The push for major healthcare reform has exposed a number of schisms between physician groups and among physician specialties. Now, a seemingly minor regulation threatens to do the same thing.
Under regulations scheduled to take effect on Jan. 1, 2010, Medicare will eliminate the Current Procedural Terminology, or CPT, code for consultation services that specialists use when they see a patient referred to them by a primary-care physician. Under the current billing, specialists are paid for evaluating the patient and then writing a report that the patients' regular physicians use to guide their treatment.
The American Association of Clinical Endocrinologists, or AACE, however, says that the change will lead to reduced income for its members, and that will result in them seeing fewer Medicare beneficiaries with diabetes and will lessen the quality and coordination of care their patients receive.
“It's sort of a recipe for discoordinated, uncoordinated or poorly coordinated care,” says Jeffrey Garber, M.D., AACE president and chief of endocrinology at Harvard Vanguard Medical Associates. “We're cognitive specialists, and they're taking away the essence of what we do.”
Garber says endocrinologists whose practices don't depend much on referrals from primary-care physicians might not be affected much—but, for those whose practices do, “you lose.”
Not true, says Lori Heim, M.D., president of the American Academy of Family Physicians and a hospitalist at 102-bed Scotland Memorial Hospital in Laurinburg, N.C. She says the elimination of the consulting code will be almost entirely offset by a 2% increase in reimbursement for codes relating to inpatient evaluation and management service and a 6% boost for ambulatory evaluation and management codes.
Heim describes the consultation code as “overvalued,” and says that it led to the CMS paying for paperwork—not patient care. In a Nov. 30 letter to acting CMS Administrator Charlene Frizzera, the AAFP says the rule changes could result, on average, in a 4% increase in most family physicians' allowed charges to Medicare, and Heim acknowledges this increase means other providers will get a smaller slice of the Medicare pie.
“It's budget-neutral, so it's a shuffle,” Heim says of the rule changes. “The payment has shifted, but it's not a wholesale elimination of payment. ... Some of the changes will lead to a small increase in primary-care compensations. But, if we are going to have a primary-care workforce in the future, we have to increase payment for primary care.”
The nation's largest physician groups—the Chicago-based, 236,000-member American Medical Association, and the Philadelphia-based, 129,000-member American College of Physicians—are not taking sides on the coding change other than to seek a delay in implementation. The ACP calls for a delay to “be of a duration that allows time for a constructive dialogue” between the CMS and physicians to address all pertinent issues, while the AMA is asking for a one-year postponement of the changes.
“This new policy has caused a combination of panic and confusion among many physicians,” wrote Michael Maves, M.D., AMA executive vice president and CEO, in a Nov. 25 letter to Center for Medicare Management Director Jon Blum. “A change of this magnitude cannot be accomplished under CMS' expedited time frame without creating havoc for patients and physicians.”
Garber says this position misses the point.
“The AMA letter dwelled on technicalities and the difficulty of implementation—but that's not the core issue,” Garber says, explaining that the crux of the issue is that the rule changes “threaten to marginalize” the role endocrinologists play in managing the care of patients with osteoporosis and complex diabetic conditions just as the number of people who need treatment for these conditions is increasing.
The AACE has launched a campaign and posted a Web site, keepthecodes.com, explaining how the consultation codes are also used by cardiologists, neurologists and oncologists when assisting internists, primary-care physicians and pediatricians with patients who have complex conditions.
The main focus, however, has been on treating diabetic patients, and the AACE states that there are 20 million Americans with Type 2 diabetes and about 50 million who have a “pre-diabetic” condition. In addition, the AACE says that its members are also the go-to specialists for the more than 50 million Americans with osteoporosis and low bone mass as well at the more than 10 million with thyroid disorders.
On Nov. 9, the AACE posted an online survey for its 5,000 domestic members, and 1,083—21.7%—participated. The survey notes that, under the new rules, when an endocrinologist is called to a hospital to consult on a diabetic Medicare patient, instead of the average reimbursement of $202 they now receive, they will only get $180—or, if the scheduled 21.5% Medicare payment cut goes in effect, $147. Or, if a Medicare patient comes to their office with multiple comorbidities, instead of the average $227 payment they now receive, they will only get $180—or $150 if the cuts take effect.
Under these scenarios, 32% of the respondents said that they would reduce their Medicare inpatient consultation availability, while 21% said that they would stop seeing Medicare consultation patients in the hospital altogether. Half said that they would reduce office consultations for Medicare patients, and 23% said that they would stop seeing Medicare consultation patients in their office altogether.
Of those surveyed, 90% said that diabetes-care accounts for at least 40% of their practice; and 84% offer inpatient consultation for diabetics.
The AMA's letter said an underlying cause for the CMS decision to eliminate the consultation code was that consulting physicians are no longer required to send referring physicians a report on their findings.
The AMA letter noted how discussions regarding the coding changes took place between 2006 and 2008, but Garber says the AACE's understanding is that “there are some CMS bureaucrats who have wanted to move this along for a couple of years” and that it wasn't necessarily being driven by the Obama administration.
“CMS is committed to ensuring that Medicare beneficiaries have access to high-quality care, and that both the beneficiary and the taxpayer get the most value for the healthcare dollar. Consultations have been paid significantly more than equivalent evaluation and management services in part because of the documentation requirements for consultation services,” says CMS spokeswoman Ellen Griffith in a written statement. “However, CMS has eased the documentation requirements for consultation services over time making the difference in value between a consultation and a visit hard to justify. Further, the Office of Inspector General has expressed concern that a significant percentage of services were billed as consultation services without appropriate supporting documentation.
“As we stated in the final rule, we have eliminated the consultation codes based on our findings that there is now little difference in the work involved in consults and the equivalent evaluation and management services and to eliminate the long-standing confusion between when a consult and an evaluation and management service can be billed,” Griffith says. “Moreover, we have used the savings from eliminating the consultation codes to improve payment for office and hospital visits. CMS will be conducting extensive outreach to physicians about how to comply with the new coding policies.”
Garber says the AACE is also concerned that this issue will not get the attention it deserves because of other healthcare issues being debated in Congress.
“It's happening at a bad time, and people are confusing it with healthcare reform,” Garber says.
In fact, Sen. Arlen Specter (D-Pa.) introduced an amendment to the Senate reform bill, known as the Patient Protection and Affordable Care Act, that calls for delaying implementation of the new coding system for one year.
“The Specter amendment will enable Medicare patients, the major segment of our population that is most vulnerable to serious illness, to continue to have access to specialists,” Garber said in a Dec. 11 press release. “It will also give CMS and Congress a chance to critically re-examine this flawed proposal.”
The release mentioned that the amendment was supported by the AACE, and more than 15 other organizations, including the AMA and the American Medical Group Association.
The AAFP sent out its own Dec. 11 release voicing its strong opposition to the amendment, and it also mobilized its Pennsylvania chapter to contact Specter's office urging him to withdraw the amendment.
“It is our collective opinion your amendment sends a message that wasteful spending is not important and that primary care is secondary to preserving excessive payments to (sub)specialists,” says a statement from the Pennsylvania Academy of Family Physicians to the senator.
The amendment, however, didn't make it into the final version of the bill put together by Senate Majority Leader Harry Reid (D-Nev.), commonly referred to as the “manager's package.”
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