The Society’s Concerns with Latest Health Care Reform Legislation

On September 16, 2009 Senator Max Baucus (D-MT), Chairman of the Senate Finance Committee, introduced the health care reform legislation negotiated by the so-called “Gang of Six” — Senators Baucus, Charles Grassley (R-IA), Kent Conrad (D-ND), Mike Enzi (R-WY), Jeff Bingaman (D-NM), and Olympia Snowe (R-ME). The Committee is scheduled to mark-up and vote on the legislation during the week of September 21.

Summary of Provisions

Medicare Physician Payment Reform
Provision: This provision proposes a temporary fix to the scheduled 21 percent reduction in Medicare physician payment rates in 2010. The fix would provide an 0.5 percent increase in 2010.

Society’s position: The Society is concerned with another temporary fix, and supports the replacement of the Medicare’s sustainable growth rate (SGR) formula with a stable mechanism for updating Medicare fees to continue to assure Medicare beneficiary access to high quality care. Fixing a bad formula should be part of any health care reform agenda.

Physician Quality Reporting Initiative (PQRI)
Provision:This provision would make changes to the voluntary PQRI program, including requiring all eligible health professionals to participate by 2011, expand the Medicare physician feedback program, and penalize physicians who utilize significantly more resources than their peers.

Society’s position: The Heart Rhythm Society has serious concerns with this provision. The Society believes that this program should be voluntary. The Society is also concerned that the measures currently in place may not provide all physicians the opportunity to participate in this program.

Primary Care Physician Bonus
Provision: Primary care practitioners, as well as general surgeons practicing in a health professional shortage area, would receive a 10 percent Medicare payment bonus for five years. Half of the cost of the bonuses would be offset through an across-the-board reduction in all other Part B physician services of approximately 5 percent.

Society’s position: The Society supports the efforts to improve access to primary care but policies should strive to maintain appropriate access to specialty care. We oppose any proposals that would provide additional payments to primary care physicians at the expense of specialists.

"Overvalued" Physician Services
Provision: This provision would require the Secretary of the U.S. Department of Health and Human Services (HHS) to identify “overvalued” physician services provided by Medicare. The Centers for Medicare & Medicaid Services (CMS) would be required to adjust payment for services “that have increased at an unusual annual rate without evidence supporting the clinical appropriateness of such growth.”

Society’s position: The Society opposes altering the current process by which services provided under Medicare are valued/re-valued. We believe that it is unnecessary and duplicative to establish another process to address suspected over-valued physician services. As part of the Resource Based Relative Value Scale (RBRVS), the American Medical Association (AMA) has already established the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The RUC provides recommendations to CMS for the valuation of new and revised codes as well as codes identified as misvalued under the Five Year Review of Work. The current process assures physician input from a variety of disciplines.

Medicare Commission
Provision: The framework would set up an independent Medicare Commission, which will submit proposals to Congress to “extend Medicare solvency and improve quality in the Medicare program.” MedPAC will still exist in its current form as an advisory body to Congress. Once the proposal is submitted to Congress, MedPAC will be required to review the proposal and present its analysis of the Commission's proposal. Congress could either pass an alternative measure with equivalent budgetary savings or HHS would be required to implement the commission proposal.

Society’s position: The Society is concerned with any provision that would remove the oversight from those who have been elected to do so — especially when the expressed goal is to enact Medicare cuts annually. The Society is also concerned that the Medicare panel would not have the expertise required to make those kinds of decisions.

Comparative Effectiveness Research
Provision: This provision includes the details of the Patient-centered Outcomes Research Act which will set up a non-profit comparative effectiveness research institute governed by a multi-stakeholder board appointed by the Comptroller General. This institute would be funded at $600 million per year and include safeguards to prohibit HHS from using the research to ration care.

Society’s position: The Society supports this provision if it includes all the details from the Patient-Centered Outcomes Research Act.

Physician Financial Relationship with Industry
Provision: Device, Drug, biological firms would be required to report any payments or transfers of value that are made to a physician or teaching hospital by posting on a government website. This mirrors the Physician Payments Sunshine Act of 2009 which was reintroduced by Senators Charles Grassley (R-IA) and Herb Kohl (D-WI) on January 22, 2009. The provision would not pre-empt any state or local laws that go beyond the scope of this federal requirement.

Society’s position:The Society supports this provision — we believe that while relationships between physicians and industry are an important component of advancing medical technologies and improving patient care, uniform procedures for transparent disclosure must be in place to minimize confusion and misrepresentation. However, the Society would like to include a provision that provides physicians with the ability to correct inaccuracies in their report and provide background information on their relationships with industry prior to the public release of this information. The Society believes that uniform procedures for transparent disclosures will minimize confusion and misrepresentation and would prefer that federal law pre-empt state laws.

Payment Bundling Pilot
Provision: This provision would direct CMS to develop a voluntary pilot program encouraging hospital, doctors and post acute care providers to achieve savings by making the most efficient use of global payments for episodes of care. This would essentially be an expansion and extension of the Medicare Acute Care Episode Demonstration project, which would permit hospital-physician gainsharing.

Society’s position: The Heart Rhythm Society supports more efficient use of resources as long patient access to quality care is not compromised and is encouraged that potential bundled payments will first be pilot tested. Gainsharing arrangements if properly structured to measure the effects of quality improvement and outcomes may be useful, but gainsharing models or similar arrangements that focus on product standardization that could detrimentally limit or deny physicians the opportunity to select and utilize appropriate devices and supplies for particular patient cases are concerning.

Imaging-Use Rate Assumption Reform
Provision: The measure would increase the utilization rate for calculating payment for advance imaging equipment from 50 percent to 75 percent over four years.

Society’s position: The Society opposes this proposal. We are concerned that the decision is based on the absence of accurate empirical data. The Society would prefer a proposal directing CMS to work with physician organizations to conduct an accurate survey of equipment usage. If a valid, current survey demonstrates that the current equipment use rate diverges from actual use rates, a more accurate rate could then be transitioned into Medicare payment over a four-year period.