A Way Forward

Dear Jay,

As you worked to formulate a letter to CMS about the OPPS proposed rule that might negate the hyperbaric physician supervision charge, I thought back to my horrible 2 years as UHMS President. In 1991, the AMA reclassified the physician work component of 99183 to “0”, which ended the payment for physician supervision of HBOT 28 years ago. Separately, CMS reduced the hospital payment for the service 75%. It was the end of hyperbaric medicine, and the only reason we survived was due to the quick action of the American College. Here is a copy of the 1993 memo from Dr. Neubauer confirming that the physician payment issue had been resolved, and the first of several pages in which I summarized my two year ordeal

Now, here we are in 2019, facing the likely loss of 99183 in the outpatient department (under the new OPPS proposed rule). It is possible that within 3 years or so, all wound care could move into the doctor’s office as a result of a “site of service adjustment” (which could, in fact, happen at any time). If CMS reopens the NCD, we could lose most of our indications for HBOT. We have had the same challenges over and over for 3 decades.

In the 1990’s, the College was needed and valuable because it represented the unique needs of practicing physicians in the USA. It seems to me that the vision has been lost over time, but I am not sure how or why.  The College has lately been seeking a raison d'être. I think it should return to its mission of leading the regulatory fight with CMS. CMS and the MACs question both appropriate use of HBOT and physician work level, both of which can be addressed with participation in a Qualified Clinical Data Registry. That is how all the other medical societies do this. I built a QCDR after my experiences as UHMS President. Specialty societies pay an average of $10 million dollars to set up a QCDR, based on survey data obtained at the recent annual meeting of specialty society registries. I would like to align the hyperbaric oxygen therapy QCDR with the American College of Hyperbaric Medicine with the goal of ensuring the survival of the field. That’s the potential “lifeboat” for hyperbaric medicine, as I mention in this article published in Today’s Wound Clinic:  https://www.todayswoundclinic.com/articles/hyperbaric-medicine-quality-reporting-building-ark-ensure-survival

It seems to me that the College should take up the banner of QCDR participation as a way to protect HBOT payment and address the onslaught of threats (CMS, the OIG and the MACs, private payers). If all hyperbaric medicine and wound care services are forced into the doctor’s office setting, then physician payment success under MIPS is vital to the future of the field. Doctors will be completely reliant on ONLY their professional revenue to fund HBOT services, contracting with private payers, purchasing other advanced therapeutics and supporting their families. The only way to optimize physician payment (right now) is through a QCDR.  Just as critical, the QCDR can be used to try to protect what we now have. Here’s a link to a 7 part series on my blog that explains why quality data submission can be a roadmap to survival: https://carolinefifemd.com/2019/07/10/counting-the-cost-and-a-roadmap-to-survival-part-1-of-7/

Here's what I propose:

  • Step 1: (no cost to anyone) Encourage all doctors that bill 99183 to sign up for the hyperbaric oxygen therapy specialty registry (run by the USWR) for FREE. The registry does not charge anything for “enrollment.”
  • Step 2: Get those registry enrolled doctors to automate the submission of their Continuity of Care Documents (CCDs) from their respective EHRs. Any EHR can do this. There is a nominal charge for participating in the registry through CCD transmission which supports the cost of “parsing” the CCDs in order to benchmark the major comorbid conditions present among HBOT patients.
  • Step 3: Once the College has a significant number of doctors enrolled, then the College can meet with CMS and make the case that, given there is a significant level of participation in a hyperbaric QCDR, submission of “appropriate use” quality measure is a valid alternative to targeted probes in order to assess adherence to coverage policy, AND that physicians voluntarily submitting appropriate use measures should have their payment protected.
  • Step 4: Publish papers on both patient complexity and the impact of HBOT on the Medicare cost per beneficiary, funded through the QCDR.

That seems a way to build on the work of the College which began 3 decades ago. The first step requires no up-front investment by the College, might recruit new College members, and is initially zero cost to the doctors. The second step involves nominal fees (a few hundred dollars). The third step involves leveraging Dr. Shah’s connections within the AMA, state and federal Medicare officials to meet with the College which would advocate that HBOT reimbursement be linked to registry submission of quality data. This means the College is out front, proactively driving the quest for quality and value in hyperbaric medicine. Success with that initiative can lead to improved payment rates for registry participants. The final step does require investment – analyzing data and publishing papers to show the value of HBOT in general and registry participation by College members in specific, by which time the private payers may be willing to provide funding.

It would mean an all out “public relations” campaign by the College for registry participation. That means every College member needs to understand the big goals of this project, specifically: protecting practitioner payment, improving patient quality of care, and obtaining data to support the value argument for HBOT indications.

Lastly, in case you think that the QCDR can’t have an impact, consider that a few days ago, 3 of our quality measures were chosen by CMS to be publicly reported on Physician Compare. These could be hyperbaric measures in the future.