The ALACC BCBS Committee had the opportunity to sit down for a two hour dialogue with several representatives of BCBS on September the 26th. The discussion was cordial, educational, and candid. The goal from the standpoint of the committee is to foster a relationship with BCBS over time that will allow the ALACC to have input in some of the policies that will be implemented in the future. There will be value based incentive programs for cardiologists in the future and we want to be able to have a role in shaping those programs. It is not legal for us to specifically discuss fees per se and thus the focus of the discussions has to be in the areas of adding value to patient care, controlling health care costs so that BCBS can continue with a stable business model that allows for fair reimbursement to health care providers, and formulating new reimbursement methods that reward sustained quality care and overall excellence in the practice of medicine. It has always been my belief that if BCBS knows and trusts our leadership that they will be less likely to leave us out of any discussions where our input would be useful. I realize the recent cuts in myocardial perfusion imaging were nothing short of draconian and stated as much in those exact words. It was quickly pointed out however that the BCBS fee schedule is still quite favorable as compared to the vast majority of private payors throughout the country – a fact that cannot be denied. Please find the following brief summary of the major topics that were discussed:
Myocardial SPECT imaging reimbursement – the history of this was discussed at length during our meeting. The original concept of bundling all three components was based on a nationwide trend that BCBS followed. The original reimbursement was based on adding the three individual amounts of payment together. BCBS looked at this and realized that their reimbursement amount was substantially higher than the rest of the country for this CPT code. The reimbursement was just over 450% of Medicare reimbursement and the stated goal of BCBS is to be at roughly 200% of Medicare for most of their reimbursement amounts over time. It was felt that to decrease the reimbursement by this amount would be too drastic and thus the current amount of approximately 300% of Medicare was set. It would seem that over time imaging may be in for more changes in reimbursement based on this concept. Clearly, there has been an increase in cardiac nuclear imaging over the past few years but the ALACC contingent pointed out that the numbers in cardiology practices have been relatively stable and we believe that a significant amount of the proliferation is due to the use of non-accredited mobile labs operated by non-cardiologists. We continue to urge BCBS to consider more rigorous standards for reimbursement to cardiac imaging labs with the stated belief that this will limit the number of poor quality studies that often do not meet the ACC’s Appropriate Use Criteria (AUC) for performance of the test. Various concepts were discussed with the largest barrier being recognized as the difficulty in implementing this concept and the desire of BCBS to avoid limiting the scope of practice of a physician based on their given area of expertise. One obvious area that we suggested be explored is the requirement of accreditation of the imaging facility, since obtaining accreditation demonstrates a commitment to quality, safety, and reliability; this alone may significantly limit the mobile lab proliferation. I am concerned that over time BCBS may require more onerous precertification of nuclear testing with radiology benefits managers (such as CareCore) which would unnecessarily delay appropriate testing of our patients. I am hopeful that a proactive stance encouraging both point of care use of the AUC and reimbursement of only accredited nuclear labs will allow BCBS to avoid further sharp cuts in reimbursement for the appropriate imaging of our patients in the future.
Coronary CTA Restrictions – it was pointed out that coronary CTA has a higher sensitivity for the detection of coronary artery disease as compared to myocardial SPECT imaging yet BCBS makes it much more difficult to utilize this study when indicated. Personal experience of ALACC members has shown that smoking and the diagnosis of diabetes often results in denials for coronary CTA imaging due to the patient being classified “high risk where catheterization should the evaluation of choice” even in cases where clearly an invasive procedure was not in the patient’s best clinical interest. The BCBS members in attendance pointed out that BCBS’s direct instructions to CareCore were “to follow ACC criteria for approving or denying the study” and there may be a problem with the implementation of this concept. BCBS will review this issue and address it. A second issue is the coverage of coronary calcium scoring. BCBS has determined that this procedure should not be covered when used as a general screening tool. However, many CCT users will perform a calcium score prior to administering IV iodinated contrast in order to determine if patients have a very high calcium score which may limit the diagnostic value of a contrast enhanced CT angiogram, and elect (properly) to not perform the CTA on those patients. BCBS has not covered the calcium score on these patients but is open to further discussion since this calcium score procedure requires definite work for the provider plus actually saves BCBS money as compared to paying for a CTA which may yield nondiagnostic results. The Chapter will continue to follow up with BCBS on this issue.
CRNP Reimbursement – BCBS agreed with the value of our CCA membership and recognizes the important role they play in the care of our patients. BCBS pays for these services but points out that numerous companies self-insure and may choose to exclude payment to physician extenders. This is the choice of the individual company and this issue should be addressed to those specific companies. One of the larger examples of this is PEEHIP which covers the active and retired education employees in our state.
Chantix – one of our council members asked that we address insurance coverage for this medication. BCBS recognizes the benefit of this medication and covers it. However, many companies that contract with BCBS for their health insurance subcontract with other non-BCBS drug plans which do not cover this medication. This is the choice again of the individual company and is not the decision of BCBS.
Quality Incentives – it was brought to my attention that BCBS is already offering a 5% incentive to primary care providers for using services such as electronic billing, maintenance of board certification, providing call coverage, and documentation of generic drug utilization. BCBS has been upfront in their desire to find methods to more adequately compensate primary care providers who are struggling in today’s difficult environment. It is the stated hope of BCBS that this might lead to a decline in some of the alternative ways many primary care providers have utilized to supplement their income. These incentives are not available to any providers outside of primary care at this time but BCBS assured us that it will extend this opportunity to the subspecialists in the future. The continued open line of communication between BCBS and the ALACC will be critical to insure that the incentives chosen are ones we as a specialty society agree are reasonable, add value to our practice, and promote the delivery of quality care to our patients.
BCBS has been, and is very likely to remain, the dominant provider in our state. They will continue to feel the dual pressure of declining enrollment and the upcoming mandates set forth by the Affordable Care Act. We believe this affords a unique opportunity for mutually beneficial interaction between BCBS and our Chapter. We are pleased that they are willing to work with us, and other physician groups, to try and improve the quality of care while at the same time keeping rising costs under control. Our goals and objectives should be in harmony. Physicians must continue to be appropriately compensated for the difficult and challenging work that we do and for the years of preparation and sacrifice required to become the health professionals that we are.
Phillip L. Laney MD FACC
President, Alabama Chapter of the American College of Cardiology