American College of Cardiology

Liability Reform Faces Uphill Battle, Frist Says
Passage of liability reform in the Senate this year may be impossible without support from Senate Democrats, Majority Leader Bill Frist, R-Tenn., said last week at an American Hospital Association meeting. While a reform bill strongly supported by physicians has already been passed by the House, negotiations over the companion bill in the Senate came to a halt in March. The ACC understands, however, that discussions about a compromise are continuing among a few key Senate Democrats who support caps on noneconomic damages, including Sen. Blanche Lincoln, D-Ark. The ACC and other physician specialty societies are meeting with those and other key Senate lawmakers and continue to press for action this year.

Proposed CMS Drug Price-Practice Expense Tradeoff Could Hurt Cardiology
CMS Administrator Tom Scully stated last week that he would act administratively to correct a perceived reimbursement imbalance for clinical oncologists. Cardiology fees could be significantly affected as a result. Scully said that a change could be made to the 2004 Physician Medicare fee schedule that would involve cutting the price of chemotherapy drugs in exchange for increasing practice expense payments to clinical oncologists for administering these drugs. The result could be reductions in practice expense reimbursement for other specialists. Nuclear cardiology and echocardiography would stand to see the most significant reductions in cardiology fees. The ACC, American Society of Nuclear Cardiology, and American Society of Echocardiography are working to develop policy proposals aimed at preventing cardiology from being unduly affected by any administrative changes in the fee schedule.

Guidance on Reimbursement for Drug-Eluting Stents
Now that the FDA has approved the first drug-eluting stent, the use of the device is expected to quickly grow. The CMS took the unprecedented step last year of announcing that it was establishing a DRG for drug-eluting stents, even though at that time a device was not yet approved. According to the American College of Cardiology Administrators, physicians will continue to bill for stent placement using codes 92980 and 92981. Hospitals will bill for inpatient cases under DRGs 526 and 527. In addition, outpatient hospital procedures involving drug-eluting stents will need to be coded to APC 0656 with G-Codes G0290 and G0291. Other APCs will also apply depending upon what is done in addition to the stent procedure. Coverage by non-Medicare payers will vary by locale, with a number of payers already indicating that they will cover drug-eluting stents. In the outpatient setting, coverage will be effective on July 1. An effective date for coverage in the in-patient setting has yet to be announced.

Final Regs on Rx Industry Marketing Activities Include Important Changes on CME
The final voluntary compliance guidelines for pharmaceutical companies issued by the HHS Office of Inspector General last week cautioned against marketing activities geared toward physicians that might cause the companies to run afoul of federal fraud and abuse laws.

The final guidelines also include some important changes from the draft guidelines related to CME that were specifically requested by the ACC and other physician organizations. The draft guidelines identified educational and policy conferences sponsored by third-party medical societies and funded by pharmaceutical manufacturers as "suspect" and areas of "risk" that could trigger a violation of anti-kickback laws. The final guidance clarifies the issue, noting that “grants or support for educational activities sponsored and organized by professional medical organizations raise little risk of fraud or abuse.” Situations that greatly increase that risk, the OIG explained, include funding for programs conditioned in whole or in part on the purchase of a product or manufacturer control over educational program content or faculty.

Large Insurers Dominate Health Insurance Market
A study released last week found that the five largest health insurers control 75 percent or more of the market in 19 states and more than 90 percent of the market in seven states. The study, conducted by the National Center for Policy Analysis, found heavy concentration in the health insurance markets in all 34 states that supplied information. For example, the largest insurer in the state controls 89 percent of the market in Alabama and North Dakota. The five largest insurers control more than half the market in 31 states, and two-thirds or more of the market in 25 states. Nationwide, the four largest insurers dominate 65 percent of the HMO small-group market.

Patients File Lawsuit Against Tenet Alleging Heart Procedures Performed Unnecessarily
More than 80 patients have filed a lawsuit against Tenet Healthcare Corp. alleging that two physicians at Redding Medical Center performed unnecessary cardiac interventions and bypass surgeries. The lawsuit is the latest event in the ongoing fallout around two cardiologists who used to work at Redding who have been accused of defrauding Medicare and are under investigation by the FBI. In the complaint, according to Health Care Daily Report, the plaintiffs allege that the hospital and its parent corporation engaged in fraud and deceit, breach of fiduciary duty, and intentional infliction of emotional distress

Medicare Reform, Minus Reimbursement Fixes, Top Congress’ Short-Term Agenda
The next eight weeks offer a “narrow window” for Congress to act on reform of the Medicare system, including a prescription drug benefit. Speaking at the American Hospital Association conference, Senate Majority Leader Bill Frist, R-Tenn., said his goal is to have a Medicare reform bill for formal consideration on the Senate floor before the July 4 congressional recess, Health News Daily reported. However, Sen. Frist cautioned providers against trying to get provisions related to improved reimbursement included in any Medicare reform legislation. Meanwhile, with predictions that the 2004 Medicare physician fee schedule may include a reduction, CMS Administrator Tom Scully last week failed to offer support to prevent the cut. “I was the number one believer last year that the payments needed to be fixed,” he said. “Now I’d say I’m on a wait-and-see approach.”

Medicare Falls Short on Coverage of Preventive Services, Report Concludes
Medicare must begin to cover proven strategies that prevent disease and should be given broader authority to make coverage decisions for preventive care, argues a report released last week by the Partnership for Prevention. The report urges Medicare to follow the recommendations of the U.S. Preventive Services Task Force (USPSTF), an expert advisory panel convened by the Department of Health and Human Services. According to the report, Medicare covers some preventive services that do not have enough evidence of effectiveness to warrant USPSTF recommendation, such as prostate cancer screening, even while it does not cover other services that are recommended, such as cholesterol screening.