Will HCFA bar women from certain procedures?

HCFA tables proposal until mid-2000

The prospective payment system proposed by the Baltimore-based Health Care Financing Administration (HCFA) for outpatient procedures in surgery centers and hospital outpatient surgery departments may prevent many Medicare women from being able to choose some of the most advanced surgical procedures.

Three breast diagnostic procedures will be reimbursed at a lower rate under the proposed surgery center ambulatory payment classifications (APCs). And some new minimally invasive procedures essentially will be unavailable to elderly women because their higher equipment costs are not recognized in the proposed APCs, according to directors at several surgery centers. Two of the three breast diagnostic procedures will see a lower reimbursement rate for hospital outpatients, with the third procedure receiving a slightly higher reimbursement than previous reimbursements to hospitals.

"The APCs might prevent women from having biopsies done with new instruments, and these new instruments are an improvement," says Beth A. Boyd, RN, clinical director and educational coordinator for The Breast Center in Marietta, GA. The Breast Center is a private surgical practice that specializes in breast procedures, including ultrasound, stereotactic biopsy, and mammography.

"Overall, to me it’s unfortunate," says Maxine Brinkman, MHA, director of women’s health services for Mercy Health Network in Mason City, IA. Brinkman also is the president of the National Association of Professionals in Women’s Health in Chicago.

"It’s a step backward and is subjecting women to less technically good procedures," she says.

Y2K concerns halt final rule

In September 1998, after months of heated outcry from surgery centers, HCFA tabled proposals for fee schedules for both outpatient surgery centers and hospital outpatient surgery departments. A major reason for the delay in completing these schedules is the need for HCFA to concentrate on the potential year 2000 (Y2K) problems that could delay Medicare payments to patients and to providers. The delay also has been extended to the controversial reimbursement system for surgery centers that was proposed in June 1998.

Both the proposed system for hospital out patient services, which was published in the Federal Register Sept. 8, and surgery centers, published June 12, rely on APCs. APCs are groups of procedures that are reimbursed at the same rate because they are similar clinically and in terms of resource costs. (For information on how to access the original documents, see box, p. 158.) The same classification system, with different rates, is proposed for surgery centers and hospital outpatient services.

Because HCFA tabled both projects so soon after the hospital-based outpatient rates were proposed, hospital-based financial managers are holding off on analyzing the reimbursement levels in detail.

"We are not conducting an in-depth analysis at this time because the rates will probably change when HCFA reissues them after the beginning of the year 2000," says Tracie Holyfield, product line specialist for women’s services at Moses Cones Health System in Greensboro, NC.

Although reimbursement for outpatient services will continue as usual for the next 13 months or longer, it is important to understand the reasons for the heated debate generated by the APCs specific to women’s surgeries and the potential impact of the lower reimbursements.

A frightening possibility if HCFA proposes similar rates in 2000 is that commercial payers will follow suit, as they usually do, and base their payment structures on Medicare’s APCs, says Jerry Henderson, executive director of SurgiCenter of Baltimore in Owings Mills, MD. The multispecialty center performs about 11,000 procedures a year, including breast procedures.

Proposed rates are disappointing

At the center of the controversy are the proposed reimbursement rates for breast biopsy diagnostic procedures. Currently these are reimbursed under these three CPT codes:

o 19100: Breast biopsy; core — $314 for surgery centers; $224 for hospitals.

(Editor’s note: Hospital outpatient rates are based on national averages and do not take into account the wage index for each urban or rural area. A cost-to-charge ratio of 45% was assumed. The source for this information is the Healthcare Financial Management Association in Washington, DC.)

o 19101: Breast biopsy; incisional — $422 for surgery centers; $699 for hospitals.

o 19125: Excision of breast lesion identified by preoperative placement of radiological marker — $482 for surgery centers; $699 for hospitals.

The new APC group definition lists CPT 19100 as APC 122, defined as a Level II needle biopsy, aspiration; and the proposed reimbursement rate is $186, a decrease of $128 from the current payment rate. Hospital reimbursement for APC 122 is $258, an increase of $34.

The CPT codes 19101 and 19125 are grouped under the APC 197 as an incision/excision breast procedure, and the proposed reimbursement for this APC is $411, an $11 decrease from CPT 19101 and a $71 decrease from CPT 19125. Hospital reimbursement for APC 197 is $642, which represents a $58 decrease.

The reduction in reimbursement is only part of the problem. The bigger issue, directors say, is that the proposed codes do not address new breast biopsy procedures.

Until 1994, for example, most stereotactic breast biopsies in outpatient settings involved using a core needle biopsy. And the gold standard was an open excisional biopsy performed in a hospital operating room. The latter procedure requires a general anesthesia, and the woman needs longer recovery time. Plus it leaves some internal and external scarring, Boyd says.

Then manufacturers introduced the stereotactic biopsy procedure with the vacuum-assisted biopsy device. The new stereotactic technology allows digital imaging on a computer during the biopsy. The new technique is minimally invasive, so it doesn’t cause as much scarring, and the woman does not need general anesthesia. The woman can drive herself to and from the outpatient facility, and the whole procedure and recovery may take two hours, she says.

"It’s a very big difference," Boyd explains. "You don’t have operating room time, pre-operative laboratory time to pay for, so it benefits the insurance companies to work with this too."

Stereotactic biopsy is better diagnostic tool

Although the stereotactic biopsy, using a vacuum-assisted biopsy device, costs more than the traditional stereotactic core needle biopsy, it is a much better diagnostic tool because it allows the surgeon to remove larger tissue samples and an entire area of abnormality in the breast, instead of only a small tissue sample, she adds.

The Biopsys Mammotome Breast Biopsy System, manufactured in 1994, is now marketed by Ethicon Endo-Surgery Inc. in Cincinnati. It was the first vacuum-assisted biopsy device, Boyd says. Norwalk, CT-based United States Surgical Corp. recently introduced the MIBB (minimally invasive breast biopsy), which also is a vacuum-assisted breast biopsy device used with stereotactic imaging.

Both devices use new technology that allows larger tissue samples and removal of the lesion through a 4 mm incision, Boyd says.

United States Surgical Corp. also manufactures the ABBI (advanced breast biopsy instrumentation), another new stereotactic breast biopsy technology that would be adversely affected by the APCs, says Kathryn Barry, senior director of health policy and reimbursement for United States Surgical Corp.

The MIBB was introduced this year, and the ABBI was introduced in 1996, which means they were not included in cost data HCFA collected in its 1994 ASC survey, Barry says.

"We are concerned they are using an outdated methodology that doesn’t keep pace with advancements of technology that are piloting a shift to ambulatory care," Barry says.

The ABBI, which uses a disposable product, costs more than the proposed APC surgery center reimbursement of $411, Barry says. Add in the cost of the surgeon, facility, and staff time, and the cost of the new stereotactic breast biopsy will exceed Medicare’s reimbursement rate.

"So this creates two perverse incentives: There are ASCs with this technology, but they won’t schedule Medicare patients for the procedure, so Medicare women will be denied access to the technology," she says.

"Or physicians will be motivated to send their patients to a hospital because the procedure is reimbursed more there." While the hospital reimbursement of $642 is more generous, hospital outpatient departments still are facing higher overhead costs than surgery centers, and those costs will not be covered by the reimbursement level, Barry says.

Ironically, while Medicare’s low reimbursement level might deny older women stereotactic technology, other government agencies are paying for it, Brinkman notes. The Atlanta-based Centers for Disease Control and Prevention (CDC) has included stereotactic procedures for low-income women in its Breast and Cervical Cancer Early Detection Program, which is funded by the National Institutes of Health in Washington, DC.

Hysteroscopy rate also falls short

Henderson points out that women also are being shortchanged with HCFA’s proposed reimbursement for surgical hysteroscopy, which is under APC code 550 and corresponds to CPT code 56356, which is for hysteroscopy, surgical, with endometrial ablation. The procedure allows a surgeon to destroy the endometrial lining of a woman’s uterus, which can be done in place of a hysterectomy.

The procedure traditionally has been done in a hospital setting, where the reimbursement rate is more than $1,000 in many states, Henderson says. The proposed hospital reimbursement for APC 550 is $893.

The proposed APC code 550 would reimburse the procedure in an outpatient surgery center setting at $610. Surgeons now have the option of new technology that uses a heated balloon to destroy the endometrial lining, which is safer and quicker but involves a disposable instrument that costs about $650, Henderson says.

"So before you have the first minute of surgery, the first staff person, and the first suture, you’re already behind," he says.