1. 2010 Medicare Physician Fee Schedule What It Means for Cardiology

2. American College of Cardiology Audio Conference November 12, 2009

3. Agenda 1.Welcome 2.Review of 2010 Final Rule 3.Impact on cardiology practice 4.ACC action plans 5.Call to action 6.Q&A

4. Medicare Fee Schedule Final Rule Overall cardiology impact Phase-in of PPIS Bundled codes for SPECT Elimination of consultation payments Changes to Malpractice RVUs PQRI and E-prescribing SGR

5. Overall Cardiology Impact CMS projection: 8% cut in 2010, 13% cut by 2013, excluding any conversion factor cuts. CMS projections measure change in aggregate payments to cardiology; provide little insight into impact at the practice level. Office based imaging and diagnostic tests will be hit hardest, but no area of cardiology is unharmed.

6. Impact for Selected Cardiology Services 200920102013 33208Pacemaker insertion $532$554$511 78452SPECT$594$379 92980Insert intracoronary stent $848$818$745 93306TTE with Doppler$268$238$173 99214Est. patient office visit $92$98$102

7. How does an 8% cut break down?

8. Impact of Policy Changes on a Single Code 93308 – limited echo – payment $114.33 in 2009, $103.51 in 2010 $2.52 loss from practice expense methodology changes $3.61 loss from PPIS implementation $4.69 loss from malpractice RVU changes

9. PPIS and Practice Expense RVUs CMS finalized proposal to use AMA PPIS survey to calculate practice expense RVUs Due to pressure from cardiology community, change will be phased in over four years ACC will continue efforts to ensure CMS uses valid data for cardiology

10. Bundled Codes for SPECT New bundled codes for SPECT myocardial perfusion studies take effect January 1 Work and practice expense RVUs were reduced as a result of the bundling. PPIS adds another cut. CMS did not apply the phase-in because these are “new codes.” The result – a 36% cut in 2010. ACC made an urgent request to CMS for a correction to phase in the change.

11. Consultation Codes CMS finalized its proposal to eliminate payment for inpatient and outpatient consultation codes in 2010. Consultation services to Medicare patients must be reported with office and hospital visit codes. Key implementation details remain unclear. ACC will continue to oppose this change, along with other specialties.

12. Malpractice RVUs Final Rule implements –Updated malpractice premium data to calculate malpractice RVUs –New resource based formula for malpractice RVUs for technical component services Impact for cardiology –Small increases for some EP services –Cuts for imaging procedures

13. PQRI Most cardiology-related measures will be reported through registries, not claims in 2010. New measures groups may make it easier for cardiologists to qualify for PQRI bonuses. ACC will offer PQRI tools for 2010.

14. E-Prescribing Physicians can qualify for 2% bonus payment for e-prescribing in 2010 New requirement: report on 25 e- prescribing encounters using qualified e- prescribing system Visit www.acc.org/hit for e-prescribing resources

15. SGR As required by current law, the final rule includes a 21.2% reduction in Medicare Physician Payment as of Jan. 1, 2010. This cut is in addition to the payment reductions that result from the proposed policy changes described above. As in previous years, Congress is expected to pass a one to two year fix this fall.

16. Impact on Cardiology Practices Three-quarters of CV practices plan to reduce staff (42%), eliminate services (33%), limit office hours (14%) or refuse to accept Medicare (13%) Solo practitioners and small practices will be hit hardest. However, medium and large practices also plan to reduce the number of Medicare patients or stop accepting Medicare payment (13% of practices overall, 17% of private practices) 28% of active, practicing cardiologists say a practice merge is on the horizon, with 30% of private practices planning to migrate within next two years Hospital integration will cause an increase in overall Part B costs, higher patient co-pays and ultimately, higher Medicare beneficiary premiums. Online survey of 543 domestic ACC members between Oct. 31 and Nov. 11. Of the sample, 409 respondents are active practicing cardiologists and 253 respondents are physicians in private practice.

17. ACC Regulatory Action Plans ACC has already requested a correction to phase-in payment cut for nuclear codes effective in 2010. ACC will challenge interim work RVUs for nuclear codes. Changes would not occur until 2011. We will explore options for changes to practice expense methodology for 2011 and beyond.

18. ACC Action Plans – Legislative and Legal ACC continues to educate Congress about cuts and impact on patients and community based practices. ACC is working with Congressional champions on legislative initiatives to reduce the damage. ACC is exploring options for possible legal action.

19. ACC Tools and Resources Practice Survival Kit (Coming Soon!) Practice impact calculator Options for Medicare participation December 8 audio conference on consultations and coding changes PQRI and e-prescribing tools PINNACLE Network™ (pinnacle@acc.org) www.acc.org/practicemanagement www.pinnaclenetwork.org

20. Member Call to Action Use the practice impact calculator to estimate the impact on your practice (www.acc.org/practicemanagement) Contact your Members of Congress to ask for their help (www.acc.org/can). Don’t forget to provide specific examples of reduced access, cuts in services and job losses Educate your patients (www.guardingheartsalliance.org) Recruit your colleagues to join the cause. PAC contributions are needed to deliver our message to lawmakers and their constituents (www.accpacweb.org) Questions? E-mail advocacy@acc.org or call 800-435- 9203.

21. Questions