On Call: The Newsletter of the Alliance of Specialty Medicine
Medicare Payment on the Chopping Block Again
Annual Proposed Cut Will Mark Another Year of Cuts to Physicians
Another year, another proposed cut to physician Medicare payments. With the summer unveiling of the Calendar Year (CY) 2024 proposed Medicare Physician Fee Schedule (MPFS), physicians who treat Medicare patients will see an estimated pay cut of 3.4%. This is the 4th straight year that physicians will have to endure a cut. By contrast, most of the other Medicare providers will again anticipate sizeable increases in their 2024 payments (e.g., inpatient hospitals (3.1%); inpatient rehabilitation facilities (3.4%); hospices (3.1%); hospital outpatient departments (2.8%); and Medicare Advantage plans (3.32%)).
The estimated 3.4% cut is due to several factors, none of which focus on the quality of the care that physicians provide to Medicare patients or the growing need for specialty care by the ever-enlarging Medicare population. Instead, physicians are on the hook due to outdated statutory budget requirements and a Congress that is slow to change them.
The first statutory requirement is budget neutrality. As mandated by section 1848(c)(2)(B)(ii)(II) of the Social Security Act (SSA), increases or decreases in the value of physician fee schedule services may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. When values are adjusted, and the threshold is exceeded, CMS adjusts – usually downwards – the conversion factor, resulting in across-the-board reductions to all physicians. For example, in the CY 2024 MPFS, CMS intends to implement a new “complex care” add-on code, prompting a 2% reduction to the conversion factor. While the addition of the new service may benefit some specialties, it will come at a high cost to others, hence the sentiment that the current physician fee schedule payment mechanism is simply “robbing Peter to pay Paul.”
The second statutory requirement is that payments to Medicare physicians cannot be adjusted for inflation. Prior to the enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician practice costs were on the rise, with the price of medical supplies, equipment, and clinical and administrative labor at substantial levels. MACRA established physician payment updates without a yearly automatic inflation adjustment. Given the lack of an automatic payment update, Medicare physician payments declined 26% from 2001 to 2023 when adjusted for inflation in practice costs. While Congress anticipated that physicians would receive value-based incentives and differential payment updates based on their participation in either the Merit-based Incentive Payment System (MIPS) or the Alternative Payment Model (APM) tracks through MACRA, many factors have led to insufficient payment updates, particularly when compared to the effort and resources physicians must devote to participate. The Medicare Trustees and other policy experts have raised concerns about the lack of an inflation measure in the MPFS. This downward financial pressure on physicians and their practices has forced many to sell their practices to health systems and private equity groups and enter into employment arrangements with these entities, further consolidating healthcare systems and increasing healthcare costs to taxpayers and beneficiaries, according to MedPAC.
Other factors circling overhead of Medicare physician payment levels are the so-called mandatory PAYGO cuts triggered by big-ticket spending programs or backroom federal spending negotiations that, again, have nothing to do with the quality or level of care needed to be delivered to Medicare patients. While these PAYGO cuts have usually been postponed, they remain a lurking threat every year.
The Alliance of Specialty Medicine will continue to work with the Administration and Congress to address these proposed cuts in the near term and will continue to work with federal legislators on longer-term reforms to stabilize Medicare physician payments.
Specialtydocs Return to Capitol Hill
First In-Person Annual Legislative Advocacy Day Since COVID
The Alliance of Specialty Medicine resumed regular order in July by hosting its first
in-person advocacy day since 2019. Nearly 100 specialty physicians representing the Alliance’s 16 national medical societies came to Washington, DC, to meet with healthcare policy leaders and discuss ways to allow greater patient access to specialty care.
In addition to the physicians meeting with their own Congressmen and Senators, the Advocacy Fly-In featured several guest speakers, including Speaker of the House Kevin McCarthy (R-CA), Ways and Means Committee Member and DCCC Chair Susan Delbene (D-WA), Sen. Bill Cassidy (R-LA), Ranking Member of the Senate Health, Labor and Pensions Committee, and Jim Matthews, the Executive Director of the Medicare Payment Advisory Commission (MedPAC).
Leading the array of issues discussed was the +3% cut in Medicare physician payment as proposed by the Centers for Medicare and Medicaid Services (CMS). Last year, Congress mitigated steep Medicare physician payment cuts for CY 2023 and CY 2024 by providing updates of 2.5% and 1.25%, respectively, and delaying reductions due to the “Pay-As-You-Go” (PAYGO) sequester as part of a year-end omnibus spending bill. However, even with these and previous years’ efforts, the Medicare Physician Fee Schedule (MPFS) conversion factor has still experienced cuts over the last four years. A contributing factor to these cuts is the lack of an automatic inflationary payment update that many other Medicare providers, such as hospitals and surgery centers.
The Alliance hosted a Congressional staff briefing on Medicare payment and urged House Members to cosponsor H.R. 2474, the Strengthening Medicare for Patients and Providers Act, which would provide an annual inflation update equal to the Medicare Economic Index (MEI) for Medicare physician payments. The Alliance also asked Members of Congress to co-sign a letter to House leadership circulated by Reps. Ami Bera, MD (D-CA) and Larry Bucshon, MD (R- IN) emphasizing that Congress must urgently work together to establish a stable payment mechanism that appropriately pays for health outcomes and ensures that we keep our communities healthy.
The Alliance also called for reforms to utilization management practices – specifically Prior Authorization and Step Therapy. Prior Authorization is a cumbersome process that requires physicians to obtain pre-approval from insurers for medical treatments or tests before rendering care to their patients. Step-therapy protocols may require patients to try and fail an insurer-preferred medication before being covered by the physician-prescribed medication. Patients are experiencing delays in care and treatment due to abuses in both Prior Authorization and Step Therapy by health insurers. The Alliance supports CMS finalizing pending rules to reign in Medicare Advantage (MA) plans’ overuse of Prior Authorization. Also, it supports the bipartisan Safe Step Act (S.652/H.R. 2630), which amends the Employee Retirement Income Security Act of 1974 (ERISA) to require a group health plan to establish an exception process to medication step-therapy protocol.
The Alliance also called for greater attention to physician workforce issues and asked Members of Congress to cosponsor the bipartisan Resident Physician Shortage Reduction Act (S. 1302/H.R. 2389). This bill would increase Medicare-supported GME residency slots by 14,000 over the next seven years, specify priorities for distributing the new slots (e.g., states with new medical schools), and calls for a study on strategies to increase the diversity of the health professional workforce. Issue briefs on these issues can be found on the Alliance website.
The VA Federal Supremacy Project:
Will Veterans Maintain Access to the Highest Level of Care?
Adapted from Retina Times, Summer 2023
A current US Veterans Affairs Administration project has the potential to expand the scope of practice for several non-physician professions beyond what is generally permissible by state licensing laws. The American Society of Retina Specialists (ASRS) explains how dangerous this could be to veterans’ eyesight and how it could impact patients well beyond the VA.
Several years ago, the VA announced it was undertaking an effort to standardize professional practice guidelines for more than 40 healthcare professions working in the VA system nationwide. These professions range widely from physician to dentist, to several different types of technicians. This VA effort has been dubbed the Federal Supremacy Projectbecause once a standard is established, it is in effect nationwide and supersedes any state-level regulations in place where a VA facility is located. Organizations representing non-physician practitioners, including optometrists, have identified this as an opportunity to garner long-sought expanded scopes of practice both in the VA and at the state level.
Looking specifically at eye care, optometrists are advocating that the VA allow them to perform some surgical and other invasive procedures. Unlike the medical education retina specialists and other ophthalmologists receive, optometrists are not trained to perform procedures. ASRS Program Chairman J. Michael Jumper, MD, FASRS, who practices in the San Francisco Bay Area, sees this as a patient safety issue. “Retina specialists have trained for ten years after receiving an undergraduate university degree to acquire the knowledge and skill to do what we do. To allow someone to provide retinal care without a medical degree and with no sanctioned training is irresponsible.”
On the policy level, a step in this direction already occurred when the VA altered its Community Standards of Practice in 2022 to allow optometrists working in the VA to provide services permitted by the state where the facility is located. Previously, the VA had prohibited optometrists from performing laser and scalpel procedures and still does where it is not permissible by state law.
Launching such an unprecedented expansion of scope through the VA is particularly troubling because it means our nation’s veterans, who have fought and sacrificed for the nation, essentially become unwitting subjects in a test of unprepared practitioners’ skills. As an Air Force veteran himself, Dr. Jumper cautions, “Veterans are a precious patient group, and we don’t want them receiving inferior care.”
ASRS Federal Affairs Committee Chairman Michael M. Lai, MD, PhD, FASRS, of Cabin John, MD, agrees. “If we believe training is important for retina specialists, there should also be a standard of practice that ensures veterans and all patients receive care and undergo procedures performed by individuals with the appropriate level of training,” he explains.
Looking at the issue broadly, if a national standard allows optometrists to perform invasive procedures within the VA system, it will be difficult to argue that states shouldn’t follow along. “This issue has the potential to legitimize treatment by inadequately trained providers,” says Dr. Jumper. “It could have an impact in all 50 states.” Beyond eye care, other non-physician practitioners could also use these same arguments to expand their scopes at the state level.
To help the VA recognize the importance of that task, the ASRS and our allies in ophthalmology and across medicine have mobilized to advocate against expanding optometrists’ scope. We are working with veterans’ groups to make them aware of the potential consequences should the VA expand optometrists’ practice scope. In addition, we’re continuing our campaign to educate patients about the differences between the care provided by retina specialists and other ophthalmologists vs. optometrists—and the vast difference in the training they receive. More information is available at https://www.asrs.org/patients.
Dr. Jumper notes it’s most important for us to remember what’s at stake. “As a veteran from a family of veterans, I wouldn’t want care from an inadequately trained provider,” he explains. Veterans are on the front lines of this battle—as they were in their military careers—and should the VA expand its scope, all patients will be, as well.
Bridging the Gap: A Pathway to Neurosurgery for Underrepresented Students
Dedicated to alleviating health care disparities, the program encourages high school students from underrepresented groups and/or disadvantaged backgrounds to pursue a career in neurosurgery. On Monday, Sept. 11, the Congress of Neurological Surgeons (CNS) Foundation hosted the program at the 2023 Annual Meeting in Washington, DC.
High school students from the E.L. Haynes Public Charter School participated in a hands-on activity lab, giving them insight into a day in a neurosurgeon’s life. Students also attended lectures from leading neurosurgeons and heard from plenary talk guest speakers.
In recognition of this noteworthy program, the District of Columbia Mayor Muriel Bowser Sept. 7-13 as Pathway to Neurosurgery Week. “The CNS is thrilled that Mayor Bowser has recognized the Pathway to Neurosurgery program. As CNS president, it has been a privilege to witness the growth and development of this critical mission-centric project, offering exposure to the wonders of neuroscience to these exceptional students,” stated Elad I. Levy,MD, MBA, FAHA, FACS, FAANS, CNS president and professor and chair of neurosurgery at the State University of New York at Buffalo.
“African Americans, Hispanic Americans, and women are significantly underrepresented in neurosurgery, and the CNS Pathway to Neurosurgery program aims to address this problem by promoting diversity, equity, and inclusion in neurosurgery. Our goal is to inspire students to consider neurosurgery as a career option to foster innovations in patient care that can improve outcomes and reduce minority health disparities,” said Tiffany R. Hodges, MD, co-chair of the CNS Diversity, Equity, and Inclusion Committee and associate professor of neurosurgery at Case Western Reserve School of Medicine. Only 4% of practicing neurosurgeons in the U.S. are Black, 5% are Hispanic, and 8% are women. In contrast, approximately 14% of the U.S. population are Black, 19% are Hispanic, and 50% are women.
to read Neurosurgery’s press release.
ASE 2023 Cardiovascular Ultrasound Trends Report
In February of 2023, nearly 1,500 people, which included ASE members and nonmembers, volunteered to participate in ASE’s 2023 Cardiovascular Ultrasound Trends Survey. Participants answered a wide range of questions, including topics about day-to-day practice management and equipment use to more specialized areas of echo application and innovation. The survey offers a point-in-time snapshot of practices, challenges, and opportunities shaping the field of echocardiography and cardiovascular ultrasound technology. The results help inform the development of ASE programs and resources and are shared, in full, with ASE’s members and Industry Roundtable partners.
This survey is intended to help members navigate the ever-changing healthcare environment by identifying changes in echo practice and advances in patient care. It also benefits research and practice management initiatives.
These and other findings from ASE’s Cardiovascular Ultrasound Trends Survey offer invaluable insight into factors driving decision-making, echo innovation, and patient care. We are very grateful for the clinicians who participated in the Trends Survey and look forward to sharing our findings.