October 3, 2001 Ms. Nancy Edwards Room 443-G Hubert H. Humphrey Building 200 Independence Avenue, SW Washington, DC 20201 Re: Federal Register Vol. 66, No. 165, Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2002 Payment Rates Dear Ms. Edwards: On behalf of the American Health Quality Association (AHQA), the membership organization of state-based Quality Improvement Organizations (QIOs), thank you for the opportunity to provide comments on the proposed revisions to payment policies under the Hospital Outpatient Prospective Payment System. AHQA is concerned that the August 24, 2001 proposed rule will interfere with an existing multiyear initiative at the Centers for Medicare and Medicaid Services (CMS) designed to improve the quality of care provided to Medicare beneficiaries. CMS has already invested significant resources to increase the frequency with which mammography services are utilized by Medicare beneficiaries. AHQA is opposed to any rule that reduces ready access to these vital and demonstrably underutilized mammography services. Quality Improvement Organizations (QIOs) are under contract with CMS to increase screening mammography rates among Medicare beneficiaries. This clinical priority area was selected by CMS because of strong scientific evidence that increasing the rate of screening mammography will result in an improvement in the quality of care received by women enrolled in the program. Appropriate and timely administration of mammography studies increases the percentage of new breast cancer cases detected at stage 1. Research has proven that women whose breast cancer is detected at earlier stages are more likely to have positive responses to treatment, and thus successful outcomes. AHQA has followed both of CMS' August Federal Notices pertaining to mammography screening services. We applaud CMS' proposal published in the August 2, 2001 Federal Register (Vol. 66, No. 149, pp. 40372-40420) that revised the Physician Fee Schedule to increase the "physician work value" payment for diagnostic mammograms by 26% for bilateral studies and 21% for unilateral studies. The proposed new rate for diagnostic physician services better recognizes the expertise and effort required for diagnostic mammograms. We are also encouraged that this rule preserves the technical reimbursement rate for screenings at $50.70 through calendar year 2002. However, should CMS use the new diagnostic APC groups as a reimbursement model for screening services, this would reduce payments and would likely reduce access to these services. The proposed rule cites the similarity in the physician work value and technical cost associated with a unilateral diagnostic mammogram and a screening mammogram. Although the rule clearly preserves the calendar year 2001 technical reimbursement rate through calendar year 2002, it implies that the value of the screening mammogram should be the same as the value for a unilateral diagnostic study. We object to the Federal Register notice published on August 24, 2001 (Federal Register, Vol. 66, No. 165, p. 44804) that reduces reimbursement for the technical costs of performing diagnostic exams, which adversely affect payment policy affecting screening mammograms. The proposed reimbursement rate for diagnostic studies is substantially lower than the actual cost of performing the study, particularly since diagnostic exams require a higher level of technical and professional involvement than screenings. We are concerned the proposed rate for unilateral studies, if applied to screening studies, will set back CMS' national initiative to improve the frequency of mammography screening in women who are Medicare eligible and under 75 years of age. The median national rate for such screenings is only 49.2% (JAMA 2000, Vol. 284, No. 18: p. 2329). Under the payment structure proposed in the August 2, 2001 rule, hospitals performing screening mammography will bill for technical services under the Physician Fee Schedule that sets screening technical reimbursement at $88.50. Approximately $51.00 of this fee is provided to cover technical costs. This fee already represents a reimbursement rate that is considerably lower than the national average for technical costs. The American College of Radiologists estimates the technical cost component of hospital-based outpatient screening mammography is $97.48. CMS' proposed rule issued on August 24, 2001 for Hospital Outpatient Prospective Payment appears to conflict with your August 2, 2001 rule for the Physician Fee Schedule. The August 2, 2001 rule values technical costs associated with screenings the same as unilateral screens and lists the technical reimbursement rate at approximately $51.00. The August 24, 2001 rule values the technical costs of unilateral screens at $32.54. We understand that CMS has recognized the lack of congruency between these two payment policies. Since screens are generally less expensive to perform than diagnostic studies, it makes little sense to pay more for the less expensive study. However, we are concerned that if CMS chooses to correct the conflicting policies by placing screening in the APC group with diagnostic studies, this 36% cut in technical payments to hospitals providing screening mammography will reduce the number of hospitals willing to provide screening mammographies to Medicare beneficiaries. We believe this result is plausible because of the tremendous disparity between the technical cost of providing the service ($97.48) and the payment received ($32.54). Many communities will find it difficult to replace hospital-based services, potentially leaving thousands of women without access to mammography services at a time when CMS is attempting to increase use of these services. The impact of this new rule will be particularly damaging to Medicare beneficiaries living in rural environments. The Health Services Advisory Group, Inc., the QIO for Arizona, shared the following with AHQA: "Arizona is one of the fastest growing states in the nation, yet our state currently has only 159 FDA certified mammography facilities, twenty percent fewer than in 1999. Beneficiaries wait up to 4 months for screening mammography in the Tucson area. Sixty percent of FDA certified mammography facilities outside the...major metropolitan areas are hospital based." The Georgia Medical Care Foundation, the QIO for Georgia, echoed Arizona's concern: "We have a conservative estimate that approximately 61% of Georgia's mammography facilities are in hospitals. In rural Georgia, approximately 71% of these facilities are hospital based. These rural, hospital-based facilities, which represent over half of Georgia's mammography facilities, will most likely be negatively impacted by these cost cutting measures." There is evidence that improved access to screening mammography services results in an increase in screening rates. Any policy that decreases the number of facilities providing screening services runs the risk of decreasing the rate of screening mammograms. In 1998, researchers (Phillips, et al.) at the University of California-San Francisco published a study entitled "Factors Associated with Women's Adherence to Mammography Screening Guidelines" (Health Serv Res 1998, Vol. 33(1), pp. 29-53). Among the list of principal findings, the authors concluded that women were more likely to adhere to screening recommendations of once every 2 years if they lived in an area with a higher percentage of mammography facilities and those facilities used reminder systems. As CMS further evaluates the implications of the proposed rules issued on August 2 and August 24, 2001, we would appreciate the opportunity to comment on future proposals dealing with screening mammograms. For questions regarding our comments, feel free to contact Mark Boesen, Pharm.D. or Ms. Jolie Crowder, MSN, R.N. at the address or phone number on our stationery or by e-mail at mboesen@ahqa.org or jcrowder@ahqa.org. Sincerely, David G. Schulke Executive Vice President