Alabama Academy of Radiology Meeting March 5, 2005 Ariel González, MA - ACR State Legislative Specialist Federal and State Legislative Update

Alabama Academy of Radiology Meeting

March 5, 2005

Ariel González, MA - ACR State Legislative Specialist

Federal and State Legislative Update

ACR Government Relations

Focus of today’s discussion

• Brief Washington Office Update

• ACR efforts during the 108th Congress

• ACR legislative priorities for the 109th Congress

• Success of RADPAC

• ACR state legislative initiatives

ACR Government RelationsStaff Changes and Additions

Ted Burnes, Director of RADPAC

• Former State Legislative Specialist

• MA in Government Relations from GWU

Gloria Romanelli, Director of Federal Affairs

• Arizona State University Law Graduate

• Former staff member for Rep. Terry Bruce (IL)

ACR Government RelationsStaff Changes and Additions

Ariel Gonzalez, State Legislative Specialist• Second year law student, Catholic University• MA in Legislative Affairs from GWU

Jay Greissing, Assistant Director, Congressional Relations

• Fordham University School of Law Graduate• Former Counsel on United States Senate

Committee on the Judiciary (Republican Staff)

ACR Government Relations• New Government Relations Office• 1701 Pennsylvania Ave• One block from the White House• Quicker access to Capitol Hill• Fundraisers

ACR Government Relations• ACR Accomplishments in the 108th Congress

– Medicare / prescription drug reform legislation – Comprehensive prescription RX package averted 4.4%

decrease in Medicare CF in ’04– 1.5% increase in CF for ’04 and ’05 additional

reimbursement – Reimbursement increases for M.D.s in rural areas– Increased reimbursement for certain mammography

procedures

ACR Government Relations• 108th Congress Legislative Highlights

– MQSA Reauthorization– Medical Liability Reform Votes

ACR Government Relations• 109th Congress Legislative Priorities

– Inappropriate Utilization of Diagnostic Imaging– Medicare Physician Payment Policy

• Link payment for performance and interpretation of CT, MRI, and PET studies to satisfaction of quality and safety standards.

• Sustainable Growth Rate (SGR)– Medical Liability Reform– Lessen the Regulatory Burden of MQSA

ACR Government Relations• Inappropriate Utilization of Diagnostic Medical

Imaging– The ACR has discussed this issue with Congress,

federal agencies, medical specialty societies, and businesses

– MedPAC recommendations


• Inappropriate Utilization of Diagnostic Medical Imaging– Meeting discussions

• The Administration has tasked Congress with implementing initiatives that will reduce the federal budget deficit

• Potential savings in Medicare, especially imaging• Amending the Stark law to close the loophole for in-office

ancillary services is a political and logistical impossibility• The future of healthcare services is a “pay for

performance” paradigm with emphasis on quality and safety linked to reimbursement


Imaging

– Meeting discussion (cont’d)• Imaging is the fastest growing type of medical

expenditure within the category of physician services in the United States

• Technological advances led to imaging equipment at reduced size and cost encouraging a shift in site of service from hospitals to physician offices

• Non-radiologist physicians are performing and interpreting an appreciably growing portion of images produced in CT, MRI, and PET studies


• Inappropriate Utilization of Diagnostic Medical Imaging– Meeting Result: Congress

• Bipartisan acknowledgement of the need to reduce over utilization of imaging services

• There will be cuts in Medicare during 109th Congress• Interested in MedPAC recommendations to improve

quality and safety.• Interested in Medicare savings that ACR’s policy may

bring – a conservative estimate of nearly $6 billion over 10 years

• Bipartisan agreement that pursuing solution that would close the in-office ancillary services exception to the Stark law is not viable


• Inappropriate Utilization of Diagnostic Medical Imaging– Meeting Result: Agencies

• OMB– Favors ACR policy over Stark approach– Impressed with ACR’s estimated savings and wants

to share with CBO.• MedPAC

– Will not consider Stark approach– Published recommendations in its March 2005 report

for Medicare physician payment policy for diagnostic medical imaging services


• Inappropriate Utilization of Diagnostic Medical Imaging

– MedPAC recommendations of chief importance• “The Congress should direct the Secretary to set standards

for all providers who bill Medicare for performing diagnostic imaging services. The Secretary should select private organizations to administer the standards.”

• “The Congress should direct the Secretary to develop standards for physicians who bill Medicare for interpreting diagnostic imaging studies. The Secretary should select private organizations to administer the standards.”

ACR Government Relations• Inappropriate Utilization of Diagnostic

Medical Imaging– ACR Policy – “Diagnostic Medical Imaging

Provider”• Certification by the Secretary of HHS is

required for lawful operation of all facilities providing CT, MRI, and PET

• In order to be certified, a facility must be accredited by a private, non-profit organization with experience in diagnostic medical imaging accreditation, including the ACR

• A facility seeking accreditation must satisfy certain quality standards.


Imaging– ACR Policy – “Diagnostic Medical Imaging Provider” (cont’d)

• Medicare payment for CT, MRI, and PET studies shall only be made for the professional component of the services if the physician interpreting the clinical image produced by such study is a qualified interpreting physician, and shall only be made for the technical component if the facility conducting the study is a certified facility.

• Qualified interpreting physician is a radiologist or other licensed physician who interprets clinical images produced in CT, MRI, or PET studies and who meets the appropriate education, training, and experience requirements established by the Secretary in consultation with the ACR.


• Inappropriate Utilization of Diagnostic Medical Imaging– MEDIC – The Medical Excellence in Diagnostic

Imaging Coalition will work to give this issue mainstream credibility by focusing on the importance of quality and safety in imaging

• Seeking allies in other specialties, private insurance companies, manufacturers, and corporations.

ACR Government Relations• Medicare Physician Fee Payments

– National fee schedule and spending target implemented in 1992 to address issues of affordability and Medicare program sustainability by slowing spending growth.

– Sustainable Growth Rate (“SGR”)– In 2003, Medicare spending for physician services totaled

nearly $48 billion, which accounted for about 1/6 of program spending overall. October 2004 GAO Report.

– Technological advances in areas such as diagnostic medical imaging services will increase the price tag of Medicare program that is already unstable.

ACR Government Relations• Medicare Physician Fee Payments (cont’d)

– SGR system targets are designed to allow spending per beneficiary (adjusted for the estimated underlying cost of providing physician services) to grow at the same rate as the national economy grows over time on a per capita basis.

• Target = annual increase is set equal to the estimated change on physicians’ cost of providing services

• High growth in volume and intensity of services causing spending to exceed the SGR target = future fee updates are set below the estimated increase in physicians’ average cost

– if the gap b/w spending and the target is wide enough, the SGR results in fee reductions

• Low growth in volume and intensity of services causing spending to fall below target = fee increases


– In 2002, physician fees reduced by 5.4% – While administrative and legislative action have

overridden the SGR for 2003–2005, physician fees are expected to fall by approximately 5% each year from 2006 until 2012.

• Future reduction attempts to offset previous excess spending

• Discourages physicians from treating Medicare beneficiaries.

– Congress will consider appropriateness of current spending targets and the SGR as a system for determining physician fee updates.


– SGR Reform• End the use of spending targets and separate fee

updates from explicit efforts to moderate spending growth

– MedPAC favors this and also recommends Medicare seek to control spending growth by identifying and addressing the rapid proliferation of diagnostic medical imaging utilization.

• Retain spending targets but modify the current SGR system to address perceived shortcomings.

– AMA wants prescription drugs taken out of the formula – CMS can do this through the rulemaking process without Congressional mandate.


Medical Liability Reform– The Liability Crisis

• Even injured parties with meritorious claims receive less than 50 cents on the dollar – Tillinghast-Towers Perrin.

• Medical liability costs add $60 billion to $108 billion to the costs of health care each year, diverting scares health care resources to the legal system and away from direct patient medical care, research and quality – Dept. of Health and Human Service.

• Alabama is a “problem signs” state – American Medical Assn’


Medical Liability Reform (cont’d)– Effect on Radiologists

• Most frequent defendants in medical liability actions because of joint and several liability.

• Misdiagnosed breast cancer – most common cause of medical liability claims.

– Effect on patients• Fewer residents pursuing fellowships in breast imaging.• Women losing access.


Medical Liability Reform (cont’d)– Cost savings if comprehensive reform legislation is signed into

law: • $14.9 billion in federal spending over the next 10 years for

Medicare, Medicaid, and Federal Employees Health Benefits Program. $6 billion in State and local government spending, including $2.5 billion for Medicaid – Congressional Budget Office.

• $16.7 billion in federal spending on health care system over the next 10 years b/c of reducing costs associated with defensive medicine – Joint Economic Committee.

ACR Government Relations• Medical Liability Reform (cont’d)

– 109th Congress - Republican Leadership continues to consider the MICRA approach:

• Limiting Non-Economic Damages• Limiting Punitive Damages• Proportionate Liability• Collateral Source Reform• Limiting Attorney Contingency Fees• Federal Statute of Limitation• Periodic Payment of Damages


– 109th Congress - Likely alternative initiatives to the MICRA approach:

• McCarran-Fergusson Reform• Medical Tribunal• Certificate of Merit• Qualified Medical Specialist• Mediation


Medical Liability Reform (cont’d)

– 109th Congress: Leading Legislation• H.R. 534 (Cox) – introduced on Feb. 2, 2005• S. 354 (Gregg/Ensign) – introduced on Feb. 10,

2005 (comprehensive reform)• S. 366 (Gregg/Ensign) – introduced on Feb. 10

(OB/GYN)• S. 367 (Gregg/Ensign) – introduced on Feb. 10

(OB/GYNs and trauma surgeons)


– 109th Congress: Congressional Realties for the MICRA Approach

• Senate procedure – 60 votes required to block a filibuster and vote on a piece of legislation.

– Because there are 55 Republicans in office, more potential to negotiate around a filibuster of the MICRA approach.

– However, some Republicans, including Shelby and Graham, will only support caps on non-economic damages if there is a carve out for catastrophic injuries, and do not want to limit attorney contingency fees.

ACR Government Relations• MQSA

– 108th Congress• H.R. 4555 (Rep. Dingell)

– Signed into law by President Bush on October 25, 2004 – Public Law No: 108-365

– Reauthorized for 2 years – until 2007– 2 industry reps on NMQAAC

– 109th Congress• IOM and GAO Reports in 2005• Reauthorization for 2007


RADPAC

• Third largest medical specialty PAC

• Have contributed over $1 million to congressional and senatorial

campaigns during the 2002-2004 election cycle.

• 89% of candidates supported were victorious in November 2002

elections.

• Valuable lobbying tool to increase radiology’s visibility on Capitol Hill

• For info go to www.radpac.org


RADPAC (cont’d)

• Alabama federal candidates supported by RADPAC:

– Jo Bonner, Alabama 1st (Republican) (on Budget Committee)

– Robert “Bud” Cramer, Alabama 5th (Democrat) (not on Committee of Jurisdiction but voted YES on H.R. Medical Liability Reform)

ACR Government Relations• State Government Relations

– The ACR offers assistance on a variety of state legislative issues of importance to our members

• Physician Self-Referral• Certificate of Need Laws• Telemedicine Licensure• Radiologist Assistant legislation• State medical liability laws

ACR Government Relations• State Government Relations – effort to analyze

inappropriate utilization of imaging services

• Request for Proposal

• Crowell and Moring Project

– Phase I – State Self-Referral Laws

– Phase II – Certificate of Need Laws

ACR Government Relations• State Government Relations (cont’d)

Inappropriate Utilization, varying solutions and challenges by state

• Maryland example

• MD Health Occupations Code 1-301 (k) (2) provides:

– Except for a Radiologist group or office consisting solely of one or

more radiologists, “in-office ancillary services” does not include:

• (i) Magnetic resonance imaging services

• (ii) Radiation therapy services; or

• (iii) Computer tomography scan services


Maryland Law

• Maryland law bars a physician in any non-radiology group

practice from self-referring patients regardless of who performs

the tests.

• Resulted in Maryland non-radiology groups trying to overturn in

legislature.

• MRS is aware and countering.


Maryland has its first enforcement case

• The case involves a neurologist self-referring for MRI scans to a facility

in which he has a significant financial interest.

• If found in violation of the Maryland Health Code, the Board may

impose sanctions against the doctor’s license including revocation,

suspension, reprimand, or may place the physician on probation and/or

may impose a monetary fine pursuant to the Maryland State Health

Code.

ACR Government RelationsThe issue manifests across the nation

California – proposing “Maryland” legislation AB 516 (2/16/05)

“except for a radiologist group practice or an office consisting solely of one or more radiologists, the prohibition of Section 650.01 shall apply to magnetic resonance imaging services, computed axial tomography services, or positron emission tomography performed within a licensee's office, or the office of a group practice”


• South Carolina

– Proposed imaging center with 49 percent physician

interest; 51 percent hospital

• Texas

• Indiana

• Rhode Island pursuing a Maryland style approach


• Phase II of the Project – state by state CON Analysis– The analysis breaks down states by “No Certificate of Need

Law”, “Limited Certificate of Need Coverage” and “Comprehensive Certificate of Need Laws” (Alabama is one of these states).

– Members may access this information by contacting Ariel

González at (703) 715-3488 or at [email protected]– A summary chart will also be available on www.acr.org

under “Advocacy” and State Government Relations

mailto:[email protected]

http://www.acr.org/

ACR Government RelationsIn Closing…

• Grassroots Activity– “All politics is local.”– ACR has a great legislative and regulatory

team in Washington– The team depends on the involvement of

physician leaders

ACR Government Relations• Get involved in the process

• Local, state or federal level

• Volunteer

• Attend/host fundraisers

• Meet with your lawmaker


Thank You!

Questions or Comments?

Documents

Alabama Academy of Radiology Meeting March 5, 2005 Ariel González, MA - ACR State Legislative Specialist Federal and State Legislative Update