There were more than a few impassioned comments from the neurologists who packed the special “Hot Topics in Education” program of the AAN annual meeting in March, aptly titled “Neurology in Crisis.” The one-hour allotted session spilled into two, as neurologists lined up with question after question: What could neurologists do in response to new codes restricting reimbursement for electromyography (EMG)/nerve conduction studies? Could they move toward adoption of quality measures and still maintain physician autonomy? What would they need to do to survive — and thrive — in this changing landscape of neurology practice?
Practice management experts Neil Busis, MD, Jonathan Hosey, MD, and Pushpa Narayanaswami, MD, led the panel discussion, offering insight into what the future holds for the specialty and practice.
Before the session, Neurology Today Associate Editor Orly Avitzur, MD — a neurologist in private practice in Tarrytown, NY, who holds academic appointments at Yale University School of Medicine and New York Medical College and chairs the AAN Medical Economics and Management Committee — sat down with Dr. Busis, chief of neurology and director of community neurology at University of Pittsburgh Medical Center — to discuss some of the highlights of the presentation. Dr. Busis serves on the editorial board of Neurology Today. Edited excerpts from the video interview appear here. To watch the video, go to http://bit.ly/aNQ4KB.
ORLY AVITZUR (OA): WHAT IS THE MOST IMPORTANT THING THAT IS HAPPENING IN NEUROLOGY PRACTICE?
NEIL BUSIS (NB): I think that the most important thing is that fee-for-service is going to go away. Instead of being rewarded and reimbursed for the volume of procedures and services, it's going to be based on quality. So, volume is replaced by value, and value-based purchasing is determined by the ratio of quality over cost. That's going to be the major change that we will focus on in the next couple of years.
OA: HOW WILL THAT IMPACT US AS PRACTICING NEUROLOGISTS?
NB: Basically, everything we think that we're measured on is going to change. Instead of just counting up the number of nerves that you submit or the number of patients that you see, you're going to have a whole new number of ways that your performance and, therefore, your reimbursement is measured. It's going to be measured based on quality, process, and also patient outcomes.
OA: THE ELECTROMYOGRAPHY/NERVE CONDUCTION CODES TOOK US BY SURPRISE. WHAT CAN WE DO TO ANTICIPATE AND RESPOND TO CHANGES IN THE FUTURE?
NB: As Louis Pasteur said, “Chance favors the prepared mind.” What we're doing in the Academy now is trying to anticipate further changes. We're getting ready by educating ourselves and others, gathering data, and advocating for our position with the regulatory agencies, insurance companies, and Congress.
We would like our own [AAN] quality measures to be used to measure our performance. We would like them to be integrated into billing systems and EHRs [electronic health records]; we would like them to be continuously updated with the latest information. We would like the insurers to follow our guidelines because we think that we're the experts in neurological care.
OA: PHYSICIANS ARE NOW PAID BASED ON THE RVU SYSTEM. DESCRIBE TO US WHAT AN RVU IS. WHAT EXACTLY WENT WRONG WITH OUR VALUES FOR EMG?
NB: In the old days, before the RVU [relative value unit] system, physicians were paid based on something called “Usual and Customary” [fees]. Everybody made up their own costs and that became their fee schedule.
In the latter part of the 20th century, they said, “We have to rationalize the fee schedule.” A fellow at Harvard came up with the relative value system; he said, “If you take something like an appendectomy, you should be able to make relative work values based on that one fee for every other one of the 7000 procedures that are in the CPT (current procedural terminology) book.” All of the medical services and procedures were put on a continuum that became the relative value system. That was set up over 20 years ago.
Since then, new codes come up and need to be valued. The RUC [Relative Value Scale Update Committee] takes these new codes and has a variety of methods to value them. They are then sent to CMS [Centers for Medicare and Medicaid Services], which usually, but not always, accepts RUC recommendations and publishes a Medicare Fee Schedule. Congress then takes a conversion factor (which is a little less than 35 dollars this year) — so 35 dollars times the RVU equals the physician reimbursement.
There are several agendas here; one of them is to cut costs. CMS may say to CPT and to RUC, “We think there are some problem codes — they are overused or not utilized well, or a code is bundled with another code — and they have to be reconsidered.” That's exactly what happened with these nerve conduction codes.
We wrote a number of our own proposals for these reimbursements that we presented to the CPT panel, and all of them were rejected. The CPT panel, under the direction of CMS, wrote the new nerve conduction codes that exist right now for 2013. They lumped together a bunch of different kinds of procedures that we usually billed separately. CMS, much to our surprise, took the values and did not accept them. CMS actually lowered [the values] even further.
OA: WHAT CAN NEUROLOGISTS DO TO RESPOND TO THESE PRACTICE CHANGES? WHAT SHOULD THEY NEVER DO?
NB: In general, what neurologists should be doing is managing their practices wisely. You need data, you need income, you need expenses, you need a spreadsheet — you need a business approach to your business.
You also don't want to leave money on the table. There are a number of incentive programs for EHRs, e-prescribing, quality reporting, etc., and if you don't do those, you will leave money on the table. In fact, in a few years, you will be penalized [for not participating].
In terms of nerve conductions specifically, clearly there are going to be some people who want to take shortcuts or game the system, but that is both wrong and not good for our patients. For example, some people may say, “I'll just use the old codes.” It turns out that's illegal. If a code is deleted from the current CPT book, even if you have a contract with the insurer that pays you so much for these codes, those codes are gone. You have to use the new codes.
The second thing is that these codes are now bundled. Some people may say, “I'll have the patient come back several days in a row and I'll split the study up — I'll do the upper limbs one day and I'll do the lower limbs the next day and I'll do the EMG the third day.” But a lot of our patients have trouble with mobility or live a distance from us, and that's just not good for the patient.
The third thing you should not do is inflate the number of studies that you do in order to reach your previous level of reimbursement. EMG and nerve conduction studies are painful, so that's also not right for your patient.
You might also start billing evaluation management services (E&M) — consult visits, office visits, and follow-up visits — with EMGs. That is perfectly reasonable, but only when it's indicated. If you spend one second with a patient, it wouldn't be right to bill an evaluation and management service with that patient. On the other hand, if you took a history, did a physical, and did the appropriate medical decision-making to fit the documentation requirements for an E&M code; then, by all means, bill for that with the EMG.
The last thing you should not do is abruptly abandon your patients because you don't like their insurance plan. That really is wrong on many levels — both morally and legally. What you can do is review all your insurance plans and see which ones are reimbursing fairly; then decide if you should drop some.
The final point is that no one can advocate for neurology like a neurologist. We would ask people to participate in all the AAN advocacy efforts, to give to the BrainPAC; if you are given a survey for new codes that come up, participate in that; if you have questions, ask us. Give us feedback so that we can work cooperatively to optimize neurology practice in the future.
OA: I'VE HEARD THAT THE RUC SURVEYS GENERALLY GET A VERY LACKLUSTER RESPONSE FROM OUR OWN MEMBERS, WHICH IS MIND-BOGGLING BECAUSE IT WAS BASED ON A RUC SURVEY THAT THE EMG/NERVE CONDUCTION CODES WERE VALUED LESS.
NB: That's exactly right. We sent out about 1200 surveys, and we got 125 respondents. So, all of the data that went to the RUC was based on 125 individuals out of 20,000 AAN members. People say these RUC surveys are very complicated, and they don't have the time. I would say, “You don't have the time not to do them because this is your future.”
OA: WHAT ELSE IS THE ACADEMY DOING TO ADVOCATE FOR OUR SPECIALTY AND WHAT CAN MEMBERS DO TO HELP?
NB: First of all, in terms of the nerve conduction issue, we have advocated and continue to advocate with CMS — through person-to-person meetings; hiring a lobbyist; having people on the ground in Washington who work for us, who go to the regulatory agencies; writing letters; trying to get on to a refinement panel, which is basically an appeals court. The [refinement panel] won't work for 2013, but may get some of these changes appealed for 2014. We had 42 members of Congress write a letter to the head of Health and Human Services protesting the cuts. We have enlisted the help of patient support groups. We are trying to gather data to show that these are important and effective tests.
Ultimately, if you put yourself in CMS' shoes, their customer is the beneficiary, not the doctor. The key to the advocacy efforts with CMS is to say, “Look, you want your beneficiaries to get the best neurologic care they can get, and that probably should come from a neurologist.” That's what we need to convince them.
On a broader sphere, what the AAN hopes to do is to set the standards for neurological care in this country. We want to go to CMS and say, “We are your resource for neurological care. So when decisions come up in the future that affect coverage reimbursement policies, we want a seat at the table. We don't want to find about [new changes] in the Medicare Fee schedule, which comes out in November and takes effect two months later.”
CMS has already made cognitive care a priority and we have to get on the list of cognitive care specialties, which we're working on at both the regulatory and legislative level. At the same time, we still have to try to protect procedures as best we can because they still reimburse better than cognitive care.
Lastly, to repeat, our members have to be engaged and have to advocate. It can't be a one way street; the AAN and the members have to collaborate together — otherwise we won't succeed.
HOW TO ADVOCATE FOR YOUR PRACTICE
How can you advocate on behalf of neurology and your practice? Pushpa Narayanaswami, MD, a member of the AAN Government Relations Committee and assistant professor of neurology at Beth Israel Deaconess Medical Center, provided an overview of the ways neurologists can get involved at the “Hot Topics” session.
- Track upcoming legislative and regulatory changes.
- Educate policy makers on why upcoming or existing legislation hurts patients. “We must engage in proactive versus reactive advocacy because ’if you're not at the table, then you're on the menu.’”
- Become active in your own state medical society, join your state neurological society, or even start your own state neurological society.
- Join the AAN's Grassroots Alliance: aan.com/go/advocacy/active/alliance.
- Organize a “Take Your Legislator to Work Day” or visit local offices of legislators and Senate.
- Testify at hearings.
- Write an op-ed for a newspaper.
- Collect data.
- Respond to Vocus alerts: aan.com/news/?event=read&article_id=8899.
- Complete surveys from RUC.
- Participate in the AAN's Palatucci Advocacy Leadership Forum: aan.com/go/advocacy/active/palf.
- Participate in Neurology on the Hill: aan.com/go/advocacy/active/noh.
- Contribute to the AAN's BrainPAC: aan.com/go/advocacy/brainpac.
TUNE IN: Neurology in crisis: What should neurologists do to mitigate changes in practice? Watch the full video interview between Neurology Today Associate Editor Orly Avitzur, MD, a neurologist in private practice in Tarrytown, NY, chair of the AAN Medical Economics and Management Committee, and Neil Busis, MD, chief of neurology and director of community neurology at University of Pittsburgh Medical Center Shadyside, on the current and predicted changes to neurology practice and what you can do to prepare: http://bit.ly/aNQ4KB.