How will health care reform affect your reimbursement?

August 1, 2009

The question is no longer if health care reform will occur, but when and what it will look like.

Both houses of Congress have agreed and were pushing for passage of bills by the end of July. If successful, the bills will need to be reconciled, and you will have the opportunity to contact your representatives while Congress is in recess. The current direction will not just affect the amount you are paid, but the way you practice.

The question is no longer if health care reform will occur, but when and what it will look like. It will take time, perhaps years, to implement any reform. For urologists, the real question is: How will health care reform impact your practice next year and beyond? This article will discuss the likely near- and long-term changes you can expect.

Hopefully, Congress will act to avoid the approximately 20% scheduled decrease in Medicare payment. There is a chance that the flawed sustainable growth rate formula will be replaced. Watch this issue carefully.

There is a possibility that the political process will push passage of a bill to late in 2009 or early next year. If this occurs, we may face a situation in which the year begins with a reduced conversion factor, only to have a retroactive fix in place in early 2010. This, coupled with the beginning of the year deductible requirement, could create a cash flow problem in January and February.

Also keep an eye on these reimbursement scenarios in 2010:

In 2010, imaging is at the highest risk for lost reimbursement. In addition to the government and private payers being fully aware that imaging is the fastest growing cost in health care, there are data suggesting that physicians who own imaging centers order imaging tests more frequently. Radiologists are in an all-out war with other specialties to prevent the loss of "their" profit centers. We are not sure how it will occur, but we can anticipate a decrease in income from those services. That decrease will continue over the next several years.

Changes in 2011 and beyond

Initially, we don't expect to see changes in the way physicians are paid in 2011. We think physicians can anticipate a continued decrease in fee-for-service payments and an increase in incentive payments for either practicing in a certain way or performing additional reporting for payment, eg, through Physician Quality Reporting Initiative participation and electronic prescription writing.

As with electronic prescriptions, bonus payments may be replaced in the near term with payment reductions assessed for non-participation in these programs.

In the long run, we will be seeing an increasing amount of income through incentive pay and a decreasing amount through fee for service. We would anticipate that Medicare will begin to make good on its promise to become a "value purchaser", rather than a passive payer of health care services. This means physicians will be paid more for practicing "quality, cost-efficient care," as opposed to being paid for providing services.

Other possible changes to watch for in 2011 and beyond:

In summary, quality and data are going to be at the forefront of all of the discussions, but the real issue is cost. Prepare to change the way you practice as the rules change. Strongly consider becoming politically active by contacting your senator or representative. Reform is taking place in the public eye, but the real decisions are being made by the politicians. Other players will try to influence the system. If urologists do not bring pressure through direct or indirect lobbying efforts, decisions will be made for you.

Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.