the economics of breast imaging - sbi-online.org imaging symposium 2016... · the economics of...

The Economics of Breast Imaging

Dana H. Smetherman, MD, MPH, FACR Section Head, Breast Imaging

Vice Chair, Department of Radiology Ochsner Health System

• U.S. health care spending is increasing and is higher than in other countries.

• Patients are experiencing greater challenges paying for medical services and “financial toxicity” (out-of-pocket expenses that poison quality of life & become an adverse effect of treatment)

• There are new financial realities for patients under the Affordable Care Act • Transition to value-based payments for health care services is rapidly

approaching & includes expectations of quality, cost-effectiveness, and improved outcomes

• To continue to save lives and improve the quality of life of our patients, our business model must be sustainable

Background

Why is breast imaging economics important to radiologists?

Health Care Spending as a Percentage of GDP

02468

1012141618

1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

US(17.1%)FR (11.6%)

SWE(11.5%)GER(11.2%)NETH(11.1%)SWIZ(11.1%)

Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers.

Source: OECD Health Data 2015.

* 2012.

Health Care Spending as a Percentage of GDP

Health Care Spending Per Capita 2013

Total health care spending

per capitae

Current health care spending per capita, by source of financinge,f

Public

Private

Out-of-pocket Other Australia $4,115a $2,614a $771a $480a

Canada $4,569 $3,074 $623 $654

Denmark $4,847 $3,841 $625 $88

France $4,361 $3,247 $277 $600

Germany $4,920 $3,677 $649 $492

Japan $3,713 $2,965a $503a $124a

Netherlands $5,131d $4,495 $270 $366

New Zealand $3,855 $2,656 $420 $251

Norway $6,170 $4,981 $855 $26

Sweden $5,153 $4,126 $726 $53

Switzerland $6,325d $4,178 $1,630 $454

United Kingdom $3,364 $2,802 $321 $240

United Statese $9,086 $4,197 $1,074 $3,442

OECD median $3,661 $2,598 $625 $181 a 2012. b 2002–2009. c 2009–2012.

d Current spending only; excludes spending on capital formation of health care providers. e Adjusted for differences in the cost of living.

f Numbers may not sum to total health care spending per capita due to excluding capital formation of health care providers, and some uncategorized spending.

Source: OECD Health Data 2015.

• Per American Cancer Society: – Growth of U.S. health economy threatens the overall economy

and the security of the country – In 2009, U.S. health care costs = $2.53 trillion (nearly 2.5 x

amount spent on food) – Health outcomes of the U.S. health care system are not

uniformly excellent despite the potential to give the best care in the world

– Significant disparities in health outcomes by race and socioeconomic level exist & may be growing as health care becomes more expensive

The Cost of Health Care

Brawley OW. The American Cancer Society and the American Health Care System. The Oncologist. 2011;16(7):920-925.

Cancer = 7% of Disease Based Health Expenditures in U.S.

Ill-defined conditions,

$247

Circulatory, $243

Musculoskeletal, $188

Respiratory, $158

Endocrine, $138 Nervous system, $133

Cancers, $124

Injury, $118

Genitourinary, $113

Digestive, $107

Mental Illness, $80

Infectious diseases, $67 Dermatological, $44

Pregnancy, birth, $39 Other, $93

Source: Bureau of Economic Analysis Health Care Satellite Account (Blended Account) and National Health Expenditure Data. Last updated January 25, 2016.

Total expenditures in US $ billions by disease category, 2012

Source: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health status: Health status indicators", OECD Health Statistics (database). doi: 10.1787/data-00540-en (Accessed on January 22,

2016). Note: Comparable countries are defined as those with above median GDP and above median GDP per capita in at least one of the past ten years.

Age-adjusted neoplasm mortality rate per 100,000 population, in years, 2010

Cancer Mortality Rates in U.S. Lower than Similar Countries

188 191

196 203 206

210 212 212 215 216

224 231

247

0 50 100 150 200 250 300

SwitzerlandJapan

SwedenUnited States

AustraliaAustria

Comparable Country AverageGermany

CanadaFrance

BelgiumUnited Kingdom

Netherlands

US Cancer & Other Mortality Rates vs. Comparable Country Average

34

40

48

60

82

203

265

23

29

29

43

63

212

243

0 50 100 150 200 250 300

Endocrine, nutritional and metabolic…

Mental and behavioral disorders

Diseases of the nervous system

External causes of mortality

Diseases of the respiratory system

Cancers and tumors (Neoplasms)

Diseases of the circulatory system

Comparable Country Average United States

Source: Kaiser Family Foundation analysis of 2013 OECD data: "OECD Health Data: Health status: Health status indicators", OECD Health Statistics (database). doi: 10.1787/data-00540-en (Accessed on January 22,

2016). Note: Comparable countries are defined as those with above median GDP and above median GDP per capita in at least one of the past ten years.

Age-adjusted major causes of mortality per 100,000 population, in years, 2010

• Lancet Oncology (2014) - Rising costs in cancer care due to:

– 1. Rising # of cancer cases in aging population - increased and longer survival, higher expectations of patients, and rising costs of therapy. Similar worldwide.

– 2. Use of imaging - 1996 to 2006, cost of cancer imaging increased by 5.1-10.3% every year (mostly attributed to PET)

– 3. Cost of drugs - Increased by 10x in 10 years with no relation to whether drugs are targeted or to their effectiveness

Kelly, R. J., & Smith, T. J. (2014). Delivering maximum clinical benefit at an affordable price: Engaging stakeholders in cancer

care. Lancet Oncology, 15(3), e112-8.

Rising Cost of Cancer Care

• From 1982 – 2010, approximate cancer deaths averted in the US (compared to Western Europe): – Breast - 67,000 – Colon - 265,000 – Prostate – 60,000 – For lung cancer, roughly 1,120,000 excess deaths occurred in the US.

• Ratio of incremental cost to QALY saved: – Colon + $110,009 – Breast + $402,369 – Prostate + $1,978,542 – Lung - $18,815

Soneji, S., & Yang, J. (2015). New analysis reexamines the value of cancer care in the united states compared to western europe. Health Affairs, 34(3), 390-397.

doi:http://dx.doi.org/10.1377/hlthaff.2014.0174

Rising Cost of Cancer Care

How do we get paid for what we do?

• Medicare – Publicly available fee schedule

• Medicaid – Typically lower rates – Opaque rules – Usually operates at loss (if accept patients)

• Commercial Insurance – Coverage typically mimics Medicare (but not always) – Rates often a percentage of Medicare depending on negotiations – Networks of providers

• “Self pay/no pay”

How do we get paid for what we do?

• Current Procedural Terminology Codes – Developed in 1966 – Owned by the AMA – About 8000 5-digit codes – Radiology codes are mostly

70000 series

15

What are Current Procedural Terminology (CPT) Codes?

• Category I o Contemporary medical practices that are widely performed o Approved by the FDA o Clinical efficacy is proven and documented o Literature support

• Category II o Tracking codes o For performance measurement

• Category III o Temporary codes for new and emerging technologies o If not converted to Category 1 after 5 years – “unspecified code”

16

What are CPT Codes?

How are CPT Codes developed?

WSJ 10/26/10

• CPT Editorial Panel – Proposes new/revised CPT codes – Codes introduced by medical specialty societies, individual physicians,

hospitals, third-party payers and other interested parties (including vendors & the public)

– Meets 3 times a year – Open to public

• Relative Value Scale Update Committee (RUC) – Assigns RVU to codes – Meets 3 times per year – Not open to the public

CPT Editorial Panel & Resource Based Value Scale Update Committee (RUC)

• RUC makes recommendation to CMS • Confidential until final determination published by

CMS in November • Fee schedule becomes effective following January • In past, CMS accepted >90% of RUC recommendations • Now see reductions in work and practice expense (e.g.,

tomosynthesis and breast biopsy codes) & changes in RVU’s

How are CPT Codes Valued?

How are Medicare payments calculated?

Payment =

(RVUWork + RVUPractice Expense + RVUProfessional Liability)

x CF x GPCI

• RVU (work) = Physician work • RVU (practice expense) = Overhead

expense (includes labor, equipment, & supplies)

• RVU (professional liability) = Risk adjusted for specialty & type of procedure

• CF = Monetary scaling factor (CY 2016 Conversion Factor of $35.8043)

• GPCI = Geographic Practice Cost Index, allows Medicare to adjust reimbursement rates to take into account regional and practice-specific factors

• Time and effort relative to a reference (PC) • Bundled stereo biopsy 3.29 RVU • I hour of critical care management 3.60 RVU • Single view, chest radiograph 0.18 RVU

• Survey process to develop physician work value

How are CPT Codes Valued? (Physician Work)

• Resources needed to perform the service • Supplies and labor

– Feet of table paper, cc of gel, etc. – Staff type

• Price of equipment • Amount of time equipment /room is used

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How are CPT Codes Valued? (Practice Expense)

• CPT codes: – Film Screen Mammography – Add on codes for CAD – Breast Ultrasound – Breast Biopsy – Breast MRI

• G codes for FFDM (temporary, created at any time, outside of CPT process, no public comment, valued by CMS)

• CPT + G Codes for DBT

Current CPT & G Codes for Breast Imaging

• Created in the Benefits Improvement and Protection Act (BIPA) of 2000

• PC unchanged from analog codes • TC:

– G0202 (Screening Mammo, Digital) and G0204 (Diagnostic Mammo, Digital, Bilateral) – 150% of bilateral diagnostic analog mammogram

– G0206 (Diagnostic Mammo, Digital, Unilateral) - Same payment as unilateral diagnostic analog mammogram, “G” code used for tracking only

FFDM G Codes

Current State of Reimbursement - Mammography & CAD

CPT Code Description RVU (PC)

77055 MMG 1 breast (film) 0.7

77056 MMG both breasts (film) 0.87

77057 MMG screening (film) 0.7

G0202 Screening MMG (digital) 0.7

G0204 Diag MMG bilat (digital) 0.87

G0206 Diag MMG unilat (digital) 0.7

77051 CAD (diagnostic MMG) (with CPT 77055, 77056, G0204, G0206).

0.06

77052 CAD (screening MMG) (with CPT 77057 or G0202).

0.06

• In 2014, CPT Editorial Panel created & RUC approved 3 new codes: 77061, 77062, and 77063

• CMS recommended only 77063 (add on with screening mmg code)

• Instead of 77061 & 77062, CMS created new add-on G code (G0279) for DBT with diagnostic digital mmg.

• G0279 (vs. 77061 & 77062) – RVU lower than RUC recommendation – 77061 and 77062 not assigned RVU value by CMS

Current State of Reimbursement - Digital Breast Tomosynthesis (DBT)

Current State of Reimbursement - Digital Breast Tomosynthesis (DBT)


77063 Screening DBT 0.6

G0279 Diagnostic DBT 0.6

• Code 76645 (Ultrasound breast, unilateral or bilateral) was identified by CMS’s Relativity Assessment Workgroup (RAW) screen (potentially mis-valued codes)

• 2 new codes requested to describe complete & limited breast ultrasound and approved for use in 2015.

Current State of Reimbursement - Breast Ultrasound

Current State of Reimbursement - Breast Ultrasound


76641 Ultrasound Breast Complete 0.73

76642 Ultrasound Breast Limited 0.68

Current State of Reimbursement - Breast Needle Biopsy


19081 Bx Breast (with placement of breast localization device when performed, & imaging of biopsy specimen, when performed; 1st lesion, including stereotactic guidance

3.29

+19082 …each add’l. lesion (including stereotactic guidance 1.65

19083 Bx Breast…including ultrasound guidance 3.10

+19084 …each add’l. lesion (including ultrasound guidance) 1.55

19085 Bx Breast…including MRI guidance 3.64

+19086 …each add’l. lesion (including MRI guidance) 1.82

Current State of Reimbursement - Breast MRI


77059 MRI, Breast, without and/or with contrast; bilateral

1.63

0159T CAD Breast MRI (Cat III code)

0.00

• National Correct Coding Initiative (NCCI) Edits – Post stereotactic biopsy mammogram (ACR successfully fought) – Cannot bill 10035-10036 (soft tissue marker codes for axillary

lymph nodes) with 19082-86 (breast biopsy codes) & 19282-88 (bundled breast biopsy codes) for marker placement in breast lesions. Can bypass with -59 modifier for axillary node marker placed as 2nd procedure same day as breast biopsy.

• CMS FAQs – 2013 DBT guidance (before DBT CPT codes created)

Other Issues Related to CPT Codes & Billing

• Many feel the current method of assigning values and payment for medical services through the CPT & RUC process is responsible for high cost of health care (at least in part)

• http://www.replacetheruc.org (among others) • What are the alternatives?

Current State of Reimbursement - Fee for Service

http://www.replacetheruc.org/

Current Reimbursement Challenges in Breast Imaging

• Price transparency • Patient responsibility • Conversion of Mammography CPT & G codes • Effects of ACA, MACRA, & APM’s • Bundling Pressure

Current Reimbursement Challenges in Breast Imaging

• Steven Brill, 2/20/13

• Charge master – Extremely high

prices – “Devoid of any

calculation related to cost”

– “Fiction”

Current Reimbursement Challenges Price Transparency

• What is the charge master? – Comprehensive list of items billable to a hospital patient or

a patient’s health insurance provider – Usually highly inflated – Typically starting point for negotiations with patients and

health insurance providers over what amount will be paid to the hospital

– Hospitals do not want to “leave anything on the table”


Current Reimbursement Challenges Patient Responsibility

• When new CPT and G codes for DBT were announced, Medicare continued to pay separate payment rates for digital and film mammography

• CMS had proposed retiring G codes for digital mammography

• Put that proposal on hold pending review of the entire mammography code family in 2015

Current CPT & G Codes for Breast Imaging

• The Patient Protection & Affordable Care Act (PPACA) aims to expand access to health care & lower cost barriers to care (per CMS website)

• Requires Medicare and commercial health insurance plans to cover routine preventive services graded “A” or “B” by the USPSTF at no cost to consumer – Only biennial screening mammograms age 50-74 have “B” rating – Some insurance plans will not cover recall mammograms from screening or

diagnostic mammograms at no additional cost to patients.

Current Reimbursement Challenges Affordable Care Act

• The Protecting Access to Lifesaving Screening (PALS) ACT was included in the Omnibus Spending Bill

• Bipartisan PALS Act protects women’s access to mammograms

• Puts 2 year hiatus on USPSTF 2015 recommendations for breast cancer screening

Current Reimbursement Challenges Affordable Care Act

• 30% of Medicare dollars paid through alternate payment models by 2016

• 50% of payments paid through such models by 2018

Current Reimbursement Challenges Alternate Payment Models (APM’s)

• Medicare Sustainable Growth Rate (SGR) enacted by Balanced Budget Act of 1997 intended to control Medicare costs (but was delayed repeatedly)

• SGR repealed by Medicare Access & CHIP Reauthorization Act (MACRA) in 2015 – stabilizes MD payments under Medicare

• Incorporates payment reforms that will accelerate value based reimbursement

• Establishes value based payments starting in 2019: – Merit-Based Incentive Payment System (MIPS) – Alternate Payment Models (APMs)

Current Reimbursement Challenges MACRA

http://www.ama-assn.org/ama/pub/advocacy/topics/medicare-physician-payment-reform.page


• APM: – Annual reimbursement bonus payment in exchange for generating

revenue through qualified risk-sharing payment models (ACO, Patient Centered Medical Home, Bundled Payment Models)

• MIPS: – Combines & replaces PQRS, Value-based Payment Modifier, and

Medicare HER incentive program – Provides payment adjustment to fee-for-service based on composite

score of: Quality, Resource Use, Clinical Improvement, Meaningful use of EHR


Current Reimbursement Challenges Alternate Payment Models (APM’s)

• What would APM’s in breast cancer look like? – Breast cancer screening for a panel of patients or group of covered lives? – High risk patients? – Different patient population demographics and geography? – Different payers? – Patients who seek care and services at different, unrelated facilities? – Bundle breast cancer screening with all screening and wellness? – If bundled payment for episode of care (like hip replacements), how far would

the bundle go? • Screening and recall • Until breast cancer diagnosis for an individual • From diagnosis to treatment

• Component Coding provided granularity in past • Allows:

– More accurate description of complex services – Many different procedures to be described with a small code set – Data about exactly what services were performed – 2 different physicians or different guidance modalities

• Bundling mandated for services performed together most of the time – perception of duplication of work (e.g.., most radiology biopsy/interventional codes)

• Example – Percutaneous Breast Needle Biopsy Codes

Current Reimbursement Challenges Bundled Coding

Component Coding – Vacuum Assisted Breast Biopsy

Code Descriptor Value

19103 Biopsy of breast; percutaneous, automated vacuum assisted or

rotating biopsy device, using imaging guidance

3.69

76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration,

injection, localization device), imaging supervision and interpretation

0.67

Clip placement Image guided placement, metallic localization clip, percutaneous, during

breast biopsy/aspiration 0.00

Total 4.36

19083 Biopsy, breast, with placement of breast

localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the

biopsy specimen, when performed, percutaneous; first lesion, including

ultrasound guidance 3.10 RVU (29% decrease)

• Payment policies are rapidly evolving with considerable uncertainty.

• Reimbursement will continue to be challenging for breast imaging in the foreseeable future.

• U.S. government involvement in health care in general and breast imaging in particular is likely to continue and even expand.

• In order to continue to transition from volume to value based reimbursement, we must be mindful of both quality and cost.

Conclusion

the economics of breast imaging - sbi-online.org imaging symposium 2016... · the economics of...

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