Medicare Sticks With E/M Pay Plan Over Some Groups' Objections

Kerry Dooley Young

August 04, 2020

The Trump administration is sticking with a plan to boost certain Medicare pay for many primary care and other specialties focused heavily on office visits while lowering that for other groups to balance these increased costs.

On Tuesday, the Centers for Medicare & Medicaid Services (CMS) posted on the Federal Register draft versions of two of its major annual payment measures: the physician fee schedule and the payment rule for hospital outpatient services. On Monday evening, CMS informally posted a copy of the physician fee schedule on its own website, allowing medical groups to begin reading the more than 1300-page rule.

Federal officials normally use annual Medicare payment rules to make many revisions to policies as well as adjust reimbursement.

The draft 2021 physician fee schedule, for example, calls for broadening the authority of clinicians other than physicians to authorize testing of people enrolled in Medicare.

CMS intends to allow nurse practitioners, physician assistants, and certain other health care professionals to more widely supervise diagnostic psychological and neuropsychological tests, in keeping with applicable state laws.

The draft 2021 hospital outpatient rule proposes a gradual changeover to allow more procedures to be performed on an outpatient basis. This shift could save money for Medicare as well as for the people enrolled in the giant federal health program who need these services, CMS explains.

Medicare would begin with a change in status for almost 300 musculoskeletal-related services, making them eligible for payment in the hospital outpatient setting when appropriate, CMS writes in a fact sheet.

The initial reaction to Medicare's proposed 2021 rules centered on its planned redistribution of funds among medical specialties. CMS had outlined this plan last year. It is part of longstanding efforts to boost pay for primary care specialists and other physicians whose practice centers more around office visits than procedures.

There is broad support in health policy circles for raising pay for these specialties, but there also are strong objections to the cuts CMS plans to offset the cost of rising pay for some fields.

Susan R. Bailey, MD, president of the American Medical Association (AMA), addressed both of these ideas in an AMA news release on the proposed 2021 physician fee schedule. The increase in pay for office visits, covered under evaluation and management services (E/M), stems from recommendations on resource costs from the AMA/Specialty Society RVS Update Committee, Bailey said.

"Unfortunately, these office visit payment increases, and a multitude of other new CMS proposed payment increases, are required by statute to be offset by payment reductions to other services, through an unsustainable reduction of nearly 11% to the Medicare conversion factor," Bailey explained.

In the news release, Bailey asked Congress to waive Medicare's budget-neutrality requirements to allow increases without the cuts.

"Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time," she said.

Winners and Losers

CMS details the possible winners and losers in its payment reshuffle in Table 90 of the proposed 2021 physician fee schedule. In the proposed rule, CMS notes in the draft that these figures are based upon estimates of aggregate allowed charges across all services furnished by physicians and other clinicians.

"Therefore, they are averages, and may not necessarily be representative of what is happening to the particular services furnished by a single practitioner within any given specialty," CMS said.

Specialties in line for increases under the 2021 draft rule include allergy/immunology (9%), endocrinology (17%), family practice (13%), general practice (8%), geriatrics (4%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (8%), rheumatology (16%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–9%), emergency medicine (–6%), general surgery (–7%), infectious disease (–4%), neurosurgery (–7%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–11%), and thoracic surgery (–8%).

An umbrella group, the Surgical Care Coalition, on Monday night had a quick statement ready about the CMS proposal. Writing on behalf of the group was David B. Hoyt, MD, executive director of the American College of Surgeons.

"Today's proposed rule ignores both patients and the surgeons who care for them. The middle of a pandemic is no time for cuts to any form of health care, but today's announcement moves ahead as if nothing has changed," Hoyt said in a statement provided to Medscape Medical News. "The Surgical Care Coalition believes no physician should see payment cuts that will reduce patients' access to care."

The Surgical Care Coalition already has been asking Congress to waive budget-neutrality requirements. Making a similar request Tuesday in a unified statement were the American Physical Therapy Association (APTA), the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA).

"Our organizations call on Congress and CMS to advance well-reasoned fee schedule payment policies and waive budget neutrality," the groups said. "While APTA, AOTA, and ASHA do not oppose payment increases for primary care physicians, we believe these increases can be implemented without imposing payment reductions on other providers."

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