Payment Reform: What's at Stake for Cath Lab?

CHICAGO -- With alternative payment models inching closer, interventional cardiologists convened to discuss what's at stake for their finances.

James C. Blankenship, MD, of Geisinger Medical Center in Danville, Pa., told the audience at the American College of Cardiology 2016 Scientific Sessions that the era of "fee for service" reimbursement is over.

Although newer payment models will continue to evolve over the next few years, Blankenship noted, interventional cardiology has made small gains recently by becoming a specialty recognized by Centers for Medicare & Medicaid Services (CMS).

This specialty self-designation is "easy to do" and elevates the field as a whole, suggested Blankenship, who is president of the Society for Cardiovascular Angiography and Interventions. Being placed in a new category means an opportunity for interventional cardiologists to be paid for work previously done for free (such as consulting with patients referred by general cardiologists). It also means not having their outcomes compared with those of general cardiologists, who may not see as many risky patients.

So what does a cardiologist have to do to designate his or her sub-specialty?

Blankenship pointed to form 885i provided by the CMS. Because the form has not been updated to reflect the new category, he instructed, interventional cardiologists should check "undefined" and list "P-interventional cardiology" as their sub-specialty designation.

Yet far less clear was the impact of alternative payment models themselves.

Thomas M. Maddox, MD, of Denver VA Medical Center, discussed the Merit-Based Incentive Payment System (MIPS), a value-based program consisting of a score that would determine how much compensation a clinician receives in a year.

The score and its components -- 30% quality of care, 30% resource use, 15% clinical practice improvement activity, and 25% meaningful use of electronic health record technology -- is still open to discussion, he pointed out, as hard definitions for each category have not been provided. That's why "it's up to us to drive that conversation," Maddox emphasized.

Then again, he reminded the room that "MIPS will go away in 2022, eventually giving way to alternative payment models."

Describing one such payment model, William Borden, MD, of George Washington University in Washington, D.C., said that the goal for an accountable care organization (ACO) is to fill in the gaps in care "across settings and across time" with an emphasis on team coordination. The hope is that with more contact with patients, hospitalizations and rehabilitation can be reduced, he said.

In a system where financial gains and losses are shared, these healthcare savings can mean better compliance with the set budget dictating what should be spent for each clinical scenario.

Kirk N. Garratt, MD, of Christiana Care Health System in Wilmington, Del., addressed bundled payment for percutaneous interventions. Inherent in the bundled payment system, a model with a budget akin to that of an ACO, is the incorporation of costs associated with treating the primary problem and giving ancillary services, transitional, and follow-up services.

"It is likely that angioplasty will be targeted [for bundled payment] because it is a common and expensive procedure," he said. "There's no doubt that the old model is failing and new models are needed."

Yet Garratt warned of many obstacles for the bundled payment system, which is being tested in several areas for certain procedures.

He took issue with the fact that compensation is tied to value provided, which in turn is risk stratified: The physician chooses to accept responsibility for a set percentage of outlier expenses (in return for possibly greater financial reward) or to elect protection from risky outcomes.

"This model does not discourage unnecessary episodes of care," he said. Instead, it may encourage inappropriate physician behavior, such as rejecting high-risk patients, up-coding illness severity, limiting access to specialists, delaying additional care until bundled payment end-date, and minimizing services excessively, he suggested.

Thus, bundled payments may "unfairly penalize" academic centers that service economically disadvantaged populations, Garratt noted.

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