• Political

I'm sitting at the Society of NeuroInterventional Surgery annual meeting in San Francisco. As usual, I am enjoying the wondrous variety of materials that are being presented. Having rotated off the board of directors a number of years back, I find myself able to participate in the sessions in a more robust way than previously. There are new technologies, existing ones that are iteratively improved, emerging concepts for classic diseases, and many other topics that continue to come to the fore.

For the entirety of my career, I've watched neurointerventional (NI) surgery grow in strength, scope, and power. Close to three short decades ago, industry allowed for NI specialists to reproducibly enter the intracranial circulation with a commercially manufactured microcatheter. In 2015 we are celebrating the 25th anniversary of the first detachable coil, the Guglielmi detachable coil—this changed our NI world. A similar seismic shift is occurring after publication of the positive endovascular stroke trials. While these historic moments in our specialty have been intended by design, they have occurred within broader historic changes in healthcare policy that will continue to mold our NI sphere. To some extent, while those policy changes are themselves thoughtfully designed, their power can derive from unintended consequences.

Until recently, the single biggest development in the delivery of US healthcare in the last 50 years was Title 18 of the Social Security Act: the creation of Medicare. Who can forget the iconic image of the former President Harry Truman receiving the first Medicare insurance card?

When Medicare was established in 1965, physicians received payments based on their usual and customary charges. Indeed, providers were encouraged to balance their books by billing beneficiaries for the full amount of the bill—that is, the difference between what Medicare paid and what they charged. Physicians were thus paid the full amount that they charged for each service. This system was modified in 1975; payments could not exceed the increase in the Medicare Economic Index (MEI), a fixed fee schedule that was based on 1973 prices. The MEI approach failed to contain costs. This led to a legislatively mandated change in fees from 1984 to 1991.1 The Omnibus Budget Reconciliation Act of 1989 established a Resource-Based Relative Value System (RBRVS) as the basis for professional side physician reimbursement. This went into law in January 1992. This Relative Value Unit (RVU) system with which our current cadre of practitioners are familiar became the dominant method of paying professional side fees and moved things away from reimbursement based on usual and customary charges. In order to fix the federal budget deficit, the Sustainable Growth Rate (SGR) was introduced in 1998. While the budget was indeed balanced in subsequent years, the SGR remained in place—hanging like a sword of Damocles over providers that accepted Medicare.2

Although facing increasing criticism, often from primary care providers, the RBRVS system has continued to be important for determining specialty reimbursement. Through a complex interplay between various American Medical Association committees and the Center for Medicare and Medicaid Services (CMS), physicians engaging with their members provide feedback on what they believe fair payment for services ought to be.3 ,4 Neurointerventionalists (while not uniquely represented) enjoy the support of friendly societies, most notably the American Society of Neuroradiology and the American Association of Neurologic Surgeons.

In 2010, President Obama signed the Affordable Care Act (ACA) into law. Unfortunately, this was one of the most contentious legislative issues in recent memory and divided uniquely along party lines. There are multiple goals associated with the ACA; intrinsic to the title is the concept of making medicine more affordable. Terms like ‘accountable care’ entered the vernacular and providers prepared to shift into a value over volume paradigm.5 ,6

The first few years of the ACA remained quite acrimonious and dominated several election cycles. Five years later, despite multiple house resolutions, there remains a number of components that would be difficult to roll back. Moreover, the Supreme Court has sided with the administration on the issues on which they have expounded.7 My point is that, whether one likes it or not, the ACA is probably here to stay.

Sylvia Burwell, the Secretary of Health and Human Services, opted to sketch out some of her plans for transforming healthcare delivery in a comment in the New England Journal of Medicine in January 2015 and we analysed her approach in this journal.8 ,9 She laid out an ambitious agenda for the transformation of volume-based to value-based care. The time frame for that change was such that people entering training today would find themselves in a value-driven world by the time their endovascular fellowship was complete.

The ACA did not specifically address the SGR. Somewhat surprisingly, the political parties worked together to produce the Medicare Access and Chip Reauthorization Act (MACRA). The headline news was that the SGR was permanently repealed. The less studied but equally important information to assimilate is that both political parties in both houses of government voted, in overwhelming fashion, to codify methods of transforming volume-based care into value-based approaches. One could argue that, while in some ways this might delay Burwell's suggestions, the reality is that, with bipartisan bicameral support, it is now clear that the value-driven agenda is here to stay.10 ,11

NI specialists, by and large, exist currently in a fee for service environment. The interplay between the CMS, Current Procedural Terminology (CPT) and the Relative Value Scale Update Committee has resulted in clearly defined component codes associated with the neurovascular procedures that we perform.12 ,13 Critics of component coding believe that this system incentivizes practitioners by allowing for additional billing for more procedures that are done. An example would be performing a four vessel cerebral arteriogram when a single injection would suffice.

Value-based programs change this dynamic entirely. Rather than receiving an explicit fee for an individual service, neurointerventionalists would find themselves sharing from a larger pool and needing to justify their roles in the patient care continuum. This carries both risk and opportunity. Ischemic stroke provides an insight into areas where optimized patient care might easily line up with value. If one can demonstrate that the system is less strained by the upfront cost of expensive endovascular treatment, people with enterprise wide responsibilities will be highly supportive of doing it.14 ,15

However, activities and procedures that NI practitioners might take for granted, such as diagnostic cerebral angiography, would probably need to be evaluated in the context of alternative studies. This evolution is well underway in other elements of diagnostic radiology and, indeed, is now largely assumed as part of the patient care reality.16 Value-driven models would ensure that non-NI colleagues will be asking many of those questions. To date, there are very few NI specialists leading the charge on developing alternative payment models.

I believe that NI specialists can do well in the value-driven models of the near future. However, this will require us to come to the realization that the broader world around us has changed. The question is no longer whether we can do these procedures, but whether each procedure that we do is adding value to overall patient care. As stewards of NI, we need to be able to answer that question and to defend that which we state. The future of our changing neurointerventional world depends on it.