Medicare Plan for E/M Pay Draws Some Specialties' Opposition

Kerry Dooley Young

October 04, 2019

Medicare officials are facing opposition to their plan to increase pay for office visits for certain specialties such as family practice and endocrinology, while shaving it for others, including surgeons, ophthalmologists, and physical therapists, according to comments in its draft 2020 Medicare physician fee schedule.

The proposed schedule includes a proposal to change payment for evaluation and management (E/M) services, which covers office visits, in 2021.

The Centers for Medicare and Medicaid Services (CMS) said it is seeking to peg these payments to time spent treating the growing number of patients with greater needs and multiple medical conditions. The effort has the support of the American Academy of Family Physicians (AAFP), which asked CMS to speed up the timeline for the E/M overhaul.

Because "most family medicine practices already operate on extremely thin margins and these services have been undervalued for decades, we implore CMS to implement these changes in 2020 rather than 2021 as proposed," wrote Michael Munger, MD, AAFP's chairman, in a September 18 letter submitted to CMS in the comments section.

Some Win, Some Lose

But Medicare needs to find savings to offset increases within the physician fee schedule. Thus its E/M overhaul proposal would make cuts for some specialties.

In the draft physician fee rule's table 111, Medicare officials estimated that the combined impact of proposed E/M payment and coding policy changes would result in a variety of increases or decreases for multiple specialties.

Among them would be an increase of 16% for endocrinology, 15% for rheumatology, and 12% for both family practice and hematology/oncology.

But table 111 also shows decreases, such as a 10% drop for ophthalmology and 8% for cardiac surgery as well as physical and occupational therapy and pathology. Plastic surgery would be in for a 5% dip.

Not surprisingly, groups slated to receive cuts have asked CMS to reconsider this plan. In an August 30 letter to CMS included in the fee schedule comments, Robert S. D. Higgins, MD, president of the Society of Thoracic Surgeons (STS), said his group supports the agency's efforts to pay more for time spent with people with serious medical conditions.

But STS objects to how Medicare intends to redistribute more than $1.5 billion among medical specialties through the E/M payment overhaul, Higgins said. 

"STS appreciates that physicians should have a way to identify outlier patients where additional payment is warranted, regardless of service performed (surgical or office visit)," Higgins wrote.

With the proposal, Medicare would be "effectively destroying the relativity of the fee schedule and violating the law requiring that all physicians should receive the same payment for the same service," Higgins wrote in the STS letter.

STS also was among 53 organizations that sent CMS a joint letter on August 15 protesting its plan for E/M services. Other signers to this letter include the American College of Cardiology and the American College of Surgeons.

The dissenters question how Medicare intends to apply recommendations of a powerful panel of medical groups, the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC).

In the letter, the groups say that CMS is selectively using RUC recommendations in an "arbitrary, piecemeal fashion." The agency's failure to adjust certain measures, known as global codes, "is tantamount to paying some doctors less for providing the same E/M services, in violation of the law," the groups said in their letter.

CMS is in the process of reviewing the comments submitted on the draft 2020 rule, which it must finalize by November 1.

Congress Getting Involved

Members of Congress also have asked Medicare to reconsider its plan.

Many of the physicians serving in Congress signed a September 27 letter to CMS, which argued that the agency's approach would be "equivalent to paying some physicians less for providing the same E/M services."

Among the more than 20 signers to this letter were Republican physicians, including Reps. Phil Roe, MD, of Tennessee, and Andy Harris, MD, of Maryland, and Democratic ones, including Rep. Kim Schrier, MD, of Washington, and Raul Ruiz, MD, of California.

In addition, another group of lawmakers wrote to CMS protesting the proposed cuts for physical therapy.

"The timing of these cuts is particularly alarming as occupational and physical therapists are on the front lines addressing pain management for many who would otherwise have no other option than to utilize opioid medications to address their pain," wrote Rep. Bill Johnson (R-Ohio), and colleagues in their letter.

In its comment to CMS on the proposed 2020 physician fee rule, the American Medical Association (AMA) suggested that medical groups seek to broaden the pool of funds available for payment.

"CMS should work with the medical community to urge Congress to implement positive updates to the Medicare conversion factor to offset the justified increases to office visits," wrote James L. Madara, MD, AMA's chief executive, in the September 24 comment on the proposed rule.

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