Critical Issues
in Cardiovascular & Interventional Radiology Gary Price
Washington Report: Interventional Radiology the past decade, federal health policy discussions have focused on limiting government spending. Implementation of prospective payment for hospitals was the first step in the attempt to rein spending in the Medicare program. This was followed by extensive study of the physician payment mechanism. Subsequent legislative directives have set a course for total reform of physician payment under government programs. New payment systems are now being implemented. Some of the reimbursement changes have been developed with utilization control in mind. Policymakers will now be developing programs to directly control the utilization of health care services. Several issues are critical in the study of utilization of services, and each will affect the practice of interventional radiology, The critical issues can be described with Washington "buzz words": expenditure targets, volume performance standards, outcomes, standards of practice, standards of care, therapeutic value, effective care, and efficient care. These concepts range from attempts to regulate the total number of services nationwide to specific controls on individual practitioners and procedures. An expenditure target is the broadest attempt to control the utilization of services and thereby control the total dollars spent for health care. This concept involves setting an annual target for Medicare expenditures for all physician services. This target would reflect the previous year's expenditures and be adjusted by factors such as long-term change in procedure mix and the increase or decrease in the number of Medicare beneficiaries. The target would serve as the basis for adjusting fee-schedule conversion factors in future years. If a target increase of 10% is set for a given year and that target is exceeded, the subsequent year's target would be adjusted downward. It is possible that conversion factors would still increase, but the increase would be smaller as a result of "missing the target." Policymakers speculate that physicians as a group would adjust their mode of practice to meet the target and therefore prevent further reductions in future years. Critics point out that the rewards and punishE OR
r
Index term: Radiology and radiologists Radiology 1990; 174:921-922
1 From the American College of Radiology-Society of Cardiovascular and Interventional Radiology, ACR Division of Government Relations, 1891 Preston White Dr, Reston, VA 22091. Received October 20, 1989; accepted November 1. Address reprint requests to the author. RSNA, 1990
ments of such a system are too far removed from the practice sphere of individual physicians to have an effect on utilization of services. If a target is not met, the resulting reduction in conversion factors would affect the physicians who attempted to change their practice patterns, as well as those who ignored the targets. Volume performance standards have been advanced as an alternative to expenditure targets. While in concept these two entities are the same, the use of volume performance standards would offer the alternative of performance standards for subsets of physicians and / or procedures. Performance targets could be set for radiology as a whole or for individual procedures such as angioplasty. If the target was physician group specific, radiologists, for example, would hope to meet a target set for all radiology procedures expected to be performed by radiologists in a given year. Procedure specific targets, such as those for angioplasty, would have to be met to prevent a downward adjustment in a conversion factor specific to angioplasty. The concepts of expenditure targets and volume performance standards are based on the assumption that voluntary action will be taken by physicians to modify practice patterns in order to meet goals. Proponents have speculated that organized physician groups would take the initiative in establishing practice guidelines and standards that would help individual physicians meet their targets. The policymakers who are less optimistic about voluntary action are proposing a more organized approach to standard setting. To establish standards of medical practice, the government intends to study medical outcomes and effectiveness. The research necessary to set standards will no doubt include research on government involvement and funding. Current proposals include the study of outcomes by mean's of grants and contracts with research centers, a literature review, and a study of Medicare claims data. The government has exerted considerable effort during the past 5 years to refine its data collection activities. The addition of recent requirements for physicians to identify diagnosis by ICD-9 code (International Classification of Diseases, 9th revision) and to identify performing and referring physicians broadens the scope of data that are available to the government for studying trends in delivery of medical care. While the study of medical outcome and effectiveness and development of standards are closely related, health policymakers are attempting to separate the issues. An active government role in development of standards of care or standards of practice is being shunned by congressional policy committees. Current proposals would establish mechanisms for involvement by physician groups, other health professionals, and 921
consumers and would preclude government adoption of any standards developed through this consensus process. Development and distribution of standards of care and practice may not directly involve government officials, but it would be naive to believe that government health programs would not adopt standards believed to represent a consensus of health providers. This is particularly true if the use of the standards is seen as a tool to reduce utilization of services. The results of study of outcome and effectiveness will be directly reflected in payment and medical necessity screens used by the government. Some government research is under way to fill the gap in research of outcomes. Last year the National Center for Health Services Research and Health Care Technology Assessment awarded grants totaling nearly $4 million in 1styear costs to measure the effectiveness of alternative medical procedures in treating specific health conditions. These grants represent the start of a long-term effort toward research on effectiveness of medical procedures. Research performed with the first study grants will attempt to focus on conditions that affect a large number of Americans every year, such as heart attack, cataracts, prostate gland enlargement, and lower back pain. These conditions account for a large share of Medicare expenditures. The government has also begun a comprehensive effort to expand the role of peer-review organizations (which review medical care to determine appropriateness). While hospital preadmission review has been common in the past few years, peer-review organizations now are charged with preprocedure approval for several categories of service including coronary angioplasty. These screens no doubt will be expanded. Nongovernment groups are also escalating efforts to create effectiveness review programs. The Blue Cross
922 • Radiology
and Blue Shield plans, managed care organizations, and the Joint Commission on Accreditation of Healthcare Organizations have all begun to address the subject of quality described by any of the terms in vogue: parameters, guidelines, standards, and outcomes. The American Medical Association has also begun an effort to set practice parameters. While standard setting has recently mushroomed among regulators and insurers, medical specialty societies have long been involved in the setting of standards and guidelines. Part of the motivation for this activity in the past has been "turf" battles among the various medical specialties. The resulting policies regarding standards and guidelines have been used to establish criteria for hospital privileges and rules and regulations for hospital departments. The Society of Cardiovascular and Interventional Radiology has been one of the most active societies in developing credentialing criteria and guidelines. While the target of much of this work has been ensuring that interventional radiology procedures are performed with the highest possible quality, the guidelines may likely find a place in the government's attempts to identify the most efficient and effective physicians. Most physicians still view the introduction of practice guidelines as an erosion of their clinical autonomy. As a result, many individual physicians and many medical societies will resist participation in the development of parameters and the study of effectiveness and efficiency. Their nonparticipation reflects their hope that all the government intrusion will go away. That is unlikely. Health care policymakers will implement programs to control utilization of medical services. Should medical societies resist participation, guidelines and standards may be adopted that reflect the bias of the government or other physicians who are willing to participate in the process. •
March 1990 • Part 2
in Cardiovascular & Interventional Radiology Gary Price
Washington Report: Interventional Radiology the past decade, federal health policy discussions have focused on limiting government spending. Implementation of prospective payment for hospitals was the first step in the attempt to rein spending in the Medicare program. This was followed by extensive study of the physician payment mechanism. Subsequent legislative directives have set a course for total reform of physician payment under government programs. New payment systems are now being implemented. Some of the reimbursement changes have been developed with utilization control in mind. Policymakers will now be developing programs to directly control the utilization of health care services. Several issues are critical in the study of utilization of services, and each will affect the practice of interventional radiology, The critical issues can be described with Washington "buzz words": expenditure targets, volume performance standards, outcomes, standards of practice, standards of care, therapeutic value, effective care, and efficient care. These concepts range from attempts to regulate the total number of services nationwide to specific controls on individual practitioners and procedures. An expenditure target is the broadest attempt to control the utilization of services and thereby control the total dollars spent for health care. This concept involves setting an annual target for Medicare expenditures for all physician services. This target would reflect the previous year's expenditures and be adjusted by factors such as long-term change in procedure mix and the increase or decrease in the number of Medicare beneficiaries. The target would serve as the basis for adjusting fee-schedule conversion factors in future years. If a target increase of 10% is set for a given year and that target is exceeded, the subsequent year's target would be adjusted downward. It is possible that conversion factors would still increase, but the increase would be smaller as a result of "missing the target." Policymakers speculate that physicians as a group would adjust their mode of practice to meet the target and therefore prevent further reductions in future years. Critics point out that the rewards and punishE OR
r
Index term: Radiology and radiologists Radiology 1990; 174:921-922
1 From the American College of Radiology-Society of Cardiovascular and Interventional Radiology, ACR Division of Government Relations, 1891 Preston White Dr, Reston, VA 22091. Received October 20, 1989; accepted November 1. Address reprint requests to the author. RSNA, 1990
ments of such a system are too far removed from the practice sphere of individual physicians to have an effect on utilization of services. If a target is not met, the resulting reduction in conversion factors would affect the physicians who attempted to change their practice patterns, as well as those who ignored the targets. Volume performance standards have been advanced as an alternative to expenditure targets. While in concept these two entities are the same, the use of volume performance standards would offer the alternative of performance standards for subsets of physicians and / or procedures. Performance targets could be set for radiology as a whole or for individual procedures such as angioplasty. If the target was physician group specific, radiologists, for example, would hope to meet a target set for all radiology procedures expected to be performed by radiologists in a given year. Procedure specific targets, such as those for angioplasty, would have to be met to prevent a downward adjustment in a conversion factor specific to angioplasty. The concepts of expenditure targets and volume performance standards are based on the assumption that voluntary action will be taken by physicians to modify practice patterns in order to meet goals. Proponents have speculated that organized physician groups would take the initiative in establishing practice guidelines and standards that would help individual physicians meet their targets. The policymakers who are less optimistic about voluntary action are proposing a more organized approach to standard setting. To establish standards of medical practice, the government intends to study medical outcomes and effectiveness. The research necessary to set standards will no doubt include research on government involvement and funding. Current proposals include the study of outcomes by mean's of grants and contracts with research centers, a literature review, and a study of Medicare claims data. The government has exerted considerable effort during the past 5 years to refine its data collection activities. The addition of recent requirements for physicians to identify diagnosis by ICD-9 code (International Classification of Diseases, 9th revision) and to identify performing and referring physicians broadens the scope of data that are available to the government for studying trends in delivery of medical care. While the study of medical outcome and effectiveness and development of standards are closely related, health policymakers are attempting to separate the issues. An active government role in development of standards of care or standards of practice is being shunned by congressional policy committees. Current proposals would establish mechanisms for involvement by physician groups, other health professionals, and 921
consumers and would preclude government adoption of any standards developed through this consensus process. Development and distribution of standards of care and practice may not directly involve government officials, but it would be naive to believe that government health programs would not adopt standards believed to represent a consensus of health providers. This is particularly true if the use of the standards is seen as a tool to reduce utilization of services. The results of study of outcome and effectiveness will be directly reflected in payment and medical necessity screens used by the government. Some government research is under way to fill the gap in research of outcomes. Last year the National Center for Health Services Research and Health Care Technology Assessment awarded grants totaling nearly $4 million in 1styear costs to measure the effectiveness of alternative medical procedures in treating specific health conditions. These grants represent the start of a long-term effort toward research on effectiveness of medical procedures. Research performed with the first study grants will attempt to focus on conditions that affect a large number of Americans every year, such as heart attack, cataracts, prostate gland enlargement, and lower back pain. These conditions account for a large share of Medicare expenditures. The government has also begun a comprehensive effort to expand the role of peer-review organizations (which review medical care to determine appropriateness). While hospital preadmission review has been common in the past few years, peer-review organizations now are charged with preprocedure approval for several categories of service including coronary angioplasty. These screens no doubt will be expanded. Nongovernment groups are also escalating efforts to create effectiveness review programs. The Blue Cross
922 • Radiology
and Blue Shield plans, managed care organizations, and the Joint Commission on Accreditation of Healthcare Organizations have all begun to address the subject of quality described by any of the terms in vogue: parameters, guidelines, standards, and outcomes. The American Medical Association has also begun an effort to set practice parameters. While standard setting has recently mushroomed among regulators and insurers, medical specialty societies have long been involved in the setting of standards and guidelines. Part of the motivation for this activity in the past has been "turf" battles among the various medical specialties. The resulting policies regarding standards and guidelines have been used to establish criteria for hospital privileges and rules and regulations for hospital departments. The Society of Cardiovascular and Interventional Radiology has been one of the most active societies in developing credentialing criteria and guidelines. While the target of much of this work has been ensuring that interventional radiology procedures are performed with the highest possible quality, the guidelines may likely find a place in the government's attempts to identify the most efficient and effective physicians. Most physicians still view the introduction of practice guidelines as an erosion of their clinical autonomy. As a result, many individual physicians and many medical societies will resist participation in the development of parameters and the study of effectiveness and efficiency. Their nonparticipation reflects their hope that all the government intrusion will go away. That is unlikely. Health care policymakers will implement programs to control utilization of medical services. Should medical societies resist participation, guidelines and standards may be adopted that reflect the bias of the government or other physicians who are willing to participate in the process. •
March 1990 • Part 2
