Medicare reimbursement cuts threaten access to care

Physicians and patients alike are feeling the impact of Medicare reimbursement cuts that went into effect on January 1, 2013. With an additional 2% sequestration cut to roll out on April 1, it's likely that physicians who treat Medicare patients will be faced with difficult decisions as operating margins continue to shrink.

The the 2% cuts may seem modest, but they come on the heels of much larger cuts to reimbursement for nerve conduction studies (NCSs) of 40-70% for Medicare beneficiaries. These cuts were announced November 1, 2012, and went into effect on January 1, 2013, allowing providers little time to prepare.

While all Medicare providers are feeling the squeeze, private practices are likely to experience the most impact. "These cuts may force private practice physicians to choose between seeing Medicare patients and keeping their practice open," said Catherine French, AANEM senior analyst of medical economic affairs. French is concerned that the sequestration cuts will be adopted by private insurers, too. "It is possible that private insurers will follow suit and reduce reimbursement by 2% because most model their payment rates on Medicare."

Cuts Threaten Access to Care
According to Kristi Snihurowych, MD, a spine interventionalist in Salt Lake City, UT, the cuts pose a serious risk to access to care. Snihurowych has decided to discontinue EMG and NCS testing, which previously made up an eighth of her total practice. "Given the cuts, it's no longer feasible to perform these tests in-house. The problem is, I cannot find anyone to do them for me," said Snihurowych. "It seems everyone has had to give them up, and not just for Medicare patients. Providers anticipate that other payers will soon follow suit, so many have stopped offering EMGs all together."

Snihurowych suspects unnecessary and costly procedures will be among the cuts' ripple effects. "I am seeing patients go to surgery without a definitive diagnosis of, for example, carpal tunnel syndrome because the surgeons cannot get confirmation by an EMG or NCS test."

Utah-based physiatrist Faisel M. Zaman, MD, PC, agreed, "People will pay with their health. Of course there will be financial costs associated with unnecessary surgeries, but the biggest cost will be to the patients with scars and pain from procedures they didn't need."

Zaman is a spine specialist who has had several cases where an EMG has prevented patients from undergoing major surgery. In one case, a healthy and active 70-year-old male patient was referred by a vascular surgeon who thought the patient was experiencing symptoms of peripheral vascular disease. But the surgeon wanted to rule out spinal problems before he did a major bypass operation. Following EMG testing, the man was diagnosed with spinal stenosis.

"EMG was critical in this case," said Zaman. "It turns out that he is a great candidate for nonvascular treatments that will improve his condition. Without the lower-extremity EMG, he would have undergone major surgery. It's scary to think of the consequences to patients if the availability of EMG testing becomes more limited. Ultimately, it would hurt patients the most."

Claire Wolfe, MD, AANEM past president, has similar concerns regarding access to care. Nearing retirement and working part-time, she is the only physician performing EDX studies for an office of 23 physicians, as well as some outside referrals. Before the cuts, two other physiatrists in her office performed EMGs.

"There will be greater uncertainty around diagnoses of upper and lower limb pain/numbness; neck surgeries rather than carpal tunnel releases and vice-versa; delayed diagnoses of motor unit diseases; and delayed recognition of folks with metabolic disorders like diabetes if patients don't have access to an electrodiagnostic study that may catch peripheral neuropathy changes before the diagnosis of the underlying disorder is made," Wolfe said.

Unfortunately, the impact of the cuts may be long-lasting. "These cuts will significantly impact Medicare beneficiary access to appropriate management of their disabling neurologic disorders, limit further the number of neurologists who are currently seeing Medicare patients, and discourage budding physicians from the field of neurology," said Mohammed Zafar, MD, in response to an AANEM survey about the Medicare reimbursement cuts for EDX procedures.

Looking Forward
With the cuts to Medicare reimbursement, AANEM members are asking what can be done to protect their practices and to ensure access to care for patients into the future.

Get Involved in Policymaking
AANEM state liaison P. Caudill Miller, MD, actively encourages physicians who practice EMG to get involved in policymaking. Miller is a neurologist practicing at Neurology Consultants of Montgomery in Montgomery, AL. A longtime member of the AANEM, he has been involved in EMG quality control issues and has worked to improve insurance reimbursement.

"We have one year to prove the impact of the cuts on patient care," said Miller at a recent meeting of AANEM member physicians in Birmingham, AL. "More than ever it's important that fraud and abuse be reported."

In fact, now is an ideal time to reach out to your local representative's office, as the federal legislature is on break March 25 through April 5 and many representatives are in their home states.

Seek Certification and EDX Laboratory Accreditation
In December, AANEM representatives met with Jonathan Blum, deputy administrator and director at the Center for Medicare & Medicaid Services (CMS), who explained that the cuts resulted in part from the CMS' concern over the substantial increase in use of NCS codes. AANEM President Peter Grant, MD, explained that we are working hard on abuse issues that affect increased use of NCS codes. The AANEM is working to provide input to CMS on how best to curb abuse, including recommending proper tests are performed by certified physicians in accredited laboratories.

"One way to combat abuse is to ensure EDX testing is performed by a board-certified neurologist or physiatrist, preferably by the American Board of Electrodiagnostic Medicine," said Grant. "Also, it is important that EDX laboratories apply for the AANEM's EDX Laboratory Accreditation Program. The program is meant to identify and acknowledge EDX laboratories for achieving and maintaining the highest level of quality." There is precedent for CMS only paying for studies performed in accredited laboratories. For example, reimbursement for mammography is dependent on accreditation of the facility where the test was performed, and sleep medicine is held to a similar standard.

While it's true that the cuts to EDX physicians are the reality facing many procedure-based fields, it is still important for AANEM members to become involved. Please see the "How you can help" section on this page for more information.