DENVER—As the future model of healthcare reform is not yet set in stone, those working in nuclear cardiology must first get a grip on how to modify the current system to charge less per service rather than compromising care with less volume, William A. Van Decker, MD, professor of Medicine at Temple University School of Medicine in Philadelphia, said during a presentation Sept. 9 at this year’s American Society of Nuclear Cardiology (ASNC) scientific sessions.

First things first
Those working in the trenches to figure out how nuclear cardiology will be affected by healthcare reform and possible cuts will need to get a grip on five things:

• Changes in the practice environment: These include changes from the Relative Value Update Committee (RUC) and moving outpatient services to the hospital;
  
• The Budget Control Act of 2011 (debt reduction);
• Pilot Projects of Utilization Management, which will affect imaging in the future;
• How the Patient Protection & Affordable Care Act (PPACA) affects nuclear cardiology today in 2010-2011; and
• How PPACA will affect the future (2012-2015).

How to curb heightened costs
“Costs are rising, especially for the government, due to the fact that the Medicare population is booming and we are supplying more services,” Van Decker offered. “We can’t print money so the only thing we can do is provide less service or charge less per service.” However, Van Decker added that this will be difficult to accomplish, particularly in the current fee-for-service model.

What becomes most problematic, is the fact that hospital fees for outpatient procedures differ from inpatient procedural fees, making testing more expensive on the outpatient side. This has shifted testing to the inpatient side, forcing physicians to become employed by hospitals.

While Van Decker said that the reimbursement cuts to cardiac imaging were “dramatic,” he said they had to do with the process of reviewing Relative Value Units (RVU), rather than healthcare reform. In fact, Van Decker noted that cardiologists lacked involvement in the process, which may have led to the large number of cuts.

“This year’s hit will be hospital-based rather than office-based,” Van Decker predicted. He added that “there has been a massive move to transfer cardiology procedures from the office to the hospital.” While currently nearly 40 percent of physicians are employed by hospitals, Van Decker said that it remains uncertain whether this strategy will curb costs and what the long-term result will be.

As far as the Medicare pilot project for utilization management goes, agencies and cardiologists will need to focus on ensuring that imaging studies are being used appropriately.

PPACA includes various mechanisms including: healthcare exchanges, which cause pressure for third party payors; e-prescribing, which has become a hassle for many who have hardship implementing the program; Physician Quality Reporting System (PQRS), which asks physicians to report quality measures; and integrating EMRs to meet meaningful use criteria. While Van Decker said these are all notable goals, so far hospitals have had a hard time meeting them. The issue will only get worse when the government starts to decentivize hospitals who do not meet these criterion.

In 2012-2015, the focus will move toward risk-sharing models, however, it is not yet known what these models will look like, Van Decker offered. The same holds true for accountable care organizations (ACOs). “We don’t know what this structure will look like," he said.

The main concern for nuclear cardiology will be to understand “how we get some form of capitation out of this," Van Decker offered. “For nuclear medicine this will center on bundling episodes of care, population-based risk and comparative effectiveness research.

“Will wide open contracting models of capitation work?” asked Van Decker. “How will imaging centers stay informed and make informed business model discussions while still protecting care? The question is not whether cardiovascular care will need to be delivered but how, at what cost and under whose direction?”