US Health Care Reform and Transplantation, Part II: impact on the public sector and novel health care delivery systems.

The Patient Protection and Affordable Care Act passed in 2010 will result in dramatic expansion of publically funded health insurance coverage for low-income individuals. It is estimated that of the 32 million newly insured, 16 million will obtain coverage through expansion of the Medicaid Program, and the remaining 16 million will purchase coverage through their employer or newly legislated insurance exchanges. While the Act contains numerous provisions to improve access to private insurance as discussed in Part I of this analysis, public sector coverage will significantly be affected. The cost of health care reform will be borne disproportionately by Medicare, which faces nearly $500 billion in cuts to be identified by a new independent board. Transplant centers should be concerned about the impact of the reform on the financial aspects of transplantation. In addition, this legislation also utilizes the Medicare Program to drive reform of the health care delivery system, by encouraging the development of integrated Accountable Care Organizations, experimentation with new 'models' of healthcare delivery, and expanded support for Comparative Effectiveness Research. Transplant providers, including transplant centers and physicians/surgeons need to lead this movement, drawing on our experience providing comprehensive multidisciplinary care under global budgets with publically reported outcomes.

US Health Care Reform and Transplantation. Part I: overview and impact on access and reimbursement in the private sector.

The Health Care Reform (HCR) legislation passed by Congress in 2010 will have significant impact on transplant centers, patients and health care professionals. The Act seeks to expand coverage, limit the growth in health care costs and reform the delivery and insurance systems. In Part I of this two part series, we provide an overview and perspective of changes in private health insurance resulting from HCR. Under the plan, all Americans will be required to purchase coverage through their employer or via an improved individual/small group market. This legislation limits abusive practices such as limitations on preexisting conditions, lifetime and annual coverage limitations and dropping of beneficiaries if they become sick. The legislation will also limit high-cost plans and regulate premium increases. Private sector reforms are likely to benefit our patients by increasing the number of patients with access to transplant services, since the use of 'preexisting' conditions will be eliminated. However without a concomitant increase in the organ supply, longer waiting times and greater use of marginal organs are likely to increase the cost of transplant. Furthermore, transplant providers will receive reduced reimbursement as a result of market consolidation and the growing power of large transplant networks.

American Society of Transplant Surgeons transplant center outcomes requirements--a threat to innovation.

The transplant center regulations recently published by the Centers for Medicare and Medicaid (CMS) mandate that observed program-specific survival outcomes to fall within expected risk-adjusted outcomes. Meeting these outcomes is essential to continued participation in the Medicare program. Both donor and recipient variables not considered in current risk adjustment models can result in inferior outcomes and therefore may cause an overestimation of transplant center expected performance, precluding participation in the federally funded Medicare program. We reviewed the most recent four reporting periods published by the Scientific Registry for Transplant Recipients on their public website. We identified kidney, liver and heart transplant programs that were flagged for having outcomes statistically lower than expected as well as those that failed to meet CMS criteria. We also analyzed whether center volumes correlated with outcomes in these centers. We highlight the need for mitigating factors that could justify inferior outcomes under specific circumstances. Failure to reach consensus on such a mechanism for appeal may result in risk-averse behavior by transplant centers with respect to innovation and therefore hamper the ability to advance the field of transplantation. We propose a methodology that may address this emerging dilemma.

Transplant center regulations--a mixed blessing? An ASTS Council viewpoint.

The Centers for Medicare and Medicaid Services (CMS) has developed a set of regulations that spell out the Conditions of Participation (CoPs) for provider hospitals that wish to be certified (and thus eligible for reimbursement) by Medicare for transplant services. The American Society of Transplant Surgeons (ASTS) Council has played a major role in providing CMS with advice and guidance in the development and ongoing implementation of these conditions through a process of fruitful dialogue. In this report, we highlight the events that led to the development of the regulations and describe the process to date in implementing the CoPs. We have raised some important questions regarding the effectiveness of the regulations for improving safety, and we have highlighted the cost associated with their implementation. This report has been vetted by and represents the opinions of the Council of the ASTS.

Health Care Financing Administration release of final physician payment reform regulation.

The Health Care Financing Administration has released final regulations concerning physician payment reform. The new method will significantly affect global, technical, and professional reimbursement. The American Society of Echocardiography is preparing response to these regulations.

Mechanism of age-related differences in frequency discrimination with backward masking: speed of processing or stimulus persistence?

In Experiment 1, frequency-discrimination thresholds were estimated in a 2-interval, forced-choice, backward masking procedure with a masker acoustically dissimilar to the targets. Young subjects were more efficient in escaping the effects of masking than were their elderly counterparts. In Experiment 2, young and elderly subjects performed the same task, with a masker acoustically similar to the targets and with a target-dissimilar masker. Under target-similar masking and at short target-masker intervals, the elderly demonstrated significant improvement, reaching the level of performance of the young, whereas under the target-dissimilar masker, the age-related differences were restored. Both age-related slowing of information processing and increase in stimulus persistence can account for the results of Experiment 1, but only increased stimulus persistence explains the results of Experiment 2.

Reimbursement update: looking toward the 1990s.

Some Medicare carriers have independently decided to treat all billings for echocardiographic services as radiologic, whereas others have decided to treat billings from multispecialty practices that include a radiologist as radiologic services. The result is that the radiology fee schedules are being applied, even though the services were not supplied by radiologists.

Auditory memory and age-related differences in two-tone frequency discrimination: trace decay and interference.

We investigated age-related differences in the time course of two-tone frequency discrimination. Healthy young and elderly adults with normal hearing acuity in the 500-2000 Hz range performed a two-alternative forced choice frequency discrimination task. The stimuli were short tones separated by either a 250-ms (short), 850-ms (medium), or 3000-ms (long) silent inter-interstimulus interval (ISI). Frequency discrimination thresholds were estimated using an adaptive staircase procedure. Although young listeners performed better than the elderly at all ISIs, the latter showed a dramatic elevation of discrimination thresholds at 250 ms, while the thresholds of the young subjects increased significantly at 3000 ms. These results suggest that the elderly may be especially vulnerable to the effects of masking produced by the second tone at the short interval, whereas the young listeners tend to be differentially affected by the trace decay at long ISI. The results are discussed in the framework of stimulus persistence hypothesis.

Changes in Medicare reimbursement for echocardiographic procedures.

Medicare reimbursement for echocardiographic procedures is clouded by the fact that Medicare defines ultrasound services to be "radiologic." As such, a 40% limitation has been imposed in some states. In addition, as a result of the Omnibus Budget Reconciliation Act of 1987, a new radiology fee structure was negotiated with Medicare, without the input of internists and cardiologists, that may significantly affect reimbursement patterns for echocardiographic services. Those who perform and interpret cardiac ultrasound studies are again urged to use the medicine codes (90,000 series) rather than radiology codes (70,000 series).

Consequence of the Omnibus Budget Reconciliation Act of 1987: elimination of markup for certain diagnostic tests.

The Omnibus Budget Reconciliation Act of 1987 has significantly changed the rules governing the way in which charges must be made to Medicare concerning certain tests, including ultrasound, by a physician who provides these tests by means of an outside supplier. If the physician does not identify the supplier or indicate the amount charged by the supplier for the test, no payment is allowed, and the physician may not bill the beneficiary any amount for the test.

Interpretation of echocardiographic data: are physicians and sonographers violating the law?

When a sonographer renders diagnostic interpretations from echocardiographic data, the possibility exists that state statutes concerning the unauthorized practice of medicine may be violated. Problems likely exist in this regard when the sonographer renders such interpretations without proper physician interaction or when the physician delegates such responsibilities to the sonographer. In such situations the physician may be guilty of aiding and abetting the unauthorized practice of medicine. Such practices may also violate various reimbursement rules and policies. Given such a situation, even the rendering of preliminary results by sonographers without appropriate supervision by the physician may be in violation of various state statutes and rules governing reimbursement procedures.