Physicians score victory on Medicare surgicenter coverage

Washington -- Responding to pressure from the American Medical Association and other groups, the Bush administration has backed away from its plan to limit Medicare coverage of procedures at ambulatory surgery centers.

The Centers for Medicare & Medicaid Services prompted outcry last November when it proposed deleting scores of entries from the list of procedures for which Medicare will reimburse in the ASC setting. CMS made a nearly complete reversal after hearing complaints from dozens of physician organizations.

"After strong opposition by the AMA and specialty societies to a CMS proposal to delete 100 procedures from the list of services that Medicare covers in ambulatory surgery centers, CMS recently chose to delete only five codes and add an additional 65 codes to the ASC list," said AMA Chair J. James Rohack, MD. "We are pleased that CMS listened to our concerns and made changes so that Medicare patients' access to certain procedures at ASCs will not be hampered."

Before regulators changed their minds about the plan, physicians were contemplating a situation in which ambulatory surgery centers would be effectively off-limits for Medicare patients requiring such common procedures as prostate biopsies and diagnostic cystoscopies. The administration also had planned to approve only 25 new procedures for coverage but more than doubled the number when physicians complained that the list wasn't large enough.

Led by the AMA and the Federated Ambulatory Surgery Assn., doctors quickly made their voices heard.

Physician delegates from Georgia called on the Association to oppose the CMS proposal at the AMA Interim Meeting last December. After that action, the AMA sent the agency a detailed letter of comment outlining how cutting the size of the list would harm patient access, increase costs for the federal government and prevent doctors from making determinations about the best setting in which to administer care.

The government's final decision "was a huge win on the deletions, and the AMA played a huge role in helping us accomplish that," said Kathy Bryant, executive vice president of FASA. "Their objections to the deletions and their work in joining us to talk about the importance of physicians making these care determinations was integral."

The effort also attracted the attention of at least one influential lawmaker in Washington.

Senate Finance Committee Chair Charles Grassley (R, Iowa) sent a letter to CMS last month in which he said that the proposed plan would hinder patient access to care, especially in rural areas where ambulatory surgery centers are often more convenient than hospital outpatient facilities.

In reviewing comments from physician groups and others, the agency determined that compelling reasons existed for conducting some of the procedures in question at the centers, rather than in physicians' offices or hospitals.

"The comments we received provided clear, clinical evidence that deleting the procedures, as we had proposed, could have led to reduced access, or riskier care for patients with more complicated medical conditions, if performed in a physician's office rather than an ASC," said CMS Administrator Mark McClellan, MD, PhD.

Safety first

The CMS rationale for proposing the 100 deletions was that the procedures are performed predominantly in the physician office setting.

But those commenting successfully argued that individual patient circumstances sometimes require the more advanced resources of an ASC. They noted that for many of the procedures, doctors consistently recommend an ASC setting roughly 20% of the time.

"Even though many of those procedures are done the majority of time in the physician's office, over a number of years there are consistent numbers that are performed at the ASC," said Jack Egnatinsky, MD, an anesthesiologist living in St. Croix, Virgin Islands, and the president of FASA. "It shows that doctors aren't doing these at the surgery centers because they own the centers, they are doing them there because those patients need to have the special facilities of a surgery center."

Certain Medicare patients, for instance, might have conditions that require anesthesia or a sterile operating room even for minor procedures, he said. CMS conceded in its final rule that if surgery centers were placed off-limits, many of these cases would need to be referred to hospital outpatient facilities, where the total costs can be much higher.

Starting in July, Dr. Egnatinsky said, physicians will encounter more flexibility when it comes to ordering surgical procedures such as certain colonoscopies and bronchoscopies.

The five procedures that CMS has deleted from the list received no comments calling for their preservation and are likely performed almost exclusively in the physician office setting, he said.

Based on historical data, there will be a slight increase over time in the percentage of the 65 added procedures that are performed at the surgery centers, Dr. Egnatinsky said. Doctors will not rush to take advantage of the ASC alternative because the physician office remains the most logical site of care for the majority of patients, he added.

FASA, AMA and their allies, meanwhile, continue to push for the addition to the Medicare list of more procedures, such as laparoscopic cholecystectomies, that are routinely performed in surgery centers for private-pay patients, Bryant said. The association had called for nearly 50 more additions beyond the 65 that Medicare eventually approved.

The group also continues to urge CMS to abandon the inclusive list for an exclusionary one, in which any medically appropriate procedure could be performed on a Medicare patient at an ASC unless it is specifically prohibited. Such an overhaul, which the AMA supports, might have to wait until the agency implements an entirely new payment system for the centers at the beginning of 2008, Dr. Egnatinsky said.