James D. Thomas, MD, FASE, FACC, FAHA, FESC

Many of us have jam-packed days as physicians and sonographers, seeing patients, performing clinical and research studies, teaching, publishing, and handling the myriad responsibilities encompassed by ASE’s members. It’s easy to leave the work of protecting reimbursement of cardiovascular ultrasound to others. ASE’s mission in advocacy is to represent the interests of our members and patients, while advocating to create an environment for excellence in the practice of cardiovascular ultrasound. We work to represent echocardiography on Capitol Hill, to regulatory agencies, and to private payers. We need your help on all of these fronts!

I find it helpful to think of advocacy as divided into micro and macro issues. The micro ones are the myriad of challenges that face us every year, while the macro ones are tectonic policy issues that can shape access and reimbursement for years to come. We are in the midst of just such a macro challenge, but before we dive into that, let’s review some of the skirmishes we’ve fought this year, where we’ve had some real success in preserving payment from the Center for Medicare and Medicaid Services (CMS) and private payers. Recent accomplishments that were achieved with the help of our members include:

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  The additional payment for the use of contrast with a transthoracic echo (TTE) will increase from $90 to $180 next year, which will more completely cover the cost of contrast and its administration and thus encourage its appropriate use in more studies. (Unfortunately, reimbursement for a contrast-enhanced stress echo will still be $3 LESS than for an unenhanced stress echo, but we’re working on that, too.)

  
  
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  ASE convinced CMS to make methodological changes that resulted in restoration of $14 in proposed cuts for TTE with spectral and color Doppler made under the Hospital Outpatient Payment System.

  
  
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  ASE worked with the American College of Cardiology (ACC) to preclude payment reductions proposed by CMS for limited spectral Doppler and is currently working to preclude payment reductions for limited TTE (CPT 93308). Thanks to the diligence of our members, a total of 83 usable surveys were returned to provide data on the periodic reevaluation of this code. This data should be sufficient to maintain the current relative value unit (RVU) for 93308. A number of other codes will be revaluationed next year; if you are asked to take a survey, please fill it out diligently. If the survey pertains to “physician work” it must be completed only by physicians. However, if the survey applies to “practice expense,” guidance from those directly involved, like lab administrators, is permitted within the AMA rules.

  
  
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  ASE discovered $15 million in underpayments made to hospitals for outpatient echoes in 2009, and alerted the affected hospitals about how to recover these underpayments.

  
  
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  ASE volunteers worked with United Healthcare to assure appropriate coverage of TTE under its revised echo coverage policies.

  
  
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  Recently, Blue Cross Blue Shield of Delaware was fined $300,000 and ordered to implement the ACC FOCUS program to guide appropriate use of imaging tests rather than more disruptive precertification. This program derives largely from the ASE APEGS project spearheaded by Dr. Parker Ward.

  
  
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  ASE is working with the Sonography Licensure Coalition (SLC) and Alliance for Quality Medical Imaging and Radiation Therapy on strategies to best enact sonographer licensure legislation.

  
  
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  ASE staff has helped members use the correct modifiers to facilitate insurance reimbursement for inpatient echocardiograms performed on the same date of service as hospital visits.

So you can see it’s been a very busy year for our advocacy team, headed by Advocacy Committee Chair Dr. David Wiener, our reimbursement consultant Dr. Diane Wallis, coding consultant Judy Rosenbloom, ASE Health Policy Manager Irene Butler, and of course our loyal consulting attorney Diane Millman. But while attention to these tactical battles is critical, we must not lose sight of the massive structural changes underway in American medicine.

Among the changes mandated by the Affordable Care Act of 2010 is a shift in payment towards Accountable Care Organizations (ACOs), in which groups of doctors, hospitals, and other entities band together to better coordinate care with the goal of reducing the cost of caring for Medicare patients. One way of doing this is by expanding the concept of the Diagnosis Related Group (DRG), which currently provides a fixed payment for the technical aspects of in-patient hospitalization. The Department of Health and Human Services has recently called for demonstration projects where specific diagnoses (such as heart failure or acute coronary syndrome) will have global physician and technical payments bundled together for the in-patient and/or subsequent out-patient episodes. Given its lower costs and excellent safety profile in comparison to other modalities, echo should figure prominently in such plans, but it is critical that health care workers budget for all appropriate echoes anticipated during the episode of care. We are working diligently, both on our own and with ACC and other organizations, to assure a prominent place for echo in health care reform.

As complex as all this may seem, it pales in comparison to the challenges of the American political situation. Between now and early November, the 12-member Joint Select Committee on Deficit Reduction (aka “Super Committee”) is charged with finding $1.5 trillion in funding cuts (even more if short-term stimulus is included in the equation). Now more than ever it is important for our members to foster relationships with their congressmen and senators, particularly those on the Super Committee or other key committees. For example, Dr. Judy Mangion has begun regular communication with Senator John Kerry’s office to ensure he and his staff are aware of the negative impact that some recent proposals will have on echocardiography. And Dr. Ed Gill recently flew to Montana to attend Senator Max Baucus’ annual barbecue and was able to advocate for excellence in cardiovascular ultrasound (presumably between bites of pulled pork). Thanks for taking one for the team, Ed!

As medical professionals, we are on the front lines shaping our health care system; legislators need to hear from us. As a constituent you have the ability and duty to educate your legislator. Our advocacy department would like to work with you to develop effective advocates in Congress. If you have a relationship with a legislator, or are willing to pursue one , please contact advocacyinfo@asecho.org . Our success depends on your voices.

I know this has been quite a rapid tour through the confusing landscape of advocacy. I encourage you to click on the advocacy tab at www.asecho.org to learn about these issues. Our advocacy committee and staff have done a great job of translating this morass of regulations into English. And while you’re there, why not reward yourself by clicking on the Echo Hawaii or State of the Art links and enjoy some education in the sun this winter? Hotels and courses may sell out early, so don’t delay!