The “Alphabet Soup” of Federal Healthcare Agencies

Benjamin F. Byrd III, MD, FASE

The federal government has tremendous influence over the delivery of healthcare in this country. What initially seems a small, insignificant change in federal policy can have vast repercussions across the medical system. Moreover, there is a myriad of regulatory bodies, federal offices, and other entities that influence healthcare policy. To understand the legislative and regulatory changes impacting echocardiography—more of which will follow on next month’s President’s Message—one must understand the basics of federal agencies’ interactions with our field. This President’s Message, thus, provides a brief introduction to the “alphabet soup” of federal healthcare agencies.

The President, Congress, and the Supreme Court all directly impact the country’s medical system, as we have seen in the past two years. Before Congress votes on a bill, there are several Congressional committees that shape the legislation. In the House of Representatives, the Ways and Means, Appropriations, Energy, and Commerce Committees have primary oversight of healthcare legislation. Similar committees exist in the Senate, where the Health, Education, Labor and Pension (HELP); Finance; and Budget Committees have primary jurisdiction over healthcare issues.

Additionally, the Congressional Budget Office (CBO) is a nonpartisan office that produces independent analyses of budgetary and economic issues for Congress. While the CBO does not make policy recommendations, its reports do calculate anticipated costs and savings that generally have significant implications for the future of any legislation.

The Government Accountability Office (GAO) is the audit, evaluation, and investigative arm of Congress. Its audits and investigative reports contain findings, conclusions, and/or recommendations which often influence policy, including healthcare.

The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency that was established to advise the U.S. Congress on issues affecting the Medicare program. MedPAC has 16 members, five of whom are physicians. Its mandate includes advising Congress on payments to Medicare private health plan providers, on payments to Medicare’s traditional fee-for-service providers, and on access and quality of care issues. MedPAC produces two reports each year, in March and June, which list its findings and often provide the basis for adopted legislation.

The United States Department of Health and Human Services (HHS) is a Cabinet-level department of the US federal government charged with “the goal of protecting the health of all Americans and providing essential human services,” and it has direct oversight over healthcare policy. The Centers for Medicare & Medicaid Services (CMS) is an agency within HHS responsible for the administration of numerous crucial federal health care programs. These include managing the Medicare program and working with state governments to oversee Medicaid. CMS releases a proposed rule each July that updates the Physician Fee Schedule (PFS), which sets the Medicare payment schedule for physicians and procedures done in physician offices; and the Hospital Outpatient Prospective Payment System (HOPPS), which sets the reimbursement schedule for hospital outpatient offices. There is an open period for comment once the proposed rule is announced in July. The final rule is issued in November and generally goes into effect in January.

Many of the pricing recommendations issued by CMS come from the Relative Value Scale Update Committee, or RUC. The American Medical Association (AMA) founded the RUC in 1991 to act as an expert panel in developing relative value recommendations to CMS on certain codes in the Current Procedural Terminology (CPT) book. As the frontiers of medicine advance, new or revised CPT codes are introduced to the RUC by the AMA’s CPT committee—on which the American College of Cardiology (ACC) has a seat, and with whom ASE works closely. Meeting three times a year, the RUC panel makes recommendations on values assigned to new and revised CPT codes and conducts a rolling five-year review to examine CPT codes that appear potentially incorrectly valued. The RUC recommendations are used, often with little modification, by CMS in its annual updates to the Medicare relative value scale.

There are many other organizations within HHS—and thus, reporting to the President through the Cabinet—which shape healthcare policy. Some of the more important ones are the Food and Drug Administration (FDA), National Institutes of Health (NIH), Public Health Service, and the Agency for Healthcare Research and Quality (AHRQ).

Today we have explored the legislative and regulatory maze which our ASE Advocacy staff and volunteers must negotiate successfully. Our annual ASE Advocacy budget of $350,000 is small when compared with the ACC. We share our subspecialty expertise and collaborate closely with ACC at the federal level to achieve our primary goal—promoting excellence in the practice of cardiovascular ultrasound. And, very importantly, we have an effective team advocating for echo, including our Advocacy committee Chair Dr. David Wiener; our legislative counsel, Diane Millman; our coding expert, Judy Rosenbloom; our Health Policy Manager, Irene Butler; and our CMS consultant, Denise Garris.

Next month, this President’s Page will focus on new CMS proposed rules expected in July—including ones which will affect reimbursement for echocardiograms performed in hospital-based outpatient offices.

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Jun 1, 2018 | Posted by in CARDIOLOGY | Comments Off on The “Alphabet Soup” of Federal Healthcare Agencies

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