With the clock running down on the latest “patch” to the Medicare Sustained Growth Rate (SGR), Congress next month may finally take up whether to scrap the formula Medicare uses to set physician payments, but short of that, it will probably forestall a looming 24 percent decrease in physician reimbursements with another patch.

In the process, Congress could have an opportunity to delay another government mandate: implementation of ICD-10 codes. While dismantling key Affordable Care Act components and outright repeal are dominating the attention of health policy experts since Republicans gained control of both houses of Congress, physicians are more focused on what will happen as the latest SGR patch runs out March 31. 

“The answer to SGR relief is probably what’s happened all the other times; if the SGR doesn’t get fixed, there will almost certainly will be a patch and of course, it will probably be at the last minute,” says Michael X. Repka, MD, AAO medical director for governmental affairs. 

A better answer would be to permanently fix the SGR by repealing or restructuring it. The American College of Physicians, for example, has called on Congress to replace SGR with a program of incentives for physicians to improve quality and participate in innovative delivery systems like patient-centered medical homes.

The current price tag for a permanent SGR fix is about $144 billion, and last year Congress was close to doing just that but then backed away when Democrats and the GOP could not agree on how to pay for it, Dr. Repka says. “In terms of getting it fixed, I guess one would say we have both houses that are run by a single party; maybe there’s a better chance of getting an agreement to have something passed,” he says. 

However, Congress must contend with the “pay-for rule,” the Congressional mandate that federal budget cuts must offset any new spending. If Congress can waive that and reach agreement on an SGR fix, President Obama would probably sign it unless the fix taps into the Affordable Care Act to fund it, Dr. Repka says. Both Congressional caucuses discussed a permanent SGR fix at their respective retreats last month, according to Dr. Repka. “Maybe they’ll have a plan,” he says.

Without a permanent solution, continuous patching will only cost more. The Congressional Budget Office has estimated the cost of patches over the next 10 years at around $16 billion. 

When Congress passed the SGR patch last year, it also voted to delay implementation of ICD-10 by a year to October 1, 2015. A similar scenario could play out again this year, says Rob Tennant, Medical Group Management Association senior policy adviser for government affairs. Since last year, resistance to another delay has hardened, led by the so-called Coalition for ICD-10 comprised of health insurers and health information management groups. While the AMA is pushing for another delay, the MGMA has not taken a position. 

The AAO does have reservations about the ICD-10 deadline. “We have commented before to CMS that we thought that Oct 1 was a bad date to do it because it was not in synch with all the other reporting requirements for PQRS, but that’s more of a technical detail,” Dr. Repka says.


A New Clue to the Trigger for AMD
New research from scientists at the University of Maryland School of Medicine has found that tiny lumps of calcium phosphate may be an important triggering factor for age-related macular degeneration. This is the first time these mineral deposits have been implicated in the disease, which affects more than 10 million Americans. The article appeared in the Proceedings of the National Academy of Sciences.

Biochemist Richard Thompson, PhD, along with his colleague from University College, London, Imre Lengyel, PhD, and a multidisciplinary international team studied retinal samples from a group of elderly patients, some of whom had AMD. They found that the AMD samples contained tiny spherules of a mineralized calcium phosphate known as hydroxyapatite, or HAP. HAP is common in the body—it comprises the hard part of bones and teeth—but it had never been identified in that part of the eye before.

AMD develops slowly over decades, with the buildup of fatty protein deposits in the retina, which cause damage by blocking the flow of nutrients into the light-sensitive portion of the eye, and of waste products out. Scientists have known about these deposits for over a century, but their origins remained a mystery. Dr. Thompson and Dr. Lengyel discovered that the deposits appear to form around the tiny bits of HAP. Once these chunks appear, the fatty protein material coalesces around it; over years, these globules build up.

They discovered the possible role of HAP by examining tissue samples from patients using X-ray diffraction and fluorescent staining chemicals. “We had no idea that HAP might be involved,” says Dr. Thompson, who is an associate professor of biochemistry and molecular biology at the school. “That’s what makes this work so exciting. It opens up a lot of new research opportunities.”

The researchers are looking into the possibility of using the presence of HAP as an early warning signal for AMD risk with a hope that this will aid early intervention before patients have suffered irreversible vision loss. Eventually, they say, it may be possible to devise methods to reduce HAP deposits or limit the growth and progression of the disease. “We think HAP plays a key role in this process,” said Dr. Lengyel. “This is a new explanation for how these deposits start.”

“This work epitomizes the school’s mission,” said Dean E. Albert Reece, MD, PhD, MBA, who is vice president for Medical Affairs, University of Maryland, and the John Z. and Akiko K. Bowers Distinguished Professor and Dean of the School of Medicine. “Dr. Thompson and his colleagues have provided new insight into the deep mechanisms of this terrible disease, and in doing so, they have created new avenues of research that have the potential to help millions of people.”

The work was supported in part by the Bright Focus Foundation in the United States and the Bill Brown Charitable Trust in the UK.


A New Tack in Avoiding TED
A University of Michigan study reports that patients with Graves’ disease had a significantly reduced risk of developing thyroid eye disease after taking statins or undergoing surgical removal of the thyroid. The study, based on an analysis of health-care claims data and published in the December issue of JAMA Ophthalmology, suggests that physicians may, for the first time, be able to modify their patients’ risk for TED through medical or surgical intervention.

Individuals with Graves’ disease, an autoimmune condition characterized by overproduction of a thyroid hormone, often develop TED, which can cause bulging eyes, double vision, dry eye and in some cases, vision loss. “Previously, aside from recommending not smoking cigarettes, we did not know of ways to prevent TED from developing in patients with Graves’ disease,” says Joshua D. Stein, MD, MS, a study author and health-services researcher at the University of Michigan Kellogg Eye Center. “There are only a few known risk factors that can be modified, for example, smoking and exposure to radioactive iodine.”

Dr. Stein and colleagues analyzed longitudinal health-care claims data for 8,404 individuals with newly diagnosed Graves’ disease. The data included the patients’ diagnoses, tests ordered, medications prescribed and surgeries performed. Of that group, 8.8 percent eventually developed TED.

The study found that surgical thyroidectomy, alone or combined with medical therapy, was associated with a 74-percent decrease in risk for TED, compared with radioactive iodine therapy (RAI) treatment alone. Statin use for 60 or more days was associated with a 40 percent reduced risk for developing TED compared to less or no use of statins.

“We wanted to know whether medications or other interventions could keep patients with Graves disease from developing TED,” says co-author, Raymond S. Douglas, MD, PhD, oculoplastics surgeon and director of Kellogg’s Thyroid Eye Disease Center. “Specifically, we investigated whether standard approaches for managing hyperthyroidism in Graves’ disease—anti-thyroid medications, RAI therapy and thyroidectomy—altered the risk of developing TED.”

The team chose to investigate statins, a drug class typically used to lower cholesterol, after reviewing recent studies showing that statins also reduce inflammation, which is believed to play a role in TED. The study authors also say that several reports have shown that statins reduce fibrosis and excess connective tissue in the orbit associated with the eye disease.

While the findings are promising, the authors propose to conduct a clinical trial before recommending any changes in treatment. Dr. Stein adds that because all treatments have side effects, it will be important to learn whether statins or thyroidectomy offer patients with Graves’ disease benefits that outweigh the risks associated with these interventions.