Physicians blast Medicare plan to curb surgery center procedures

Washington -- Ambulatory surgery centers would be able to start billing Medicare for some additional types of medical procedures under a recent federal proposal, but the update would come at a steep price: Four times as many other procedures would disappear from the covered list.

When the Centers for Medicare & Medicaid Services issued a proposed ASC coverage update in November 2004, some physicians were pleased to see that 25 procedures made the list, including knee arthroscopies and bladder repairs. But CMS removed 100 other Medicare-subsidized treatments, such as prostate biopsies and diagnostic cystoscopies. Doctors have been administering these procedures at the centers for decades.

The move met with strong protest from the ASCs and at least 30 doctor organizations, including the American Medical Association. Deleting so many procedures amounts to the government making arbitrary decisions about the best site of care for a given condition, the groups said.

"The AMA believes the physician, who has firsthand knowledge of the patient's medical history and attendant risk, should have the ability to make an informed decision on a case-by-case basis about the most appropriate surgical environment for Medicare patients," AMA Executive Vice President and CEO Michael D. Maves, MD, wrote in a Jan. 25 letter to CMS. The AMA recommended that the agency drop the deletion proposal altogether.

Forcing doctors to perform the excluded surgeries in their own offices or to refer the patients to hospital outpatient departments could be a serious detriment to patient safety, said Jack Egnatinsky, MD, an anesthesiologist living in St. Croix, Virgin Islands, and the president of the Federated Ambulatory Surgery Assn.

"A patient with severe emphysema or significant heart disease that needs to be monitored might have a procedure that itself could be done very easily in a doctor's office," Dr. Egnatinsky said. "But the office would not be equipped to monitor the patient or provide the appropriate care that might be required for that patient during the surgery."

The AMA agrees with this point -- that some individual patient circumstances determine that the prescribed course of treatment should occur in an ASC even when most surgeries for similar conditions take place elsewhere. "Simply because a procedure is frequently performed in a physician's office does not mean it is always appropriate for the patient to undergo surgery in the office," Dr. Maves wrote.

The Association reacted quickly to the CMS plan. During the AMA's December 2004 Interim Meeting in Atlanta, delegates adopted the Georgia delegation's call to oppose the change. The federal strategy would "significantly increase cost, adversely impact patients' access to care, significantly increase the paperwork burden, adversely impact physician time utilization and significantly inconvenience all parties," the resolution said.

Federal officials counter that the step will not have that much effect on how doctors and ASCs do business. Medicare now covers nearly 2,500 types of treatment at surgery centers.

"Most of the codes that we are proposing to delete are procedures that are being performed primarily in a physician office setting, and they do not require the more elaborate resources of an ASC to be safely performed," stated CMS in the November 2004 proposed rule. Many of the excluded codes apply to reconstructive surgery and would therefore only adversely affect the few centers that limit their services to those procedures, the agency said.

Access, pocketbooks could take hit

Surgery center advocates insist that patient access is already suffering because of the CMS plan. Washington state officials, for instance, have removed the 100 procedures from the list of treatments that Medicaid will subsidize when administered at an ASC, Dr. Egnatinsky reported.

In addition to limiting patient access, such a move also has the potential to cost the federal government and patients more than if doctors were to decide where to administer surgeries. Dr. Maves noted that splitting diagnosis and treatment between two facilities or directing more procedures to hospital outpatient departments could result in a larger bill for both Medicare and seniors.

In many cases, doctors themselves would be unable to commit the resources necessary to get their offices up to code to administer the excluded surgeries, and local hospitals might be unable to handle a large influx of surgery patients, Dr. Maves wrote.

The panel that advises Congress on Medicare reimbursement agrees with the AMA's assessment. Ambulatory surgery centers should be able to perform the same procedures as hospitals and physician offices except in cases where the surgeries are clinically inappropriate for ASCs, the Medicare Payment Advisory Commission said last year. The Association and the surgery centers support replacing the current set of included procedures with such an exclusionary list, which would require action by Congress.

"The whole philosophy of having an inclusive list is outmoded and based on some factors that existed 20 years ago -- when Medicare first started covering ambulatory surgery centers -- but that no longer exist," Dr. Egnatinsky said.

CMS plans to issue a final rule this spring, and the modified coverage list will take effect July 1.