Practicing Physicians Advisory Council (PPAC) UpdateDate: September 18, 2003 The Practicing Physicians Advisory Council, (a council of 15 physicians from across the country whose job is to advise Medicare on the effects of regulatory changes on physician practice), met on September 15th and 16th 2003. I would like to report our discussions to you. LIMITED ENGLISH PROFICIENCY PATIENTS The Office for Civil Rights has issued guidance on physiciansı responsibility to provide, (and pay for), a competent interpreter for patients who have limited English proficiency. This law applies to any physician who accepts Medicaid patients. PPAC pointed out that the fees physicians must pay to interpreters are often a significant proportion or are potentially higher than the payments for the service and that physicians have no means to assess and guarantee the proficiency of translators. The Office of Civil Rights has the laudable goal of eliminating health disparities among the 10.5 million Americans with limited English proficiency, and they demonstrated awareness of the practical difficulties in doing so. Enforcement of this 1964 law will only be by complaint, and evaluation of the complaint will be based on the number of limited English proficiency persons likely to be served, the frequency of contact, the nature and importance of the service, and the costs and resources available. PHYSICIAN GROUP PRACTICE DEMONSTRATION PROJECT The Director of the Office of Research, Development and Information provided testimony on the Physician Group Practice Demonstration Project. This is an interesting pilot project to be conducted with three large physician groups (over 200 doctors each) to encourage coordination of Part A and Part B benefits and promote the efficient use of health care resources. If improved patient management leads to decreased cost and improved quality, the physician group will share in the savings. PPAC was concerned about extrapolating results from the pilot project into an assumption that only large doctor groups can effectively coordinate care. However, this is a great opportunity to see if savings generated by the transfer of care from the expensive inpatient setting to an outpatient setting can be quantified. This might demonstrate to CMS that it is worthwhile to transfer payments amounts from Part A to Part B when services are performed in the outpatient setting. This is also an opportunity to compare groups who use a commercial disease management company with groups who internally manage patients and determine whether commercial disease management organizations save money or add value. Information technology will also be an integral part of this process so we may get some guidance on which features of an electronic medical record would facilitate better patient care or decrease costs. PROPOSED RULE MAKING FOR ADMINISTRATION OF MEDICATIONS INCIDENT TO PHYSICIAN SERVICE Medicare (CMS) has issued proposed rule making on the administration of intravenous or injectable drugs given in an office incident to a physician service. This will affect many specialties, including urology, infectious disease, neurology, as well as oncology. I must point out that as an oncologist I have a very personal stake in this issue. The existing system devised by Congress overpays for drugs and underpays for administration of chemotherapy and associated services. CMS suggested four scenarios in their proposed rule making to adjust these inequities, but by my personal calculations all four leave cancer care payments below the cost of providing services. (I had a CPA calculate the actual cost of treating a breast cancer patient, a lung cancer patient, and a lymphoma patient in the office and then compared the reimbursement from Medicare to arrive at this opinion). Other specialties commented that their reimbursements were currently low enough that they were unable to meet the costs of providing "incident to" drugs. PPAC recommended that:
PPAC also recommended that the competitive acquisition model not be accepted because vendor distribution organizations have not demonstrated any savings to CMS or any improvements in patient care. PROVIDER ENROLLMENT CMS wishes to establish a uniform database on physicians because of concerns from the Office of the Inspector General that CMS is not appropriately eliminating providers from the program when licenses are revoked or for other reasons. Their estimate was that less than 2% of physicians are inappropriately allowed to be Medicare providers. Most of the perceived problem is with the suppliers of DME. However, CMS plans to have all physicians fill out a 27 page form every 3 years and that payments should be withheld if the form is not properly accepted or if the UPIN number is not used in 3 months. PPAC suggested that CMS continue to pursue simplified alternatives to this proposed rule and seek less expensive and less onerous ways to get the data that CMS requires. We also requested that CMS retain the current practice of allowing four consecutive calendar quarters to pass before a billing number becomes inactive and that CMS use a web based enrollment system that can provide immediate feedback on the completion of the form with a 21 day time limit for CMS response. We requested that CMS refrain from imposing the 3 year re-validation requirement and to continue working with the physician community to resolve differences concerning all the other burdensome requirements of this proposal. We also suggested that CMS assess the costs to the Medicare trust fund of not removing the small percentage of ineligible physicians and compare it to the cost of more frequent re-validation of all physicians. OTHER ACTIONS PPAC also requested that CMS not substitute ICD-10 codes for ICD-9 codes since ICD-10 is designed for hospitals and not physician billing. We requested that CMS evaluate electronic prescribing in developing uniform standards without a mandate to send or receive prescriptions electronically. We felt that this technology is not yet affordable, accessible and secure, but would be extremely valuable if and when it becomes so. We also requested that the HIPAA contingency plans for payment when organizations are not able to be compliant by the October 16, 2003 deadline be implemented and that CMS encourage other private and public payers to do so as well. We were concerned that there would be a large gap in payments for noncompliant organizations. CMS has put the Correct Coding Initiative on line. This means you no longer have to subscribe to get them. I hope this report is helpful. If you have questions or comments, please forward them to me. I used many of the previous e-mailed comments in discussions with PPAC and found them to be extremely helpful. For the next meeting we will be discussing the final rule on EMTALA, so any comments on that would be particularly helpful. (I've downloaded the final rule from the Federal Register, and if you click on the link in the preceeding sentence, you will download it to your computer as a PDF file.) Thank you for your time in reading this. Sincerely, Barbara L. McAneny, MD, FACP
|
