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Government Relations Department of the ACR 101
Every day decisions are made in Washington DC regarding health care
policy, the profession of radiology, and more recently, physician
reimbursement. These processes and health policy happen with or without
our involvement. Without our voice being heard in the decision process
for things like self referral, someone else's voice is being heard
instead. That person may or may not be your ally. And in the realm of
self-referral, our allies are few and far between!
Without our active involvement, future policy could not only affect the
way you do your job as a radiologist but who does your job in the
future. Your profession depends on the ACR's proactive stance!
So how does it work? What goes on in Washington DC?
The Creation of A Bill
In order for health care policy to be adopted, there are a number of
things that need to happen. The official legislative process begins when
a bill or resolution is numbered (H.R. signifies a House bill and S. a
Senate bill), and then referred to a committee.
Once in the committee, it is considered by the committee or by a
subcommittee within the committee to report back to the main committee.
If a bill is referred to a subcommittee, a hearing may take place on the
bill. Pertinent testimony from all sides may be recorded for the record,
in addition to expert testimony and opinions from the executive branch.
Following the hearing, the subcommittee can refer the bill with any
amendments made, or vote for it to not pass out of the subcommittee.
Again, if this is the recommendation, the bill goes no further.
"Ordering a Bill Reported" is the next process. After the committee
hears a bill that has been reported on by a subcommittee and votes on
the subcommittees amendments and the bill itself, the committee then
votes on its recommendations to the House or Senate. These
recommendations are then written into a final report that is presented
to the House or Senate, which also includes dissenting committee members
opinions, the effects on current law and practice, as well as the scope
and intent of the legislation.
After the report is submitted, the bill is placed on a docket. The order
in which the legislation reaches the floor is determined by the Speaker
and Majority Leader. Once on the floor, the bill is debated and amended.
The final form is then voted on, and, if it passes, it then goes to the
other "side" (House or Senate) for the same process, beginning at the
committee level. If significant changes are made, the House and the
Senate must agree on the changes or the bill dies.
Exhausting isn't it?
Finally, once approved by both the House and Senate, it is sent to the
President. If the President approves of the legislation, he signs it and
it becomes law. Or, the President can take no action for ten days, while
Congress is in session, and it automatically becomes law. If the
President opposes the bill he can veto it; or, if he takes no action
after the Congress has adjourned its second session, it is a "pocket
veto" and the legislation dies.
So what does the ACR do?
In addition to the process of bill creation, those who create and debate
the policies that will ultimately become law play a significant role in
what happens on the Hill. Without their support, policy simply does not
happen. Thus, in order to affect health policy, you must have a
connection and a voice with these policy makers. The Government
Relations department of the ACR does this for all of us. The GR staff
attend numerous fundraisers throughout the year to talk with the
congressmen and congresswomen who ultimately will have the final say in
the outcome of policy that pertains to the profession of radiology. They
also attend meetings such as the AMA on your behalf to address
legislative concerns or to foster a general awareness of the issues.
But this is only a portion of the government relations job. Developing
constituent-based political effectiveness is also one of the primary
goals of the Government Relations Department. An example of this was the
recent Call to Action held on Tuesday, September 20th. Despite the
technical difficulties, your involvement resulted in over 2,000 ACR
members calling their U.S. House Representative. Every state
participated, and 373 of the Representatives were called, representing
86% of the total House of Representatives. This sends a clear message
that not only are we an organization that pays attention to the health
policy that affects our profession, but we are also voting constituents.
The ACR also provides annual funding for a visit by a member from the
Government Relations department to travel to your state to facilitate
involvement and awareness at the state level.
How does RADPAC fit in?
In DC, like anywhere, money talks. To address this, the ACR formed the
RADPAC in 1999. The goal of RADPAC is to support and elect pro-radiology
candidates at the federal level through the voluntary contributions of
dues-paying ACRa members. RADPAC works through the political process to
keep the concerns of radiologists in the legislative forefront. With the
support of radiologists nationwide, the recently released financials of
RADPAC show that we are now the second largest health subspecialty group
PAC! Currently to date, we have 1,365 members who have donated funds to
RADPAC, raising $434,004.37. It is this kind of monetary support that
allows the PAC to actively support those candidates who support us.
For more information, visit www.radpac.org, or email hkaiser@acr.org for
more information.
What are the Issues?
- Self Referral
Self referral is the practice of non-radiologists referring patients for
studies to imaging equipment in which they have a financial stake. This
creates an economic incentive and conflict of interest that is not in
the best interest of the patient. Furthermore, these studies are often
interpreted by non-radiologists or "farmed out" to a radiologist, while
the referring doctor is still collecting technical fees for every study
he or she orders. The end result is a disproportionate growth in imaging
utilization of 50% compared to a 30% growth in overall cost (based upon
Medicare data.) Because of this, there is a push to cut costs. Proposals
to do this range from getting preauthorization to do cross sectional
imaging, to across-the-board cuts in funding, including physician
reimbursement (more on that later). Other suggestions have been cuts in
the technical components for consecutive body parts and establishing a
unique conversion factor for imaging.
Although the self referring subspecialty groups would like to attribute
this growth to new technology, the data clearly show that there is
disproportionately higher rates of utilization among self-referring
physicians. Blue Cross data from 2003-2003 demonstrates an approximate
15% discrepancy in utilization comparing radiologists to
non-radiologists for the cross sectional modalities. A US GAO report
further confirms this data showing that self referring doctors are 2-5
times more likely to order a study than those who have no financial
incentive.
Although Stark I and Stark II attempted to combat self referral, the
in-office exemption loophole has made it possible to continue to
self-refer. While closing the loophole would solve the problem, this is
not felt to be feasible or sustainable at this point. Thus, in an effort
to combat this growing problem, the ACR is actively supporting the
recommendations of the MEDPAC (Medicare Payment Advisory Commission),
which promote imaging quality and standards for both the physician
interpreting the studies as well as the facilities that carry out
imaging, similar to programs already in effect for Mammography. While
this will not fully solve the problem, the hope is to eliminate the
substandard imaging occurring on outdated equipment or with inadequate
training. This is projected to save $4-6 billion.
We have very few friends on this issue:
AMERICAN MEDICAL ASSOCIATION
HOUSE OF DELEGATES
Resolution: 235(A-04)
RESOLVED, That our American Medical Association reaffirm current policy relating to physician self-referral; and be it further
RESOLVED, That our AMA work collaboratively with state medical societies and specialty societies to actively oppose any and all federal and state legislative and regulatory efforts to repeal the in-office ancillary exception to physician self-referral laws, including as they apply to imaging services.
Resolution Sponsors:
- American College of Cardiology
- American College of Physicians
- American Urological Association
- American Association of Neurological Surgeons
- Congress of Neurological Surgeons
- American Gastroenterological Association
- American Academy of Orthopaedic Surgeons
- American College of Obstetricians and Gynecologists
- American Medical Group Association
For more information on Self Referral:
- Levin DC & Rao VM. Turf Wars in Radiology: The Overutilization of Imaging Resulting From Self-Referral. JACR 2004; 1: 169-172 [March 2004]
- Levin DC & Rao VM. Turf Wars in Radiology: The Quality of Interpretations of Imaging Studies by Nonradiologist Physicians – A Patient Safety Issue? JACR 2004; 1: 506-509 [July 2004]
- Levin DC, Rao VM, Orrison WW Jr. Turf Wars in Radiology: The Quality of Imaging Facilities Operated by Nonradiologist Physicians and of the Images They Produce. JACR 2004; 1: 649-651 [Sept 2004]
There is more to the story!
For a more in depth discussion on self referral, click here.
- Physician Reimbursement and the Medicare Conversion Factor
Physician reimbursement is determined by an extremely complex medicare
physician conversion factor. Problems with the formula arise because it
is tied to the GDP and to the sustainable growth rate (SGR). This means
that when imaging exceeds expected expenditures, physician
reimbursements are subsequently cut to compensate for the excess
expenditure. In the past, the formula would have required a 4.2% cut in
reimbursement for 2004. The Medicare Modernization Act created a
temporary fix for 2004 and 2005, instituting a 1.5% increase in
reimbursement. It was the ACR that lobbied for this fix at the 2003
Annual meeting! More recently, largely in part due to our Government
Relations department, the Senate Finance Committee did recently pass a
provision that would provide a 1% increase in physician payment in 2006
rather than the CMS proposed 4.4% cut. Furthermore, no legislation was
included to cut technical component fees for imaging or to create a
separate conversion factor for imaging.
The fallout from decreased physician reimbursement is a well recognized
problem for the health community. Decreased reimbursement by medicare
means less participation in Medicare by physicians. This limits access
to health care for those who need it most and most often… the elderly.
- Medical Liability Reform
Medical Liability Reform has been an ongoing issue for the past decade.
Frivolous lawsuits drive malpractice costs through the roof, and as a
result, rural community doctors cannot afford the insurance to sustain
their practice. The result is limited health care. As an example for
the rapid rise in malpractice, overall indemnification for breast cancer
malpractice litigation averaged $438K in 2002, up 45% from 1995. The ACR
Government Relations actively supports legislation that caps
non-economic damages, in cases where gross negligence is not
established. Some states already have well established caps, such as
California's MICRA (1975) ($250K cap on non-economic damages). This has
slowed the growth of insurance premiums, increasing 182% since 1976,
compared with 569% nationally. State legislation is extremely variable
on the issue. There is such a discrepancy between the neighboring states
of Oklahoma and Texas, who recently passed Liability reform in the last
three years, that a trial attorney in Oklahoma sent letters to attorneys
in Texas telling them to send their clients north for the better
business. Grassroots action at a state level will continue to pressure
legislators to advocate reform.
For more information on Medical Liability Reform, go to www.ama-assn.org.
Author:
Amy Kirby, M.D.
Secretary
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