Join Us in Our Quest to Continue Quality & Convenient Patient Care and Fair Reimbursement

December 10, 2013

Letter to Doctors, Staff and Patients of NeuroSpine Institute,

 Usually around this time we panic about sustainable growth rate (SGR) cuts which are scheduled to be 20% pay cut again unless congress fixes it temporarily or permanently. However, we have a much bigger problem this time.

 As a Thanksgiving gift on November 27, 2013, Centers for Medicare and Medicaid Services (CMS) posted the 2014 final rules for physician payments as well as hospital outpatient and ambulatory surgical center payments the day before Thanksgiving. New rates will be effective January 1, 2014.

 It is all about universal health care and administration attempts to go to single payor system with consolidation of hospital industry with elimination of physician practices.

 This may put 40% of pain physicians out of practice

  • Reduce access to care
  • Increase Medicare expenses by $187 million.

 It is an understatement to say that the cuts are draconian and it will be devastating. Unless we act upon the issue this may be the end of interventional pain management practice for almost 40% of the physicians who base majority of their practices out of office setting.

 With these unforeseen reckless cuts, we have entered the perfect storm. We are no longer over the cliff, we are in deep waters. This is not an exaggeration. The cuts for physician payment for cervical and lumbar epidural injections in the office setting are 58 and 51% respectively and, and also significantly reduced in the ASC/Hospital as well 36 and 23 % respectively. This does not include the potential 20% SGR cuts. This will also likely shift care into more expensive sites of services setting, namely hospitals and ASC's and have devastating effects on physician reimbursement. This will further empower hospitals under Affordable (Obama) Care.

 Recently we have been hit with multiple problems:

 1.Noridian developed national local coverage determinations (LCDs) and threat of national coverage determinations (NCDs) with severe restrictions.

 2. Cigna and other insurance coverage issues essentially are limiting interventional pain management either in duration or indications.

 3. The usual threat of SGR cut of 20.1%.

 4. ICD-10, RACs, OIG, single-dose vials, EHRS, and continuing expansion of HIPAA

 5. Now the mother of all, physician payment final rule for 2014 with whopping cuts -- we are facing as high as 36% for physician payment and over 58% when the procedure is performed in an office for most commonly performed procedures - namely epidural injections (CPT 62310, 62311, 62318, and 62319). We are also facing some cuts for transforaminal epidural injections as well as facet joint interventions; however, these are much less compared to caudal or interlaminar epidural injections.

 Essentially, hospitals will be reimbursed at $669.90 for the epidural procedure performed in the hospital setting; whereas, in office setting, after removing the portion designated for the physician professional fee, office practice expense will be reimbursed at $30.28 to $34.36 a whopping 2,315% to 2,668% with SGR cut and 1931% to 2312% without SGR cut more in the hospital setting.

Other cuts are related to spinal cord stimulators. When trials are performed in an office setting, starting January 1, 2014, there will also be a huge reduction in reimbursement approaching 60% for a single lead and 75% for a dual lead trial. While CMS will continue to reimburse under Medicare with CPT code 63650 and expected to be reported for each lead insertion procedure and trial, L8680 will no longer be reported for the device component. The new global payment in the office setting for 63650 has been reduced to $1,281.65 nationally. A 50% modifier will still be applied for a second lead in a dual lead trial.

 In the proposed rule, as well as in the final rule CMS also has erroneously considered percutaneous adhesiolysis - 1 day (CPT 62264) similar to ambulatory surgery center (ASC) moving it from neurolytic blocks APC group to epidural and facet joint Ambulatory Payment Classification (APC) group reducing the payment to epidural levels in hospital as well as in ambulatory surgery center settings. For many hospitals this may be okay because these are performed in a small room, without all the expenses ASCs have to go through, but it continues to be devastating for offices and represents a significant disadvantage for ASCs.

 Remember, this does not include the possible 20.1% cut expected for implementation of SGR.

 Make no mistake - this will be followed by every carrier nationally.

 This will again lead to explosion of pill mills

 All of the details are provided in the fact sheet.

 It is time to act now. If you do not act now, probably you will never have an opportunity to act later.

 You are the best lobbyist for yourself and for IPM and your office is the lobby central. Immediately without wasting a single minute start advocacy on behalf of yourself, your patients, and your staff for the future of interventional pain management.

 Based on the available information, as of now:

 The RUC process showed decreased times, but did not involve all stakeholder physician groups. Even then, the AMA RUC recommended continuing the same payment schedule. (I.e. - these changes were made by CMS and not the RUC in large part.

 Data was available in 2012, yet the proposed schedule in July did not include the proposed cuts.

 Consequently, there was no comment period even though it is required.

 Medicare has not taken into consideration Medicare Economic Index (MEI) which has been increasing substantially. Now the gap with SGR cuts will be 90% and without SGR cuts will be 70% between expenses and the revenue.  

  •  Medicare has not taken into consideration MedPAC concerns of a widening gap between hospitals and physician payments and specific recommendations for CMS to address these issues.
  •  Hospitals have increased their payment by almost 20% for the same procedures, whereas in-office procedures are facing almost a 60% cut, with no change in operational expenses (and the threat of SDV causing increased costs of care
  • In fact, moving these procedures from in an office setting to hospital outpatient department (projected to move at least 80%), will increase the costs so substantially that the patient copay itself is 4 times higher than the entire payment in an office setting, and was equivalent to full payment with proposed rates.
    •  In addition, the total costs of these procedures will increase based on 2011 statistics which showed 412,799 of 1,114,458 epidurals (only 2 codes 62310 and 62311) were performed in office setting in Medicare population. If 80% of these procedures (330,239) were performed in HOPD setting, the cost of these 2 procedures increased over $187 million per year considering the reimbursement in the proposed rule of $85-$105 per procedure
  • This may even lead to with kickback as hospitals receiving much higher facility payments and offering physicians occasionally a portion of these revenues, which will lead to troubles at a later date.
  •  This change will also fuel pill mills with increasing deaths.
  • Consequently, we request Congress to act swiftly and decisively to request Medicare withdraw the proposed final rule for the family of codes 62310-62319 and allow the public time to comment, as required within the Medicare Integrity Manual, before implementing more reasonable changes in 2015.

SUGGESTED Letter for Patients

 *You should customize and describe your own situation in physician letters. Make sure each and every physician writes a letter. Even physicians who are not interventional pain physicians may write them.

*This should be followed by all your staff members, their relatives and friends.

*Finally, the most important aspect is the access to care, so we have to get our patients involved as our partners in this survival journey. It is not just the patients, but their family members and their friends.

 Please go to www.ASIPP.com for more information on how to start your letter-writing campaign.

 We need to work on this issue vigorously and with full force. Justice is on our side, interventional pain management is not experimental, it is essential and evidence-based. We have to protect the access to all Americans.

Thank you,

The Doctors and Staff at NeuroSpine Institute, Eugene and Roseburg 

Meet our experienced physicians
Our Physicians
Carmina F. Angeles, MD/PhD

Dr. Angeles specializes in complex and minimally invasive spine surgery with an emphasis on compassionate patient care. An honors graduate of Meharry Medical College in Nashville, where she earned both a medical degree and PhD in Neurophysiology, she completed her residency in Neurological Surgery at the University of Texas in Galveston and a Spine Fellowship at Stanford University Medical Center in Palo Alto, California. She is a member of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons and is board-eligible for the American Board of Neurological Surgery.



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