2019 HSC Section 2 - Practice Management

QUALITY REPORT JACOBS ET AL VALUATION OF PHYSICIAN WORK

Ann Thorac Surg 2017;103:373 – 80

the 1980s, it was becoming apparent that the ever- increasing cost of health care in the United States of America could threaten the very solvency of Medicare and, as such, would not be sustainable into the next century. Responding to this explosive increase in health care spending and unchecked resource utilization, the federal government began to consider redesigning health care in the United States of America by establishing a system of “ relative value ” for all the work that different physicians do, regardless of whether it was interpreting an electrocardiogram, counseling a distraught teenager, or performing a coronary artery bypass operation. If done appropriately, all health care delivery would have rela- tivity, and ultimate fairness would be achieved while providing a method of accounting for both the health care that is delivered as well as the associated costs of this health care. In 1989, with the support of the HCFA, the Harvard School of Public Health published the landmark report by Hsiao and colleagues [1, 2] . This initiative represented the initial attempt by the federal government to assign “ relative value units ” to all physician work performed. As health care spending continued to spiral out of control, attempts were made to reverse this trend in a dramatic way: CMS created the annual Physician Fee Schedule, taking into account all of the RVUs generated and sub- mitted by physicians to CMS, but limiting overall pay- ment, such that a preset dollar amount, established by Congress each year, could not, by law, be exceeded. The fact that many of the relative values were inaccu- rate and were not applicable to standard clinical practice soon became evident. Nevertheless, the concept of assigning RVUs was considered the standard by which all physician reimbursement would be based. The AMA formed the RUC to provide a reliable interface between practicing physicians and CMS to address the valuation of codes. In this forum, all relative values would be adjudicated by a panel of representatives of more than 20 medical specialty societies, and this assignment of value would have to be accomplished in an environment of federally imposed budget neutrality. The decisions of the RUC, however, are only recommendations to CMS, which retains the fi nal authority to assign RVUs to each physi- cian service. The RUC consists of representatives of the AMA and representatives of the national medical specialty societies. The AMA anticipated the effects of the transition of Medicare to a physician payment system based on a RBRVS and formulated the RUC, a multispecialty com- mittee. The RUC was established to provide recommen- dations to CMS about the relative value of work as CMS annually updated its Medicare RBRVS and the Physician Fee Schedule. The RUC has 31 seats, with 21 of these seats representing many of the largest national medical and surgical subspecialties. The STS has a permanent seat on the RUC. Four of the seats rotate on a 2-year schedule, with 2 reserved for internal medicine, 1 for primary care, and 1 for any other specialty. The remaining seats are occupied by the RUC Chair, the Health Care

physician reimbursement claims, tracking procedures for research, utilization analyses, and many other purposes. AMA continues to acknowledge the importance of maintaining an updated, relevant CPT coding system [3] . Systematic reviews of existing codes, deletion of obsolete codes, and creation of new codes re fl ective of innovation and changes in medical practice are on going. The CPT codebook undergoes annual updates. The 2016 CPT codebook included 350 code changes, of which 140 were new codes, 134 were revised, and 93 were deleted [3] . CPT is maintained by the CPT Editorial Panel. This 17- member panel is authorized to revise, update, and modify CPT. Eleven of the seats on the Editorial Panel are nominated by the national medical specialty societies and approved by the AMA Board of Trustees. The remaining seats are nominated by the Blue Cross and Blue Shield Association, America ’ s Health Insurance Plans, CMS, and the American Hospital Association. Included within the AMA-nominated seats is a representative with experi- ence in performance measures. The second key participant in the “ CPT process ” is the CPT Advisory Committee, which includes representatives of constituent societies from the AMA House of Dele- gates. Participation in the CPT Advisory Committee is the mechanism through which The Society of Thoracic Sur- geons (STS) and the American Association for Thoracic Surgery (AATS) are represented. The STS and AATS both have an advisor and alternate advisor on the CPT Advi- sory Committee. The Advisory Committee assists the Editorial Panel with the creation of code set changes; commenting on coding proposals submitted by other specialty societies, insurance carriers, and industry; participation in Work Groups; writing of CPT Assistant articles; and answering coding questions; among other things. The full CPT Panel has three 3-day meetings each year to achieve these goals. The description of CPT from the Web site ( https://www. ama-assn.org/about-us/current-procedural-terminology-cpt- editorial-panel ) is very useful: “ The Current Procedural Terminology (CPT) Editorial Panel is tasked with ensuring that CPT codes remain up to date and re fl ect the latest medical care in new and emerging technologies provided to patients. In order to do this, the Panel maintains an open process and con- venes meetings 3 times per year to address applications to revise the CPT code set, such as adding or deleting a code or modifying existing nomenclature, soliciting the direct input of practicing physicians, medical device manufacturers, developers of the latest diag- nostic tests, and advisors from over 100 societies repre- senting physicians and other quali fi ed health care professionals. The group has the fi nal authority to decide on assigning a code ’ s category, whether it is a Category I or Category III. ” RVUs and the RUC HCFA, later to be known as CMS, was charged with administration and oversight of Medicare. However, by

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