ACC Outlines Provisions of Congress's 2014 SGR Patch

March 31, 2014—The American College of Cardiology's (ACC’s) Cardiology magazine reported that the Protecting Access to Medicare Act of 2014 (H.R. 4302) passed in the United States Senate despite a last-ditch effort by Senate Finance Committee Chairman Ron Wyden to permanently repeal and replace the Sustainable Growth Rate (SGR) formula. Approved in the Senate by a vote of 64 to 35, the legislation delays for 12 months a 24% Medicare physician payment cut that was set to take effect April 1. This is the 17th patch that Congress has enacted on the SGR formula since 1997. Last week, the House passed the bill by voice vote.

The ACC stated that although the legislation includes provisions that it has advocated for within the scope of full SGR repeal, failure to permanently repeal the SGR given the significant bipartisan/bicameral legislative efforts this year represents a wasted opportunity to finally provide much needed stability within Medicare.

In Cardiology, the ACC further outlined the legislation’s key provisions:

• Prevents 24% cut scheduled for April 1, 2014; provides a 0.5% update through December 31, 2014, and a 0% update from January 1 to March 31, 2015.

• Requires consultation with appropriate use criteria and clinical decision support for advanced diagnostic imaging.

◦ Appropriate use criteria must be developed or endorsed by professional medical societies

◦ Clinical decision support software must be available to providers at no cost

◦ Beginning in 2017, claims that fall under the appropriate use criteria requirement will only be paid if they include data that indicate clinical decision support tools were consulted

◦ Hardship exemptions are available (rural areas or insufficient Internet access)

◦ Beginning in 2020, the Department of Health and Human Services (HHS) Secretary will identify outlier providers based on data from 2 previous years

◦ Outliers would be subject to prior authorization—no more than 5% of total providers

• Allows the HHS Secretary to revise payments for potentially misvalued codes within the physician fee schedule based on information collected from providers.

◦ Policy applies to fee schedule for years 2017–2020

◦ Target for value reduction is 0.5% of the estimated amount of total fee schedule expenditures for the given year

◦ If the total relative value unit for an identified misvalued code is scheduled to be reduced by ≥ 20% due to the reevaluation, the adjustment must be phased in over 2 years

• Extends the HHS Secretary's medical review activities regarding the “Two-Midnight Rule” for the first 6 months of 2015.

• Delays the transition to ICD-10 for 1 year.

• Extends funding for the National Quality Forum for measure endorsement through July 2015.

• Beginning January 2016, requires all CT services to be provided by equipment adhering to NEMA (National Electrical Manufacturers Association) dose standards.

◦ Applies to fee schedule and Hospital Outpatient Prospective Payment System services

◦ Payment for services rendered with equipment not consistent with the above standards would be reduced 5% in 2016 and 15% in 2017 and subsequent years

• Consolidates the 2% Medicare sequester cut scheduled for full year 2024 into a 4% cut in the first 6 months of 2024.