Thomas A. Bensinger, MD
Hematology-Oncology Consultants, Greenbelt, MD
Councillor for Clinical Practice, ASH Executive Committee
Editor’s Note: Dr. Thomas Bensinger is a long-standing member of the Society and currently serves as the Councillor for Clinical Practice on the ASH Executive Committee. He has operated an independent, freestanding practice in community hematology-oncology for 27 years in Greenbelt, MD, and has a deep interest in patients with hematologic disorders.
Community-based private hematology practices are a valuable resource for the care and treatment of many patients with hematologic problems. Unfortunately, hematologists have recently seen a rapid increase in what had been a slow erosion of the incentives to enter and remain in such practices. Costs are higher; reimbursements are lower. Medicare is the greatest, albeit not the only, culprit. Examples of the “wounds” being inflicted on the practice community include:
- Medicare has eliminated “consult” CPT codes 99241-99245 and substituted “new patient encounter” codes 99201-99205; of course, the new codes are paid at a lesser rate. I feel like Medicare has changed the name of what is demanded of me in my job solely to pay less for the same service.
- Hematologists are trained to review the peripheral blood film under a microscope. Among other things, the following are identified: sickle cells, target cells, schistocytes, stomatocytes, eliptocytes, microcytosis, megaloblastic changes, and platelet clumping. Patients being treated for thrombotic thrombocytopenic purpura (TTP) require multiple blood film reviews for schistocytes. Yet, there is a long-standing Medicare policy not to pay for any peripheral blood film review in an outpatient setting and to only pay for one review in an inpatient hospitalization.
- Medicare recalculates the cost of office-administered medications every three months but only adjusts for increased costs every six months. The payments are not retroactive to the time of the increase, leaving the physician responsible for the increased cost. The Patient Protection and Affordable Care Act (PPACA) that was enacted last year directed Medicare to develop Accountable Care Organizations (ACOs). The ACOs would mete out payments. This could put the hematologist in direct competition for any payment with hospitals and other physicians or agencies involved with a patient’s care.
- The Food and Drug Administration (FDA) has also contributed to increasing unreimbursed costs in private practice. The FDA requires pre-approval every 28 days for some medications frequently prescribed by hematologists (e.g., thalidomide and lenalidomide). Pre-approval is a time-consuming process for offices that requires working with the patient on paperwork and follow-up surveys. While this generates important information for the manufacturer, I also think the manufacturer should pay for the office time rather than the physician. Private insurers also require extensive, unreimbursed paperwork and telephone-tag time. For example, I have never understood the gall of an insurance company to require pre-approval for something they are going to approve but not require that they have someone available by phone or fax to actually grant approval in a timely fashion.
- Pre-approval for procedures such as CT scans, MRIs, and PET scans is required by many private insurers. Usually the ordering physician is required to get the authorization for the doctor who will perform the study and be reimbursed for it. Medicare does not require pre-approval for these studies, but if the patient’s secondary insurance requires pre-certification, that is the rule that has to be followed. This means referring doctors must spend unreimbursed time to thoroughly investigate each patient’s secondary coverage requirements by company and by individual policy or run the risk of the radiologist not getting paid anything more than 80 percent of Medicare’s allowable rate. In every other instance that I am aware of, Medicare rules take precedence over secondary insurer rules. For example, when Medicare allows $100 for a drug or a procedure, but the secondary insurer allows more, the Medicare allowable is primary. In short: Medicare rules take precedence when it saves the secondary insurer money, and secondary rules take precedence when it saves the secondary insurer money.
Reimbursements by Medicare for the care of patients have been eroding for the last five years. Since many other carriers use Medicare as a reference point for their reimbursements, the amount paid to physicians has increased very little, if at all. At the same time, part of a significant increase in overhead is the increased demand by insurance carriers for non-reimbursable services. Where is the incentive for a young physician whose primary interest is the community-based care of patients to choose hematology?
Hematologists individually, and ASH as our representative, need to rigorously educate both Medicare and the private insurance sector that a valuable resource for care and treatment of many patients with hematologic problems is being severely compromised.
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