Four reasons the DOJ settlements will lead to more—not less—scrutiny from the federal government

Brian Maher, Cardiovascular Roundtable

The coming announcement of the implantable cardioverter defibrillator (ICD) settlements is one of those seminal events in national efforts to curb wasteful utilization and spending.

It will end a highly controversial and publicized battle between providers, CMS, and the Department of Justice that has played out over the past decade. And while it may finally bring some resolution to this specific investigation, it definitely does not end the issue at hand–that there is still significant variation in the use of expensive health care services.

In fact, I would argue that things will begin to intensify. Here's four reasons why:

  1. No clinical service or procedure is immune from scrutiny. This investigation affirms that any type of test or treatment–no matter how expensive–is open to scrutiny over medical necessity. We see this playing out in cardiovascular services extensively, where stents, pacemakers, and even relatively routine diagnostic tests are all being measured for their appropriateness.
  1. If you can't comply with evidence-based guidelines or coverage policies, you're opening yourself up to investigation. There's a national call to embrace evidence-based care, and it's why we see professional societies and other agencies continuing to develop new and update existing guidelines to promote it. You can expect to see more appropriate use criteria (AUC) become available for all different types of clinical tests and treatments. And it's now the norm that providers are expected to not only adhered to such guidelines, but also to continuously improve.

Why CV services are overused, and how to fix the problem

  1. The government is recouping significant dollars. Presumably hundreds of millions of dollars are being returned back to Medicare. With such an influx of savings, it would not be surprising if this paves the way for other federal efforts to recoup expenditures for potentially unnecessary care. Could this lead to a resurgence of the Recovery Audit Contractor program to take back overpayments? Could this create more incentive for providers to adhere to AUC in order to be reimbursed? Or for services that don't meet AUC to be denied reimbursement? I think all options are on the table.
  1. It's not just about medical necessity, it's site of service as well. For services that are medically unnecessary, there likely is a justifiable case to withhold reimbursement. But what about services that are medically necessary, but are performed and/or billed in the wrong setting? For example, the scrutiny over short-stay inpatient versus extended outpatient observation care continues even with the "two-midnight rule" in place. Also, site-neutral payments would create a levelled reimbursement system for services provided in freestanding offices and off-campus provider based sites (like an employed physician practice). Spoiler alert: things are about to get ugly in the next 2-3 years on when it comes to site-of-service payment issues.

So, what do you need to have in place to combat the scrutiny over appropriate utilization and payments?

  1. Strong partnerships between hospitals and physicians. Hospitals and physicians need to be working in lockstep to adopt evidence-based standard of care, promote adherence, and drive improvements. Read our CV Specialist Partnerships publication for guidance on how hospitals and cardiovascular physicians can become more strategically aligned and partner together to promote value-based care.
  1. Build an infrastructure to support evidence-based care. You need to have a solid infrastructure to track, manage, and use evidence-based guidelines. There are many barriers which need to be overcome, such as perception of the value of evidence-based guidelines and making them part of daily practice. Visit our dedicated resource page to adopt evidence-based guidelines and make the best use of appropriate use criteria.
  1. Perfect the management of short-stay patients. This continues to be an evergreen challenges for many hospitals, with operational issues often impeding the best use of outpatient and observation status. Come join us at our 2015-2016 national meeting series, where we'll be sharing a number of different strategies to appropriately manage short-stay CV patients.

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