There were several changes made in 2014 to healthcare coverage and spine surgeon pay; 2015 promises to bring even more updates.
Spine surgeons will feel the impact of trends in insurance coverage and overall physician pay. Additionally, more spine cases are now moving to the outpatient setting, throwing additional changes into the mix. Here are 50 things to know about spine surgeon pay and insurance coverage for 2015:
Health insurance exchanges
1. There will be a shorter application process for HealthCare.gov for the 2015 sign-up period. There was once 76 online screens to apply for health plans in the past, but now there are only 16 screens for the basic application.
2. The HealthCare.gov website will be less likely to crash this year, as federal officials have revamped the site to handle at least 125,000 simultaneous users. However, the performance capabilities haven't been shown yet.
3. There are "window shopping" capabilities for health plans without creating an account. However, people still can't search for plans by physician name.
4. There will be a higher penalty next year for not having insurance. The penalty will now be $325 per person, or 2 percent of the annual household income — whichever is higher. This year the penalty was $95 per person or 1 percent of household income.
5. There are still many people who don't have insurance, and several who qualify for assistance don't realize they could access subsidies. These people will need personal assistance, likely even more than last year.
6. Around 7 million people who signed up for the exchange plans last year could revisit the marketplace to review their options and ensure their plans are still the best fit.
7. The Congressional Budget Office projected 13 million will be covered through PPACA next year.
8. There were around 7.3 million people enrolled in the exchanges as of mid-August 2014. That is 700,000 less than the enrollment number officially released in the spring, but exceeding CBO projections of 6 million.
9. There are 63 more insurers who plan to offer federal marketplace coverage in 2015. Preliminary data from 36 states with federal marketplaces show 57 more insurers offering plans next year, a 30 percent net increase over 2014.
10. States that established their own marketplaces have six more insurers offering plans on average next year. This would be a 10 percent increase over 2014.
Physician/spine payment
11. The AMA Editorial Panel also announced a new Category I CPT code for two-level cervical total disc arthroplasty. The procedure was previously reported by a Category III CPT code. The transition to a Category I Code will allow for the existing Category III CPT code to be updated to describe a three- or more-level arthroplasty.
12. Minimally invasive sacroiliac joint fusion is currently reported by a Category III CPT code, 0334T. The AMA created this procedure code effective July 2013. At the recent Editorial Panel meeting it was determined that the procedure had satisfied the evidence threshold necessary to transition to a Category I CPT.
13. In 2014, several Medicare contractors have updated their coverage to include minimally invasive sacroiliac joint fusion procedures, and more could join next year.
14. The 2014 CMS Final Physician Fee Schedule Rule significantly reduced reimbursements for several interventional pain procedures, including cuts for cervical and lumbar epidurals. Physicians now receive $42 payment for performing these procedures.
15. The 2014 CMS Final Physician Fee Schedule Rule that included payment rate decreases for physicians performing spinal cord stimulation in-office trials. However, facilities supporting procedures will receive an increase. Beginning Jan. 1, 2014, physicians were required to bill CPT 63650 for each lead implanted, which has been revalued to include the cost of trial leads.
16. The Sunshine Act went into effect this year and will continue to publish payment data from industry to physicians on their website next year. There have been reported glitches in the site, but during the first five-month period examined 4.4 million payments were made to more than 500,000 healthcare professionals, valued at $3.5 billion.
17. Anyone — including patients — is able to search the online database. The information is made public in an effort to promote transparency, which could eliminate unsavory behavior and inform patients about their physicians' payments. Some surgeons already disclose their industry ties to patients, and studies show in the spine field, patients don't think the financial relationship inhibits their surgeon's performance.
18. There are still issues with the Open Payments data — around 40 percent of the records aren't tied to a specific healthcare professional or hospital. These records account for around 64 percent of overall payments.
19. The average cost for a laminectomy for people without insurance coverage to treat spinal stenosis for people older than 50 is $50,000 to $90,000, according to a Cost Helper Health report.
20. Spinal fusion for patients without health insurance typically costs $80,000 to $150,000 or more, depending on which implants are used.
21. For patients with insurance, out-f-pocket costs require 10 percent to 40 percent coinsurance, with patients paying $200 to $2,000 or more out of pocket typically.
Health plans
22. Around two-thirds of Americans insured under the Patient Protection and Affordable Care Act plan to switch health plans in 2015, according to the Global Market Research survey.
23. Those who are covered under the PPACA plan to shop around for coverage but only 20 percent say they are unsatisfied with their current plan.
24. The top priorities for those who are planning to switch are lower costs and improved access to physicians.
25. Employers are expected to offer higher-deductible health plans in 2015, according to Kaiser Health News. The premiums are expected to rise around 4 percent next year.
26. Around 68 percent of employers are changing their 2015 health plans to keep cost growth in check. This is 55 percent higher than two years ago, according to Mercer.
27. There are around 75 percent of companies with more than 1,000 employees that offer high-deductible health plans linked to health savings accounts or health reimbursement arrangements.
28. Nine percent of companies with more than 1,000 employees plan to add high-deductible options.
29. Smaller company employees will likely have fewer changes in their coverage. For businesses with fewer than 50 employees with 80 percent planning to renew their small group plans, even when they were not compliant with the PPACA.
30. The Hill published a report showing nearly 50,000 Americans are losing their current health plans over the next few weeks leading up to the midterm elections due to healthcare reform. The cancellations are largely due to state regulators only allowing the "keep your plan" fix to last one year, and some insurers recently decided to stop offering old policies on their own.
CMS updates
31. The Centers for Medicare and Medicaid Services released the 2015 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Policy Changes and Payment rules in July. The proposed rule for next year includes 10 new spine procedures approved on the ASC payable list:
• Neck spine fusion & removable c2
• Neck spine fusion
• Lumbar spine fusion
• Spine fusion extra segment
• Neck spine disc surgery
• Laminectomy single lumbar
• Removal of spinal lamina (code 63045)
• Removal of spinal lamina (code 63047)
• Decompression spinal cord
32. The proposal recommends a 1.2 percent payment update for ASCs and 2.1 percent payment updates for HOPDs. Currently HOPDs receive 81 percent more than ASCs for the same services. If the rule is approved without changes, HOPDs would be paid 85 percent more than ASCs for the same services.
33. CMS is also proposing a transition of all 10-day and 90-day global codes to 0-day global codes by 2017 and 2018 because current global packages may not reflect the typical operative care provided. It's difficult to obtain data verifying the number, level and cost of postoperative visits in the global package. Many physician groups are opposed to the measure and have commented on the proposed rule, including the North American Spine Society.
34. CMS proposed increasing the requirements for successful PQRS reporting, but also would like to decrease the number of measures reported. The decrease would remove the Back Pain Measures Group and the Perioperative Measures group next year while still requiring spine care providers to meet nine measures across three National Quality Strategy domains.
35. Relevant PQRS measurements for neurosurgeons include:
• Osteoporosis: Communication with physician managing on-going care post-fracture of hip, spine or distal radius for men and women aged 50 years and older
• Osteoporosis: Management following fracture of hip, spine or distal radius for men and women aged 50 or older
• Osteoporosis: Pharmacologic therapy for men and women aged 50 years and older
• Screening or therapy for osteoporosis for women aged 65 years or older
• Osteoarthritis: Function and pain assessment
• Stroke and stroke rehabilitation: Venous thromboembolism prophylaxis for ischemic stroke or intracranial hemorrhage
• Stroke and stroke rehabilitation: Discharged on anti-thrombotic therapy
36. A federal audit shows several Medicare health plans improperly rejecting medical service claims, unjustly limiting coverage on prescription drugs and unfairly delaying patient access to care. The violations include:
• Aetna, which was fined $500,000 for "widespread and systemic failures" of managing prescription drug benefits for Medicare patients.
• Geisinger Health Plan in Pennsylvania, which faced fines of $184,000 for restricting access to certain prescription drugs.
• Tufts Health Plan in Massachusetts, which was fined $137,700 for eight serious compliance violations.
• Moda Health in Oregon, which had to pay $312,300 for a variety of violations regarding drug benefits, coverage decisions and the handling of consumer complaints.
37. Next year Medicare Part A premiums will decrease while Medicare Part A deductibles will increase. The Part A deductible will cost $1,260, up $44 from this year. Part B will have a $104.90 monthly premium, while the annual deductible is $147.
38. The HHS Office of Inspector General said CMS and state agencies need to strengthen access to care services for Medicaid managed care enrollees. The state standards for access to care vary significantly.
Medicaid expansion
39. Some states are still opting out of the Medicaid expansion. Here are the top 10 states with the largest coverage gaps according to the Kaiser Family Foundation:
1. Texas — 1.05 million uninsured fall into the coverage gap
2. Florida — 764,000
3. Georgia — 409,000
4. North Carolina — 319,000
5. Louisiana — 242,000
6. South Carolina — 194,000
7. Missouri — 193,000
8. Alabama — 191,000
9. Virginia — 191,000
10. Indiana — 182,000*
40. The National Committee for Quality Assurance ranked the top Medicare plans based on combined Healthcare Effectiveness Data and Information Set, Consumer Assessment of Healthcare Providers and Systems survey and NCQA Accreditation standards scores. Here are the top 10:
1. Kaiser Foundation Health Plan of Southern California
2. Kaiser Foundation Health Plan of Northern California
3. Kaiser Foundation Health Plan of the Northwest (Ore., Wash.)
4. Capital Health Plan (Fla.)
5. Kaiser Foundation Health Plan - Hawaii
6. Kaiser Foundation Health Plan of Colorado
7. HealthSpan Integrated Care (Ohio)
8. Kaiser Foundation Health Plan of Georgia
9. Kaiser Foundation Health Plan of the Mid-Atlantic States
(Washington, D.C., Md., Va.)
10. Geisinger Health Plan (Pa., N.J
41. The National Committee for Quality Assurance ranked the top Medicaid plans based on combined Healthcare Effectiveness Data and Information Set, Consumer Assessment of Healthcare Providers and Systems survey and NCQA Accreditation standards scores. Here are the top 10:
1. Network Health (Mass.)
2. Fallon Health Plan (Mass.)
3. Neighborhood Health Plan (Mass.)
4. Boston Medical Center HealthNet Plan (Mass.)
5. Neighborhood Health Plan of Rhode Island
6. Kaiser Foundation Health Plan - Hawaii
7. UnitedHealthcare Community Plan (R.I.)
8. AMERIGROUP New York
9. Meridian Health Plan of Michigan
10. Meridian Health Plan of Illinois
42. States with Medicaid expansion expect an 18 percent enrollment growth next year, according to the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.
43. Where Medicaid was expanded, there is an expected 18.3 percent spending increase, but only 4.4 percent increase in state spending.
44. The 23 states that haven't expanded Medicaid are expecting a 5.2 percent enrollment growth next year.
45. States without enhanced federal funds are expecting 6.8 percent increase in state spending for Medicaid.
Bundled payments
46. A new study published in The Spine Journal examines Medicare payments for episodes of spine surgery. Hospitals in the highest quartile reported episode payments more than twice the amount made to hospitals in the lowest quartile. The highest quartile received $34,171 on average for an episode of care, compared with $15,997 for the lowest quartile.
47. Total episode payments to hospitals in the highest quartile remained 47 percent higher than the lowest quartile even after risk- and price-adjustment. The average amount paid to these hospitals was $9,210 higher than the lowest quartile.
48. Even after adjusting for the type of procedure chosen — fusions are associated with higher costs — the hospitals in the highest quartile were still 28 percent more expensive than in the lowest quartile. According to the report, procedure choice is a major determinant of total episode payment.
49. Post-acute care use was also different across hospitals. The post-acute care use accounted for the bulk of residual variation in payments across the hospitals.
50. The hospital payments varied similarly after subgroup analyses for the three different procedures. The hospitals in the highest quartile for one procedure were also expensive for the other spinal diagnoses.
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