December 16, 2020
By Julie Gould
Peter Hollmann, MD, president- elect of the American Geriatrics Society and co-chair of the American Medical Association, discusses the recent news from CMS in regard to improvements made in reimbursement for geriatrics and primary care under the 2021 Medicare PFS final rule, highlighting how these cuts impact patient care.
Can you talk a little about the recent news from CMS in regard to improvements made in reimbursement for geriatrics and primary care under the 2021 Medicare PFS final rule?
The office visit codes, which account for approximately 20% of the spend under the physician fee schedule, were revised by the AMA Current Procedural Terminology (CPT) Editorial Panel to respond to concerns that the structure of code selection based upon history, exam, and medical decision-making was administratively complex, resulted in unnecessary documentation, and failed to reflect what mattered most in care of the patient in the office setting. Additionally, revisions then led to the codes being assessed by the AMA/Specialty Society Relative Value System Update Committee (the “RUC”) for their recommended relative value, and it had long been felt that these services were undervalued. The RUC recommended increased values for the higher-level codes, based on survey data about work effort, and time and practice expense data.
CMS accepted these recommendations, but the agency still felt that these values inadequately addressed the work and expense of providing longitudinal care in the office. It therefore created a complexity add-on code (a code added to the primary service) for the primary care of chronic condition or conditions or the specialty care of a serious condition. CMS expects this code will be added to most office visits, but prohibits its addition to other visit types, such as nursing facility visits.
These combined events will significantly increase payments overall for professionals who predominantly perform office visit services, thereby benefiting primary care physicians and geriatricians who practice in the office.
Another significant action in the final rule relates to extending telehealth services during the pandemic. Medicare continues to be very responsive to meeting the needs of patients who are unable to get care in person and their clinicians
According to a recent press release from AGS, the organization has expressed “deep disappointment that the final rule fails to address the impending 8- to 10% cuts to nursing home, home, and domiciliary services.” Can you talk a little about how these cuts impact patient care and what you hope to see in the future to improve this? How can facilities help ensure this issue is addressed (is there anything specific facilities can do)?
Medicare has a system called “budget neutrality.” This means that any fee increase in one service is funded by a fee reduction in all other services. This way, if the volume and type of services do not change, the total payments will not change. Medicare pays for services by determining relative value units and then multiplying them times a conversion factor. The conversion factor is decreased if the projected total pool of relative value units is increased. Ironically, even the services that see an increase in relative values do not see a corresponding increase in reimbursement because the conversion factor drops. Changes in this year’s Medicare PFS dropped the conversion factor by roughly 10 percent. As a consequence, all unchanged services in the PFS – including home, assisted living and nursing home services -- will see payment drop by this percentage. We are concerned that cuts of this size will challenge the building and maintenance of a workforce willing to provide such services and create barriers to access to care. Home health and assisted living patients could be pushed to be seen in the office. In an odd twist, doing a telemedicine visit for the assisted living or home health patient will pay significantly more than going to see the patient when it is reported with the office code and complexity add-on, compared to using the home or assisted living code of the same level.
We hope that Congress will act to change the budget neutrality impacts, which exist by statute. The AMA E/M work group that I co-chair is also revising the other evaluation and management codes with a goal to have changes in effect in 2023, but we do not know how valuation will be affected, even if the code change process goes as planned. While 2023 seem a long way off, this is a process that takes considerable time because of the need for Medicare to post proposed changes and take comment.
Health care professionals and caretakers are currently major players navigating through the pandemic for the care of older adults. How do you believe the reduction payments will impact facilities – especially during a time of COVID-19?
Practices are already very financially stressed by the pandemic. Sadly, nursing homes have been hot spots for infection and workers have been at higher risk for infection, especially when personal protective equipment was in severely short supply. Navigating the pandemic has required constant adaptation and flexibility. People are getting tired. Getting a 10 percent cut in payment will increase the stress and may push some facilities past the brink. A challenging field has just gotten more challenging.
What do you hope to see happen in the coming months to better address the care of older adults?
There is much to do, but I will focus on two specific things that require Congressional action; CMS cannot do this on its own. The first would be to stop the cuts by changing the requirement for budget neutrality for at least two years. The second would be to make telemedicine services for long-term care facility residents covered by Medicare after the pandemic. This would include audio-only services, so that our patients who lack or cannot use more advanced communications technology can receive services.
Is there anything else you would like to add?
All the health care workforce that provides home, assisted living, post-acute and long-term care—including not only physicians, but other licensed professionals like certified nursing assistants and environmental services worker—has performed courageously and with extreme dedication. Our nation owes a debt of gratitude to these underrecognized individuals.
About Dr Hollmann
Peter Hollmann, MD, practices geriatrics in Rhode Island with Brown Medicine, more specifically the academic practice foundation for the Department of Medicine at Brown University Warren Alpert Medical School. He also serves as the President- Elect of the American Geriatrics Society and co-chair of the American Medical Association (AMA) workgroup on Evaluation and Management codes.
American Geriatrics Society. AGS calls on congress to protect our most vulnerable citizens by preventing cuts to key services [press release]. https://www.americangeriatrics.org/media-center/news/ags-calls-congress-protect-our-most-vulnerable-citizens-preventing-cuts-key. December 4, 2020.