to me but to have the results interpreted with my clinical condition considered. I say cut out the radiologist where where ever possible, save me time, get the results of the test from a trained physician that actually is able to manage patients and has mastered the anatomy and physiology of the body part being tested. That will save money and time. That’s my $.02 as a patient.
Lest the noncardiologists among us (and I am not one)start feeling a little too smug, remember- they’re coming for your reimbursement dollars next. And when everybody from allergy to urology has been worked over, CMS will start anew with primary care
So Obama found another way around “death panels” by making it so those of us on Medicare can’t afford to see the specialists we need and instead focusing on preventive care. Another way of saying since I’m sick, I’ve been sentenced to die. I get a social security check for $953 a month. That’s all I get to survive. I already have to choose between eating and medicine so I can’t afford cash payments for my cardiologist, neurologist, electrophysiologist, and endocrinologist. Without care from them, I will die.
Don’t get me wrong, preventive care is great but he’s clearly putting the cart before the horse. How can one provide preventive care for cancer when we still don’t have a cure? They still don’t even know what caused my circulatory system to crap out at the ripe old age of 23. I guess on a positive note, my 70 year old grandfather with lung cancer and I will die together should they pass this.
One last thing, I love my PCP dearly and will continue to see him when I get the flu or an ear infection or what have you but I did escape under his radar for 20 years when my neuro and cardio found my illnesses in less than an hour. They are specialists for a reason. They have for more training and experience and for those reasons, they deserve to be paid more. I’d rather my cardio with a Ph.D. did any surgery on me than my PCP with a minimal degree.
I am a noninvasive Cardiologist with Level III training in Echo and level II training in Nuclear Cardiology. My point is that 1)if you cut the money for the tests then the test can’t be done! A cardiologists office as well as in the hospital has tech staff for running and maintaining the study/machines. 2)Trust me…..You do not want a radiologist reading your echo! The echo is a very important extension of my physical exam as your doctor for at least one example. The other is that Cardiologist have years of specialized hemodynamic training. With the ease of use and the tremendous technology available by echo…it is not the same as a CXR!! (i.e. speckled tracking eval of abnormal circumferential LV strain was recently shown to be more predictive of CV outcomes than LV EF!!) Make Cardiologist practice by guidelines! Make Cardiac imaging a super subspecialty so the quality of readers matches the technology available!! Do not lower the money available to even provide the test!!…Dummies!
Ya know there is alot of staff out here who is going to be hurt by this… I have being doing echo for 19 years.. I have just recieved a 15 % salery cut and I am expecting another when this mess starts to kick in.. I have 3 kids one with heterotaxy syndrome who has survived 4 heart surguries he got his fontan at boston childrens he needs access not some politician cutting his fathers wages perhaps his career… I work in an office that does 250 + echo’s / month we see everybody and guess what they don’t wait they get evaluated treated and better… I got an internist but I better not get sick it takes weeks to get seen and this same guy sends us people weekly.. Anyway 15% is alot to me .. What I want to know is how the heck are we gonna stay open .. yes we are accredited and we don’t even know if we’ll be around in january.. Those of us that have been career echocardiographers are really the ones getting the shaft.. So who do I send send the thank you card to? The AMA ?
For almost a decade, the ACC and the other imaging societies have been playing ball with CMS to institute imaging lab accreditation and in addition, appropriate use criteria were used and adopted by all stake holders in the variousl cardiac imaging modalities (all of them–SEE IAC). This has entailed the use of enormous financial and intellectual capital on the part of cardiovascular provider leadership. CMS has responded by ignoring the cardiology community’s recommendation that a) labs performing procedures be accredited laboratories (either never enforced or required by CMS carriers) and b) that appropriate use criteria be implemented in order to control over use. Instead of adopting any of these commons sense recommendations both CMS and private payers have only implemented a policy of across the board cuts in reimbursement. Are cardiologist, now, with reimbursemnet rates getting near or below direct costs going to be able to now plow in the extra costs and efforts of implementing heretofore ignored recommendations for quality and appropriate use?
Thats outrageuos! Penalizing specialists for making more money? How about my EXTRA four years of hard labor,extremely long hours,pathetic pay and time away from my family during my youth while I trained extensively? Where’s the reimbursement for that? I agree that primary care is underpaid but people who are in medicine know that its becoming ‘triaging’ medicine. Cardiologists working 5-7 days a week compared with hospitalists who work 14 days/month with less than half the training making the same money? Where the sanity and fairness in this? The malpractice premiums are off the wall,overhead reaching for the skies and patients demanding immediate answers and more specialized care. Should we make primary cares come in the middle of the night for patients presenting with MIs,GI bleeds,food impactions and the like. People who have no idea how the field of medicine runs will never know its complexity. Sad!
Watching all this unfold after 30+ yrs of non invasive practice is interesting, and somewhat sad. It is time, past time, for primary care physicians and general internists to be reimbursed to the level of their skill and work, but it comes at a time that many, if not most, residing in urban and semi-rural areas are settling in for a 9-5, no weekends, work week. Hospitalists have taken over their off hour, weekend duties, and many PCP’s who consider locating to our community (city of 150,000) won’t consider coming here if they have to be “on call”.
Radiologists have night coverage as well. All those late night images, ER generated CT scans, emergency ultrasounds in the OB dept., are tele-faxed electronically to somewhere (Iowa?, India?) where a radiologist off site interprets the study and sends back a report.
Cardiologists, like trauma surgeons, however, have to respond when called. Usually by the ER: an acute MI, a severe slow heart beat requiring an emergency pacemaker, etc.
Consults, from the ER, or hospitals, are answered all evening and throughout the weekends. We now have guidelines for “door to balloon inflation” times to meet with standards of care of acute MI’s, therefore, we must respond within 20 minutes.
We are also beset by guidelines in regards to imaging. Patients with hypertension, congestive heart failure, certain cancer patients, etc., have been mandated to have their heart function documented, usually by echocardiography. We have worked hard to upgrade our techs, certify our office lab, and purchase new equipment. Now we are told to abide by these guidelines but suffer the decreased reimbursement that will not all us to maintain them.
Out patient nuclear imaging, especially in our elderly patient population with limited mobility, precludes many invasive diagnostic studies. CT angio has not matured yet as it is not a physiologic test, and the radiation dose is worrisome to many clinicians and patients.
So, I wonder, who is going to care for us in the future? Why would my nephew in med school opt for a 6 to 8 yr. cardiology or specialized surgical residency rather than a 3 yr PCP or ER one, and make the same reimbursement with less hours of work and stress? Who will be showing up at 3AM to angioplasty your abruptly occluded coronary artery, or drain your epidural bleed; a physician assistant?
I used to be a nuc tech with a cardiologist and thanks to these cuts I lost my job this week as did our EKG tech. I don’t recall ever doing a procedure on anyone who didn’t warrant the study, but many seem to the think that cardiologist are just greedy bastards that go wasting government money for the sake of it. Last time I checked heart disease was still the number one killer in the US. Now these patient will simply be referred to the hospital where some general radiologist who doesn’t know how to read a stress test (most don’t) will make some non-committal diagnosis.
So, don’t worry about me getting a job, I will just get one at the hospital doing the same heart studies, but now Medicare will be billed twice as much + for the same procedure.
Dr. Rich, did these cuts ever take effect?
The American Society of Nuclear Cardiology is doing a great job chronicling this.
It seems that the cuts did go through, but the Cardiology and other medical communities are fighting like hell through their Congressmen to get the money back:
http://www.asnc.org/mpfs2010/
Cutting Medicare will be an almost impossible task - which is why it won’t happen til the Chinese tell us that we have to.
Health care is so interlinked and country don’t have money so every one will eventually get effected. There is no difference any among noninvasive cardiology and internist because both of them are same kind of testing in there office in many states. Don’t forget that cardiologist can do both internal medicine and cardiology same time. I have seen some in Atlanta …cardiologist is now putting add….that they can take care of internal medicine and cardiac problem in single setting…. one stop shop……… Which is even better to cut the health care coast…one doc is managing most…………..I am sure we will see more and more interesting change……Its not a time to celebrate ….but watch ——carefully —–country economy.