CMS also confirmed other payment cuts that critics say will affect women's access to mammography and other breast cancer services. The agency plans to cut overall physician payment rates by 24%, due to the requirements of the SGR formula, while the conversion factor for 2014 will be $27.20. The cuts can be averted only with yet another congressional action before the end of the year.
"While Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical," CMS wrote. "We will continue to work with Congress to fix this untenable situation so doctors and beneficiaries no longer have to worry about the stability and adequacy of payments from Medicare under the Physician Fee Schedule [MPFS]."
The final rule also includes reimbursement cuts for image-guided breast biopsies and other medical imaging techniques. And these may further reduce women's access to mammography and other breast cancer services, according to the American College of Radiology (ACR).
"Targeting breast cancer procedures, along with other massive cuts, may result in reduced services or even facility closures, limiting access," the ACR said in a statement. "Women may have to wait longer for mammograms or diagnostic evaluation. This may increase patient anxiety by resulting in a delay for those who need a biopsy to determine if they have breast cancer. Worse yet, it may delay subsequent treatment for those who do."
In the final MPFS rule, CMS estimated the impact on various imaging specialties based on work, practice expense, malpractice relative value units (RVUs), and Medicare Economic Index (MEI) adjustment factors -- but took care to say that these figures are based on a constant conversion factor and don't include effects of the conversion factor change in January.
Radiology and interventional radiology will be cut 2%, while radiation oncology will actually have a payment boost of 1% and nuclear medicine will not be affected at all, according to CMS.
MPPR policy stays the same ...
The 2013 MPFS rule established a 25% multiple procedure payment reduction (MPPR) cut in Medicare's professional component for CT, MR, and ultrasound services performed by the same physician on the same patient in the same session. CMS applied this MPPR to subsequent procedures performed by other physicians on the same patient in the same session, as well as to other specialties, such as cardiology and ophthalmology.
In this final 2014 rule, there are no new MPPR policies. But that doesn't mean there won't be in the future, CMS said.
"We did not propose and are not adopting any new MPPR policies for [calendar year] 2014," the agency wrote. "However, we continue to look at expanding the MPPR based on efficiencies when multiple procedures are furnished together."
But equipment use rate increases
The rule also increases the equipment utilization rate from 75% to 90% for imaging equipment priced at more than $1 million, according to a mandate stipulated in the American Taxpayer Relief Act of 2012. This is despite objections to the change CMS received in July in response to the proposed rule.
"Several commenters objected to the statutorily mandated change in equipment utilization rate assumptions, but none provided evidence that CMS has authority to use a different equipment utilization assumption for these services," CMS wrote.
Also on November 27, CMS issued a final rule for the 2014 Hospital Outpatient Prospective Payment System (OPPS). Proposed changes in July included establishing separate cost ratios for CT and MR, and adjusting practice expense methodology to improve accuracy of payment rates in the office setting. It plans to follow through on the former -- although over four years -- but will continue to research the latter.
"We are finalizing a policy for the 2014 OPPS to remove claims from providers that use a cost allocation method of 'square feet' to calculate cost-to-charge ratios used to estimate costs associated with the CT and MRI ambulatory payment classifications," CMS wrote. "This change allows hospitals additional time to use one of the more accurate cost allocation methods, and thereby improve the accuracy of the cost-to-charge ratios on which the OPPS relative payment weights are developed."
Hospitals capture equipment cost as well as direct costs associated with a medical service in a variety of ways: through a formula that divides costs by a service's actual square footage in the hospital; through a direct allocation method, which calculates specific costs for each piece of equipment; and via a dollar value allocation method. Critics said the square-footage method for calculating CT and MR costs doesn't take into account the actual cost of running the equipment.
CMS listened, sort of. For four years the agency will exclude hospital data where the square-footage method of cost allocation was used, which will avoid more drastic cuts to office-based imaging due to a combination of that policy and imaging provisions in the Deficit Reduction Act of 2005. But hospitals will still see cuts of up to 18% depending on the type of study, according to the ACR.
The Access to Medical Imaging Coalition (AMIC) praised the move, saying that it supports delay of the proposed cost center policy.
"This delay is necessary to avoid inaccurate Medicare payments for CT and MR services, which would jeopardize the financial ability of hospitals and clinicians to continue to readily provide lifesaving diagnostics to Medicare beneficiaries," said Tim Trysla, executive director of AMIC, in a statement released on November 27.
The second change CMS proposed in July to the OPPS rule was that it would use current-year OPPS or ambulatory surgical center (ASC) rates as a point of comparison to establish practice expense values under the fee schedule -- which meant that for at least 200 current procedural terminology (CPT) codes, payments in the office setting could not be higher than OPPS or ASC rates.
But CMS did not finalize this proposal, stating instead that it plans to consider more fully the comments it received. The agency will develop a revised proposal for using OPPS and ASC rates in developing practice expense values that they will propose through future notice and rulemaking.
Both final rules will be published in the Federal Register on December 10, CMS said.
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