On July 12, the Centers for Medicare and Medicaid Services (CMS) issued its proposed plan for changes to the Medicare Physician Fee Schedule for 2019.1 Citing the need to reduce paperwork and improve patient care, the CMS detailed a number of changes to payments physicians receive from Medicare that could have a significant impact on rheumatologists.
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Among these proposals is a change that would collapse evaluation and management (E/M) coding levels into one level and impose an associated cut in reimbursement for E/M services.2 Under the proposed plan, physicians would receive a flat fee for reimbursement of E/M services regardless of the complexity of a patient’s condition. The goal, as stated by the CMS, is to reduce paperwork by eliminating the current payment schedule based on the complexity of the clinical visit (coded as visit level 2-5) and, thus, eliminate the need to audit against visit levels.
Where the ACR Stands
The ACR is deeply concerned about this proposed change and is taking a leading role among specialty organizations in urging the CMS not to move forward with the proposed cuts by emphasizing the need for appropriate reimbursement for complex critical care required for the practice of rheumatology and for the optimal care of patients. “The E/M services [provided] by rheumatologists are critical for effectively managing and reducing the long-term functional and economic costs of many debilitating diseases,” said ACR President David Daikh, MD, in a press release issued through the College.3 “These proposed cuts will have significant negative impacts on rheumatology practice.”
In prioritizing advocacy on this issue the ACR is building a broad coalition engaging with Capitol Hill and with CMS to stop this proposal from moving forward. The ACR is convening physician organizations and patient groups in coalition efforts to have members of Congress weigh in with CMS urging the agency to not move forward with the concepts as proposed, and instead work with stakeholders to identify other ways to decrease documentation burden that would not impair patient access to care.
Bad for Patients
In responding to the CMS proposals, the ACR emphasized the impact of reducing reimbursement for E/M services on the practice of rheumatology that would ultimately result in cutting off access to critical care for many rheumatology patients.
One primary way this could happen, says Angus Worthing, MD, the ACR’s Government Affairs Committee chair, is that rheumatologists may feel pressured to stop seeing Medicare patients because of insufficient reimbursement for E/M services.
“Because rheumatologists generally see patients that are more complex than average, and engage in cognitive services instead of procedures, rheumatologists will likely face reimbursement cuts if this proposal goes into effect, “he says. “Since even small reimbursement cuts are magnified after overhead expenses are paid, rheumatologists may face pressure not to participate in Medicare.”
To put this into numbers, the CMS estimates a 3% cut in reimbursement for E/M services. Such a cut, says Dr. Worthing, could be magnified by a multiple of 2 or 3 because of fixed and rising business overhead costs. For a rheumatologist with an overhead of 70%, he says, a 3% reimbursement cut may actually look more like a 10% salary cut once overhead costs are figured in.
Colin Edgerton, MD, chair of the ACR committee on Rheumatologic Care, highlighted the impact this type of financial strain will have on patient care. “Patients will suffer; they may see reduced access to rheumatologists, shorter appointments and a focus on treating fewer complaints during each appointment,” he says.
Both Drs. Worthing and Edgerton also worry about the effect this reduction in reimbursement will have on attracting needed physicians to the specialty of rheumatology.
“A bigger concern is that rheumatology is already facing a significant projected workforce reduction,” says Dr. Edgerton. “These cuts make rheumatology a less attractive specialty for graduating residents and may further reduce the number of available rheumatologists in the future.”
Priority No. 1 & How You Can Help
The ACR has made this issue its current No. 1 advocacy priority. The ACR is leading a broad coalition of stakeholders, including other medical specialties and patient groups, to advocate against the proposed changes, says Dr. Edgerton.
In addition, the ACR is meeting with lawmakers and staff on Capitol Hill and the CMS, as well as talking to media outlets. The New York Times and National Public Radio recently covered the ACR’s opposition to the proposal.
“The ACR will be sending public comments and working with partners, like the American Academy of Neurology, to organize a letter to Capitol Hill for members of Congress to express concerns with CMS, as well as a coalition letter to the CMS asking it not to proceed with this proposal that could reduce access to rheumatology care,” says Dr. Worthing.
He adds that help from members is especially needed. “Democracy requires informed input from as many people as possible, and I encourage ACR/ARHP members to send an email to their members of Congress through the ACR Legislative Action Center and to send comments directly to CMS.” Contributions to RheumPAC from U.S.-based ACR and ARHP members are another way members can get involved in the efforts.
The proposed plan is open for public comment until Sept. 10. If you’d like to send an email to your state’s members of Congress voicing your concerns, visit the ACR’s Legislative Action Center.
You can also send comments directly to the CMS.
Mary Beth Nierengarten is a freelance medical journalist based in Minneapolis.
- Centers for Medicare and Medicaid Services. Proposed policy, payment and quality provisions changes to the Medicare Physician Fee Schedule for calendar year 2019. Fact Sheet. 2018 Jul 12. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html.
- Calendar year (CY) 2019 Medicare Physician Fee Schedule (PFS) proposed rule: Documentation requirements and payment for evaluation and management (E/M) visits & advancing virtual care. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/CY2019-PFS-NPRM-Doc-Requirements-and-Payment-E-M-Visits-and-Advancing-Virtual-Care.pdf.
- American College of Rheumatology responds to the CY 2019 Physician Fee Schedule and Quality Payment Program proposed rules. Press Release. 2018 Jul 19. https://www.einnews.com/pr_news/455988190/american-college-of-rheumatology-responds-to-the-cy-2019-physician-fee-schedule-and-quality-payment-program-proposed-rules.