Centers For Medicare And Medicaid Services Research Articles

Utilization of Interventional Techniques in Managing Chronic Pain in the Medicare Population: Analysis of Growth Patterns from 2000 to 2011

Background: Reports from the United States Government Accountability Office (GAO), the Institute of Medicine (IOM), the Medicare Payment Advisory Commission (MedPAC), and the Office of Inspector General (OIG) continue to express significant concern with the overall fiscal sustainability of Medicare and the exponential increase in costs for chronic pain management. Study Design: The study is an analysis of the growth of interventional techniques in managing chronic pain in Medicare beneficiaries from 2000 to 2011. Objective: To evaluate the use of all interventional techniques in chronic pain management. Methods: The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master Data from 2000 to 2011. Results: Interventional techniques for chronic pain have increased dramatically from 2000 to 2011. Overall, the increase of interventional pain management (IPM) procedures from 2000 to 2011 went up 228%, with 177% per 100,000 Medicare beneficiaries. The increases were highest for facet joint interventions and sacroiliac joint blocks with a total increase of 386% and 310% per 100,000 Medicare beneficiaries, followed by 168% and 127% for epidural and adhesiolysis procedures, 150% and 111% for other types of nerve blocks and finally, 28% and 8% increases for percutaneous disc procedures. The geometric average of annual increases was 9.7% overall with 13.7% for facet joint interventions and sacroiliac joint blocks and 7.7% for epidural and adhesiolysis procedures. Limitations: The limitations of this study included a lack of inclusion of Medicare participants in Medicare Advantage plans, as well as potential documentation, coding, and billing errors. Conclusion: Interventional techniques increased significantly in Medicare beneficiaries from 2000 to 2011. Overall, there was an increase of 177% in the utilization of IPM services per 100,000 Medicare beneficiaries, with an annual geometric average increase of 9.7%. The study also showed an exponential increase in facet joint interventions and sacroiliac joint blocks. Key words: Interventional techniques, interventional pain management, facet joint injections, epidural steroid injections, sacroiliac joint injections, chronic pain, chronic spinal pain

Saga of Payment Systems of Ambulatory Surgery Centers for Interventional Techniques: An Update

The health care system in the United States has been criticized for skyrocketing expenditures and quality deficits. Simultaneously, health care providers and systems are under pressure to provide better and more proficient care. The landscape of the US health care system is shaped by federal and private payers which continue to develop initiatives designed to curtail costs. These include value-based reimbursement programs; cost-shifting expenses to the consumer and reducing reimbursement of providers and facilities. Moreover, there is an underlying thought to steer provision of health care to theoretically more efficient settings. Many of these initiatives are based on affordable health care reform. The major aspects of curtailing health care costs include hospital and other facility payments as well as physician payments and reductions in the approved services. Consequently, ambulatory surgery centers (ASCs) are not immune to these changes. Until 1970, all surgery was performed in hospitals The development of ASCs and site of service differential payments for in-office procedures have changed the dynamics of surgical trends with outpatient surgeries outpacing inpatient surgeries by as early as 1989. By 2008, approximately 65% of procedures were performed in all outpatient settings including hospital outpatient departments. ASCs claim that improved efficiency in health care delivery allows patients to spend less time in the health care setting with quicker turn over, improving the productivity of the health care team. However, since the majority of the ASCs are owned, in part, by the physicians who staff them, the financial incentives related to ownership have been alleged to potentially alter provider behavior. The number of Medicare certified ASCs and total Medicare payments from 1999 to 2010 increased significantly, but more recent year-to-year changes are far less substantial when compared to previous years. Net percent revenue growth from 2008 to 2009 was 3.2% and from 2009 to 2010 was 6.2% with an overall increase from 1999 of 183% over a period of 11 years. Similarly, the number of Medicare certified ASCs increased from 2,786 in 1999 to 5,316 in 2010, 1.1% increased from 2009 to 2010, however, a 91% increase from 1999 over a period of 11 years. Interventional pain management is one of the fastest growing specialties with a footprint in multiple disciplines. Interventional pain management in ASC settings has come a long way since June 1998 proposed Health Care Financing Administration’s ASC rule which seriously compromised interventional pain management in the ASC setting. There are many payment challenges facing interventional pain management (IPM) in 2012. Significant changes continue to occur in the payment systems with policies of paying a certain percent of hospital outpatient department payments to ASCs which declined from 63% in 2008 to 56% in 2011, with substantial reductions for add-on codes. The Centers for Medicare and Medicaid Services (CMS) evaluation of IPM codes also consists of multiple misvalued codes. In conclusion, overall the future of ASCs may appear optimistic, but in the near perspective, specifically in 2012 to 2014, there will be challenging times specifically for interventional pain management centers with the regulatory environment and rapid changes taking place with or without implementation of Affordable Care Act. Key words: Outpatient prospective payment system, ambulatory surgery center payment system, Government Accountability Office, Medicare Modernization and Improvement Act, interventional techniques

Physician Payment Outlook for 2012: Déjà Vu

Physician spending is complex related to national health care spending, government regulations, health care reform, private insurers, physician practice, and patient utilization patterns. In determining payment rates for each service on the fee schedule, the Centers for Medicare and Medicaid Services (CMS) considers the amount of work required to provide a service, expenses related to maintaining a practice, and liability insurance costs. The value of 3 types of resources are adjusted on a yearly basis of the combined total multiplied by a standard dollar amount, called the fee schedules conversion factor, which was $33.98 in 2011, to arrive at the payment amount. This factor will stay almost the same ($34.03) unless a 27.4% cut in the sustainable growth rate (SGR) takes place or CMS enacts further reductions. With a 27.4% cut, the conversion factor will be $24.67 in 2012 after the first 2 months if Congress fails to act. Since the inception of Medicare programs in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. The SGR was enacted in 1997 to determine physician payment updates under Medicare Part B with intent to reduce Medicare physician payment updates to offset the growth and utilization of physician services that exceed gross domestic product (GDP) growth. This is achieved by setting an overall target amount of spending for physicians’ services and adjusting payment rates annually to reflect differences between actual spending and the spending target. Since 2002, the SGR has annually recommended reductions in Medicare reimbursements. Payments were cut in 2002 by 4.8%. Since then, Congress has intervened on 13 separate occasions to prevent additional cuts from being imposed. The Medicare physician payment rule of 2012, which is still undergoing revisions -- but considered as the final rule-- is a 1,235 page document, released in November 2011. In this manuscript, we will describe important aspects of the 2012 physician fee schedule which include potentially disvalued services under the physician fee schedule, expansion of the multiple procedure payment reduction (MPPR) policy, establishment of the valuebased payment modifier, changes to direct practice expenses (PEs), electronic prescribing, the Physician Quality Reporting System (PQRS), and lab testing signatures, along with their implications. Additionally, the impact of multiple changes on interventional pain management will be described. In conclusion, interventional pain management is facing widespread challenges in the U.S. health care system. A historic reform, which has been passed by Congress and signed into law, whose survivability is not quite known yet, is affecting medicine drastically in the United States. Interventional pain management, like other evolving specialties, will probably most likely suffer under the new affordable health care law and regulatory burden. Key words: Health policy, physician payment policy, physician fee schedule, Medicare, sustained growth rate formula, interventional pain management, regulatory reform

Performance Measurement at a “Tipping Point”

The Centers for Medicare and MedicaidServices (CMS), along with key stakeholders such as theJoint Commission, the American Medical Association,the Physician Consortium for Performance Improvement(PCPI), and many medical societies such as the AmericanSociety of Anesthesiologists (ASA), are developing per-formance measures for hospitals and physicians.

Explosive growth of facet joint interventions in the medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data

BackgroundThe Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006.The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing spinal pain.MethodsThis analysis was performed to determine trends of frequency and cost of facet jointInterventions in managing spinal pain, utilizing the annual 5% national sample of the Centers forMedicare and Medicaid Services (CMS) for 1997, 2002, and 2006.Outcome measures included overall characteristics of Medicare beneficiaries receiving facet joint interventions, utilization of facet joint interventions by place of service, by specialty, reimbursement characteristics, and other variables.ResultsFrom 1997 to 2006, the number of patients receiving facet joint interventions per 100,000Medicare population increased 386%, facet joint visits increased 446%, and facet joint interventions increased 543%. The increases were higher in patients aged less than 65 years compared to those 65 or older with patients increasing 504% vs. 355%, visits increasing 587% vs. 404%, and services increasing 683% vs. 498%.Total expenditures for facet joint interventions in the Medicare population increased from over $229 million in 2002 to over $511 million in 2006, with an overall increase of 123%. In 2006, there was a 26.8-fold difference in utilization of facet joint intervention services in Florida compared to the state with the lowest utilization - Hawaii.There was an annual increase of 277.3% in the utilization of facet joint interventions by general physicians, whereas a 99.5% annual increase was seen for nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) from 2002 to 2006. Further, in Florida, 47% of facet joint interventions were performed by general physicians.ConclusionsThe reported explosive growth of facet joint interventions in managing spinal pain in certain regions and by certain specialties may result in increased regulations and scrutiny with reduced access.

CaRESS at 4 Years:Will Cumulative Data Support Changes in Policy?

This is what we have been waiting for...those of us who believe that carotid artery stenting (CAS) and carotid endarterectomy (CEA) are equivalent methods of treating carotid bifurcation disease based on personal and institutional experiences have anticipated reporting of longer-term data from larger prospective trials to substantiate our evolving biases. CaRESS (Carotid Revascularization Using Endarterectomy or Stenting Systems) was designed to focus on ‘‘non-high-risk’’ individuals who are routinely encountered in daily practice and to provide comparative CAS and CEA outcomes unique to this patient subset. The current CaRESS results add to a short list of prospective trials with midand longterm (2–4 years) data. The overall 4-year results of the CaRESS trial are most impressive. Equipoise is seen between CAS and CEA procedures in terms of individual [stroke, death, myocardial infarction (MI)] and composite endpoints. While the development of recurrent stenosis and the need for repeat angiography and/or carotid reintervention were more frequent after CAS than CEA, the proportions of patients affected by these events were small (5%–15%) and were not associated with increased adverse events. The relatively low incidence of necessary secondary intervention after CAS (6% at 4 years) can be contrasted with reintervention/ failure rates after percutaneous coronary interventions (30% at 2 years), infrainguinal endovascular procedures (20%–40% at 2 years), or endovascular repair of abdominal aortic aneurysm (20% at 5 years). In addition to early procedural safety, CaRESS data show CAS (like CEA) to be a durable treatment technique as well. The lack of outcome differences seen between various CaRESS patient subsets is of lesser importance in this article. The overall cohort size was relatively small (n5397), and post-hoc analyses are potentially underpowered to reveal true endpoint differences between smaller subsets of patients separated by gender, extremes of age, presenting symptom status, stenosis severity, or combinations of the latter two [CMS (Centers for Medicare and Medicaid Services) risk stratification]. Such information may be reliably extracted only from larger trials or carefully performed meta-analyses. The ‘‘bottom line’’ is that CAS does not appear inferior to CEA in any specific CaRESS patient subgroup. Where do we go from here? By including a majority of ‘‘non-high-risk’’ patients, CaRESS demonstrated no appreciable differences in stroke, death, MI, or composite endpoints between CAS and CEA patients with highor non-high-risk factors. As most large prospective trials have focused on high-risk patients, CMS reimbursement (based on demonstrated procedural safety) has accordingly been ex-

Using NDNQI data to manage CAUTI

ospital-acquired catheter-associated uri-nary tract infections (CAUTIs) are clas-sified as a never event by the Centersfor Medicare and Medicaid Services(CMS) and are no longer reimbursed.Never events can cause serious injuryor death to patients and result in increasedcosts from additional days in the hospital,nursing care, medical treatments, and devices.Therefore, the new rule puts forth an incentivefor hospitals to eliminate or reduce neverevents in order to avoid costs for which therewill be no reimbursement. To prepare for thisresponsibility, nurse managers must knowmore about the prevalence of never events,improve nursing assessment tools and preven-tion strategies, and identify best practices foreffective and efficient treatment of theseevents. By implementing effective practices ina sustainable manner and monitoring theimpact of those interventions, nurse managerscan reduce avoidable, nonreimbursed costs totheir facilities.The National Database of Nursing QualityIndicators (NDNQI) began collecting data onCAUTI rates for ICUs in the fourth quarter of2007. Using these data, nurse managers cancompare the CAUTI rates for their units withpeer units in similar facilities and examinetrends in their rates over time.Defining CAUTICAUTIs may be the least regarded never eventbecause they’re viewed as a minor infectioncausing less morbidity and mortality than cen-tral line-associated bloodstream infections, forexample.

Section 7: Heart Failure in Patients With Left Ventricular Systolic Dysfunction

Section 7: Heart Failure in Patients With Left Ventricular Systolic Dysfunction

Update on rural health activities: the home health perspective.

Author’s note: Medicare is undergoing many changes as a new administration seeks to understand and address the program’s complexities. In fact, renaming the Health Care Financing Administration (HCFA) to the Centers for Medicare and Medicaid Services (CMMS) is a change that should make the organization more understandable and customer-oriented for both providers and beneficiaries. This article highlights some of the changes affecting home health agencies across the country.