Comment Letter to HCFA on Calendar Year 2000 Medicare Physician
Fee Schedule Proposed Rule
September 20, 1999
Nancy-Ann Min DeParle, Administrator
Health Care Financing Administration
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Ave, SW
Room 443
Washington, D.C. 20201
Attention: HCFA-1065-P
Dear Ms. DeParle:
The Association of American Medical Colleges (AAMC) is pleased
to submit comments on the Health Care Financing Administration's
(HCFA) national proposed rule-making (NPRM) of July 22, 1999
entitled Medicare Program: Revisions to Payment Policies
Under the Physician Fee Schedule for Calendar Year 2000 (64
Federal Register 39608). The AAMC represents over 80,000
full-time clinical faculty physicians who are participating
in the Medicare program. These clinical faculty are "safety-net"
providers to indigent and uninsured patients seeking their
care at teaching hospitals across the country.
The AAMC believes that certain provisions of the July 22
NPRM are in need of substantial revision. We will restrict
our comments to the proposed provisions for: 1) a resource-based
malpractice insurance relative value unit (RVU) system; 2)
year 2 refinements of the resource-based practice expense
RVUs; and 3) use of CPT modifier-25 to bill EM services.
Proposed Malpractice Insurance RVUs
The proposed methodology for developing resource-based malpractice
RVUs will establish two national average premiums for each
specialty: one premium would apply to surgical services, and
another to non-surgical services. The methodology ignores
the fact that physicians practice in different settings and
offer a range of services and procedures of varying risk levels
to varying patient populations. In short, all physicians within
a given specialty will be treated the same in terms of their
liability and mal-practice risk.
Case-mix data for teaching hospitals shows that these institutions
often treat an adverse selection of patients. Teaching physicians
affiliated with teaching hospitals, therefore, provide care
to a sicker, more complex patient population that are referred
to these facilities by private physicians locally, and in
some cases, nationally. Frequently, this care consists of
high-risk and invasive procedures only available at the teaching
hospital and performed by teaching physicians with the unique
skills required to provide these services. This pattern of
practice puts teaching physicians in a potentially higher
risk category within their specialty, potentially resulting
in higher professional liability insurance premiums. Therefore,
any methodology that does not attempt to measure mal-practice
costs at the procedure level is likely to understate the costs
incurred by physicians treating an adverse selection of patients,
in particular, those requiring high risk, complex and invasive
procedures.
The AAMC urges HCFA to make every attempt to refine proposed
mal-practice RVUs to account for the additional costs associated
with treating an adverse selection of patients by incorporating
data on malpractice claims by procedure code. These data,
we understand, are available for the purposes of further research
and refinement of the proposed mal-practice RVUs.
Practice Expense Refinements
In the proposed rule, HCFA summarizes further refinements
to the resource-based practice expense methodology and associated
policies in preparation for implementing year 2 of the transition
period, January 1, 2000. At that time, payment of the PE-RVUs
will be based on a 50/50 blend of the old charge-based methodology
and the new, resource-based methodology.
Removal of Clinical Staff Time. HCFA is proposing
to remove the costs associated with the use of physicians'
clinical staff to provide services in facility settings from
the calculation of the PE-RVU. Currently, HCFA pays for these
costs, based on data provided to HCFA by the Clinical Practice
Expert Panels (CPEPs) that it convened four years ago. HCFA
is now proposing to disallow these costs based on its belief
that physicians do not typically utilize their own clinical
staff in facility settings, such as the hospital. The AAMC
believes that this proposal is arbitrary and agrees with MedPAC
that little is known about the prevalence and extent to which
physicians utilize their own staff to provide services in
facilities. Therefore, we believe that further research is
required before eliminating this cost from the methodology
and urge HCFA to conduct a survey of physicians to determine
what percentage of physicians, by specialty, use their own
staff to provide services in facilities and how frequently
they do so.
Use of CPT Modifier -25
HCFA is proposing to require that a physician may only bill
for a separately identifiable evaluation and management (EM)
service by using CPT modifier -25, when the EM service is
performed in conjunction with a procedure(s) that does not
have a global payment period. In addition, the physician must
document the EM service in the medical record.
The AAMC believes that the proposed policy is unnecessary
and only adds to the ever-increasing administrative burden
to bill a claim to the Medicare program. We urge HCFA to withdraw
this proposed provision and simply reinforce its existing
policy that all Medicare services billed to the program must
be medically necessary and appropriate, as this appears to
be the underlying objective.
We hope that these comments are helpful. Should you have
questions, please contact Robert
D'Antuono, Assistant Vice President for Healthcare Affairs
at 202-828-0493.
Sincerely,
Richard Knapp, Ph.D.
Executive Vice President
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