Rep. Mark Larson. VTD/Josh Larkin
A proposed reduction in Medicaid reimbursements has rattled Vermont radiologists.
Last year, the Department of Vermont Health Access trimmed reimbursement for services by 25 percent. For 2012, the department proposed another 21 percent.
The state sets rates every year using rates from Medicare as a baseline. This time, the proposed rates caused quite a stir.
When the Vermont Medical Society and radiologists caught wind of the proposed drop in funding, physicians fired off 27 separate comments on the proposed decline. In comments, doctors requested a public hearing and expressed concerns about due process. The announcement on Dec. 16 gave them only 8 working days to comment before the new rates took effect on Jan. 1.
“We were like, ‘wow,’” said Dr. Stephen Koller, secretary-treasurer for the Vermont Radiological Society. “This was a huge cut on top of a huge cut and this deserves a public forum before we quietly insert the knife.”
The Medicaid program is funded jointly by the federal government and states. The federal government pays states a specified percentage of program expenditures. States are responsible for the rest. In Vermont, the state pays for Medicaid through legislative appropriations. The state sets what providers will receive through what is called a Resource Based Relative Value System.
In response to comments from doctors, DVHA decided last week to change the drop in reimbursement from 21 percent to around 2 percent.
Mark Larson, the commissioner of DVHA, said the proposed change was designed to make reimbursements for radiologists comparable to those offered to other specialists. Historically, he said, radiologists received higher rates of reimbursement.
“Last year brought them more in line with the rest of the system,” Larson said. “Even then they were at a higher percentage of Medicare compared to other specialists.”
He said when the department modifies rates it must do so in order to fit within the Legislature’s appropriations. The process for setting rates is weighted, so if one rate goes up, another must go down. Hence, if the department decided radiologists would get paid at a higher rate, another service like respiratory and cardiovascular services could get paid at a lower rate. While radiologists saw a large percentage decrease, they would still get reimbursed at a higher rate than other specialists.
According to the department’s response to comments, DVHA reduced rates for radiologists in 2011 because in prior years they had received 104.2 percent of the baseline rates set by Medicare, while other specialists were receiving around 73 percent.
“With a limited budget, we felt it was necessary to align Medicaid radiology payments
more closely with other professional services as a percentage of Medicare,” the response states. “This year, we proposed a further reduction in an effort to further align radiology payments with other professional services paid in our RBRVS system.”
Because of budget restraints, the state is unable to pay for any services in the system at Medicare’s rates, the response states.
Radiologists reacted en masse to the proposal once the Vermont Medical Society directed their attention to DVHA’s Web site.
Realizing the new rates would have major implications for radiologists, Koller said the providers were quite concerned. With just a few working days before the rates would take effect, he said, his group elected to mobilize and get doctors to write in.
Koller said over the years the state has expanded Medicaid coverage without doing enough to figure out how to pay for more patients. He said radiologists in Vermont are reimbursed less compared to other states, and if the state wants to reimburse primary care doctors at a higher rate, it needs to bring their rates up, not decrease those for radiologists.
“If you are going to make the pie smaller and shift things around, there are going to be lots of unintended consequences, and they are not going to be good ones,” Koller said.
One of those unintended consequences, Koller said, would be an out-migration of radiologists and decreased access to medical care in Vermont.
If the state wants to save money, it should change utilization rates, he said. Primary doctors order images because they want to shield themselves from potential lawsuits if they neglect to request an MRI. Reforming medical malpractice laws could decrease the practice of “defensive medicine,” which drives up health care expenditures, Koller said.
Rep. James Eckhardt, R-Chittenden, echoes concerns that lower reimbursement rates will drive radiologists out of the state. Eckhardt sits on the House Committee on Health Care. He said he received numerous letters from doctors concerned about reimbursement. Decreased reimbursement rates could lead to a higher insurance cost shift, he said.
Eckhardt said his committee has received surprisingly little input from physicians.
“Here you’ve got the biggest group of people who are going to be affected by health care reform, and you’re not listening to them,” he said.
Larson says the rate-setting for Medicaid is related to health care reform in some ways.
“We are trying to move toward strategies based on value, not volume,” he said.
The state is trying to introduce a more rational approach to reimbursement, Larson said, as it moves toward implementation of a single payer plan. A next step will be one reimbursement rate for services, so whether a patient is covered by private insurance or Medicaid, he will pay the same for an office visit, for example. This consistency will help eliminate the cost shift toward private insurance, he said.
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As a family doctor, I agree with Dr Koller that malpractice reform will help cut back on some unneeded medical tests.Most physicians would agree that medicine is by no means an “exact” science. For example, if I order an x-ray, often the radiology report gives an excellent interpretation, but suggests a further more involved test like a CT or MRI scan. Such reports can increase numbers of unnecessary tests and costs. Hopefully, with malpractice reform, radiologists and family doctors will not order more, “just in case”.
As far as radiologists or any doctors leaving the state, the grass always seems greener on the other side. As I have mentioned to news media services before, surveys have shown that given the opportunity to work in Vermont under a single payer system that covers every Vermonter and emphasizes quality and not quantity of health care and tests, hundreds of doctors and medical students would flock to Vermont.
We all have to pay for health care in an equitable manner and doctors need to provide health care in an equitable manner. Look around the state into the eyes of your doctor(s) and I don’t think you’ll see too many docs leaving Vermont for those greener greenbacks.
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From the patient’s point of view: exactly which tests are unnecessary?
This argument about malpractice forcing unnecessary medical tests sounds more like a canard – I don’t want doctors taking wild or even educated guesses with me.
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I am a radiologist working in Rutland Vermont. The DVHA cuts were opposed by numerous groups including the Vermont Hospital Association and the Vermont Medical Society.
The State announced these proposed cuts over the holiday period allowing only 8 days for written commentary prior to the effective change.
The timing of these events lead many of us to conclude that the State does not have a genuine commitment to listening to physicians who can offer valuable input on how to contain costs while providing superior quality of care.
Many physicians cannot help but wonder if the course taken by the DVHA is predictive of the manner in which the Green Mountain Care Board will treat Vermont physicians and their patients.
Attached is a letter that went to Ms. Rader Wallack. To date, there has been no response from her office.
Respectfully submitted,
JC Biebuyck, MD
____________________________________________________
December 21, 2011
Dear Ms. Rader Wallack,
I write you on behalf of the Vermont Chapter of the American College of Radiology (“ACR”). Vermont Medical Society Executive Director Paul Harrington suggested that we communicate to you our frustration with the severe cuts to Vermont Medicaid reimbursement for diagnostic imaging procedures proposed by the Department of Vermont Health Access (“DVHA”). I also hope to follow up by speaking directly with you about this matter of vital importance to health care in Vermont , and about the important role that radiologists can play in containing health care costs while assuring that Vermonters receive appropriate, quality care.
DVHA cut Medicaid reimbursement for diagnostic imaging services by 25 percent in 2011 and has proposed to further cut it by an additional 21 percent in 2012. The proposed changes may have a significant impact on the ability of radiologists in the State to provide imaging care to its most vulnerable populations.
It is disingenuous of DVHA to announce these cuts two weeks before they are scheduled to take effect on January 1st and to request the submission of written comments during these two weeks that coincide with the end-of-year holidays. The timing of these events leads us to conclude that the State does not have a genuine commitment to working with its physicians or to funding care in a manner commensurate with the care given. Although we understand that you have a commitment to working with the State’s physicians, we cannot help but wonder if the course taken by the DVHA is predictive of the manner in which the Green Mountain Care Board will treat Vermont physicians.
Vermont ‘s radiologists want to work respectfully and collaboratively with the Green Mountain Care Board to effect substantive and real change for the better in Vermont health care. As imaging experts, we can be instrumental in developing cost-effective appropriate care and utilization management pathways for many clinical conditions and treatment modalities, including everything from breast cancer screening to cancer staging. In many instances around the State, radiologists have assumed leadership roles in their hospitals given their critical role in clinical decision-making and patient management and their central locations within hospitals.
Hospital-based radiologists are not in a position to generate referrals. We accept referrals from other physicians. Because of that role, we are in a unique position to curtail the execution of imaging procedures that are not clinically indicated, significantly reducing health care costs in the process.
We know that you are keenly interested in developing positive relationships with the State’s physicians. At the same time, your task to make health care affordable and accessible for all Vermonters while maintaining quality of care is daunting. Rather than slashing reimbursement for imaging services, health care costs are more appropriately reduced by containing inappropriate utilization by referring physicians. Radiologists are in the best position to do that, and the VT ACR wants to work with you to achieve that end.
I look forward to talking with you soon about this.
Respectfully submitted,
JC Biebuyck, MD
ACR Member
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All medical tests whether blood tests or radiological or cardiac are imperfect. Too often the test shows a “positive” result as if something is wrong with the person’s blood, bone or heart. However, in reality, these tests are imperfect, wrong and what we call “FALSE positives”. This situation usually leads to more testing and just plain old fishing for a disease state that isn’t present in the first place.
The most important steps in caring for an individual are listening to the patient’s history, examining the patient and discussing with the patient what the next step is after hearing both the upside and downside of future testing. You may be surprised at how many people know themselves and opt to hold off from further testing for maybe 2-4 weeks, hold off on an antibiotic for a viral illness, hold off on a MRI for muscular back pain. And yet when the patient’s history and exam make alert bells ring, I would hope all doctors proceed forward to appropriate testing that can uncover quickly what exactly is wrong.
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I am a radiologist working in Rutland Vermont. The DVHA cuts were opposed by numerous groups including the Vermont Hospital Association and the Vermont Medical Society.
The State announced these proposed cuts over the holiday period allowing only 8 days for written commentary prior to the effective change.
The timing of these events lead many of us to conclude that the State does not have a genuine commitment to listening to physicians who can offer valuable input on how to contain costs while not sacrificing quality of care.
Many physicians cannot help but wonder if the course taken by the DVHA is predictive of the manner in which the Green Mountain Care Board will treat Vermont physicians and their patients.
Attached is a letter that went to Ms. Rader Wallack. To date, there has been no response from her office.
Respectfully submitted,
JC Biebuyck, MD
_______________
Dec 21, 2011
Dear Ms. Rader Wallack,
I write you on behalf of the Vermont Chapter of the American College of Radiology (“ACR”). Vermont Medical Society Executive Director Paul Harrington suggested that we communicate to you our frustration with the severe cuts to Vermont Medicaid reimbursement for diagnostic imaging procedures proposed by the Department of Vermont Health Access (“DVHA”). I also hope to follow up by speaking directly with you about this matter of vital importance to health care in Vermont , and about the important role that radiologists can play in containing health care costs while assuring that Vermonters receive appropriate, quality care.
DVHA cut Medicaid reimbursement for diagnostic imaging services by 25 percent in 2011 and has proposed to further cut it by an additional 21 percent in 2012. The proposed changes may have a significant impact on the ability of radiologists in the State to provide imaging care to its most vulnerable populations.
It is disingenuous of DVHA to announce these cuts two weeks before they are scheduled to take effect on January 1st and to request the submission of written comments during these two weeks that coincide with the end-of-year holidays. The timing of these events leads us to conclude that the State does not have a genuine commitment to working with its physicians or to funding care in a manner commensurate with the care given. Although we understand that you have a commitment to working with the State’s physicians, we cannot help but wonder if the course taken by the DVHA is predictive of the manner in which the Green Mountain Care Board will treat Vermont physicians.
Vermont ‘s radiologists want to work respectfully and collaboratively with the Green Mountain Care Board to effect substantive and real change for the better in Vermont health care. As imaging experts, we can be instrumental in developing cost-effective appropriate care and utilization management pathways for many clinical conditions and treatment modalities, including everything from breast cancer screening to cancer staging. In many instances around the State, radiologists have assumed leadership roles in their hospitals given their critical role in clinical decision-making and patient management and their central locations within hospitals.
Hospital-based radiologists are not in a position to generate referrals. We accept referrals from other physicians. Because of that role, we are in a unique position to curtail the execution of imaging procedures that are not clinically indicated, significantly reducing health care costs in the process.
We know that you are keenly interested in developing positive relationships with the State’s physicians. At the same time, your task to make health care affordable and accessible for all Vermonters while maintaining quality of care is daunting. Rather than slashing reimbursement for imaging services, health care costs are more appropriately reduced by containing inappropriate utilization by referring physicians. Radiologists are in the best position to do that, and the VT ACR wants to work with you to achieve that end.
I look forward to talking with you soon about this.
Respectfully submitted,
JC Biebuyck, MD
ACR Member
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“As far as radiologists or any doctors leaving the state, the grass always seems greener on the other side. As I have mentioned to news media services before, surveys have shown that given the opportunity to work in Vermont under a single payer system that covers every Vermonter and emphasizes quality and not quantity of health care and tests, hundreds of doctors and medical students would flock to Vermont.”
And there will be a flight of specialist leaving the state. There are just not enough of us around and too many places that want our services elsewhere.
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What am I missing? The physicians mobilized and were successful in preventing DVHA from cutting reimbursement rates 21%. Indeed, DVHA agreed to reduce the cut to 2%.
With that in mind, one wonders what Dr. Biebuyck meant when he said, “Many physicians cannot help but wonder if the course taken by the DVHA is predictive of the manner in which the Green Mountain Care Board will treat Vermont physicians and their patients.”
Actually, I know an awful lot of interest groups that would love to be as effective as the doctors were here, especially in such a short period of time.
Perhaps the VT Medical Society could offer instruction to those who advocate for programs that serve low-income Vermonters.
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Gosh, I find it so disappointing when members of a proud and respected profession threaten to leave our state. Particularly when their issue is the amount of money they want to receive from state coffers.
But you know what? Despite these periodic threats, the number of physicians licensed in Vermont has just kept rising over the decades.
It’s hard not to notice that it always seems to be the physicians of the most highly reimbursed specialties who threaten to climb into the lifeboats and float away from the Green Mountain State.
Now if our rural physicians and primary care doctors and nurses threatened to abandon us en masse, then I’d start to pay attention!