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Congress Proposes SGR Fix That Starts Move Away From Fee for Service

By Jim Knaub

The latest draft proposal to eliminate Medicare’s sustainable growth rate (SGR) “fix” would freeze physician reimbursement for 10 years but add the possibility of additional payments beginning in 2017. Those additional payments would be tied to value-based criteria currently being studied in various Medicare physician quality programs. The objective is to transition away from the current fee-for-service system that rewards procedure volume. The discussion draft was released October 31 and has support from both the Senate Finance and House Ways and Means committees.

“The framework would repeal the SGR and instead hold doctors’ pay at current levels as alternative payment models are developed and tested,” wrote Mary Agnes Carey for Kaiser Health News. “It would combine some existing Medicare physician quality programs into a new initiative starting in 2017 that would offer doctors additional pay based on their performance on value-based criteria, such as making more same-day appointments for urgent needs and enhancing their use of electronic medical records.”

The comment period for the draft language ended November 12, so further details should come soon. Unless Congress acts, Medicare reimbursement would drop approximately 25% on January 1, 2014, because of the existing SGR formula. Congress has passed annual patch fixes to avoid the formula-driven cuts since the SGR’s inception in 2007.

The draft also includes language that would “require ordering physicians to consult appropriateness criteria for advanced imaging services provided to Medicare patients,” according to a release from the ACR. If enacted as drafted, the change would deny Medicare payment for the exam if the ordering physician didn’t consult appropriateness criteria and also would require prior authorization for providers whose ordering patterns are inconsistent with those of their peers.

The ACR did not comment on the reimbursement portion of the draft but supports the use of appropriateness criteria, presumably hoping they would reflect the appropriate criteria developed by the ACR.

“Use of appropriateness criteria in the ordering of exams can educate providers regarding which scan is best for the patient’s given condition and even when no exam is warranted at all,” said ACR spokesperson Paul H. Ellenbogen, MD, FACR, chair of the ACR’s board of chancellors, via press release. “This can help ensure that every patient who needs imaging care gets the right exam at the right time for the right indication and avoids care that they may not need. This is what modern imaging care is all about. We look forward to working with Congress to help move this process forward.”

Jim Knaub is editor of Radiology Today.