Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties.

OBJECTIVE: This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND: Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN: The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS: After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS: This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

The Underuse of Medicare's Prevention and Coordination Codes in Primary Care : A Cross-Sectional and Modeling Study.

BACKGROUND: Efforts to better support primary care include the addition of primary care-focused billing codes to the Medicare Physician Fee Schedule (MPFS). OBJECTIVE: To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS. DESIGN: Cross-sectional and modeling study. SETTING: Nationally representative claims and survey data. PARTICIPANTS: Medicare patients. MEASUREMENTS: Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill. RESULTS: Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services. LIMITATION: Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes. CONCLUSION: Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care. PRIMARY FUNDING SOURCE: National Institute on Aging.

[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]. / Kompensation von Leistungen zwischen Hausärzten und Kinder- und Jugendmedizinern am Beispiel der Früherkennungsuntersuchungen bei Kindern und Jugendlichen ­ Analyse von bundesweiten KBV-Daten.

BACKGROUND: Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9). METHODS: Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example. RESULTS: In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions. CONCLUSION: The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Accuracy of Valuations of Surgical Procedures in the Medicare Fee Schedule.

BACKGROUND: The Relative Value Scale Update Committee (RUC) of the American Medical Association plays a central role in determining physician reimbursement. The RUC's role and performance have been criticized but subjected to little empirical evaluation. METHODS: We analyzed the accuracy of valuations of 293 common surgical procedures from 2005 through 2015. We compared the RUC's estimates of procedure time with "benchmark" times for the same procedures derived from the clinical registry maintained by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review corrected them. RESULTS: At the time of 108 RUC reviews, the mean absolute discrepancy between RUC time estimates and benchmark times was 18.5 minutes, or 19.8% of the RUC time. However, RUC time estimates were neither systematically shorter nor longer than benchmark times overall (ß, 0.97; 95% confidence interval, 0.94 to 1.01; P = 0.10). Our analyses suggest that whereas orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used ($160 million and $40 million more, respectively, in Medicare reimbursement in 2011 through 2015), cardiothoracic surgeons, neurosurgeons, and vascular surgeons received lower payments ($130 million, $60 million, and $30 million less, respectively). The accuracy of RUC time estimates improved in 47% of RUC revaluations, worsened in 27%, and was unchanged in 25%. (Percentages do not sum to 100 because of rounding.). CONCLUSIONS: In this analysis of frequently conducted operations, we found substantial absolute discrepancies between intraoperative times as estimated by the RUC and the times recorded for the same procedures in a surgical registry, but the RUC did not systematically overestimate or underestimate times. (Funded by the National Institutes of Health.).

Reductions in Reimbursement and Relative Value Units for Interventional Radiology Procedures: Trends from 2011 to 2021 Compared with Those for Other Physician Specialties.

PURPOSE: To compare recent trends in Medicare reimbursement and relative value units (RVUs) for interventional radiology (IR) procedures similar to those performed by non-IR specialties. MATERIALS AND METHODS: Data from the Centers for Medicare and Medicaid Services Physician Fee Schedule for facility reimbursement and RVU component values for 23 commonly performed single Current Procedural Terminology IR procedures were compared with similar procedures or procedures for similar indications performed by non-IR specialties between 2011 and 2021. RESULTS: The work RVU component decreased in 18 of 23 (78.3%) IR procedures compared with 6 of 23 (26.1%) similar procedures performed by non-IR specialties. The largest change in single RVU component was a 19.2% reduction in practice expense RVU for IR compared with a 16.5% reduction for similar procedures performed by non-IR specialties. CONCLUSIONS: As a specialty, IR experienced a disproportionately greater reduction in reimbursement and RVU valuation for a range of comparable procedures performed by non-IR specialties.

Nurses' critical role in CPT code valuation.

ABSTRACT: Relative value units (RVUs) are a measurement of practice efficiency and patient complexity. RVUs are reviewed by the Centers for Medicare and Medicaid Services through the Resource-Based Relative-Value Scale Update Committee, which determines recommendations regarding the Current Procedural Terminology code valuations for the Medicare Physician Fee Schedule. This article discusses the importance of nurses' participation in the accurate valuation of their work and in the process of developing and revising RVUs.

Medicare Advantage for Most.

Policy Points Fixing the ACA requires real cost containment in addition to better subsidies. Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care. Medicare Advantage plans should serve as the public option on the ACA Marketplace. Medicare Advantage plans can also be deployed to voluntarily raise minimum employer-sponsored benefits and contain their costs.

The 2021 Centers for Medicare and Medicaid Services Fee Schedule's Impact on Adult Reconstruction Surgeon Productivity and Reimbursement.

BACKGROUND: On December 20, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule: CMS-1734-P. This 2021 Final Rule significantly changed Medicare total joint arthroplasty (TJA) reimbursement. The precise impact on surgeon productivity and reimbursement is unknown. In the present study, we sought to model the potential impact of these changes for multiple unique practice configurations. METHODS: A mathematical model was applied to CMS data to determine the impact of CMS-1734-F on multiple, theoretical TJA practice configurations. Variables tested were the annual percentage of revision vs primary arthroplasty cases performed and the annual percentage of operative vs office-based productivity. The model defined baseline annual surgeon productivity as the 2018 Medical Group Management Association hip and knee arthroplasty surgeon median productivity of 10,568 work relative value units (wRVUs). RESULTS: All modeled simulations demonstrated a year-to-year increase in wRVUs independent of practice configuration. However, simulations that demonstrated less than a 3.35% increase in wRVUs from year-to-year saw a decrease in reimbursement. Those simulations with higher wRVU increases tended to have a higher percentage of revision vs primary arthroplasty cases and/or had annual productivity that was derived to a greater extent from office encounters than surgical cases. CONCLUSION: The impact of CMS-1734-F will vary based on 3 factors: (1) the relative contribution of a surgeon's operative TJA practice compared with their office-based practice to their annual wRVUs; (2) the relative percentage of revision TJAs vs the percentage of primary TJAs performed; and (3) the relative percentage of primary TJA compared to non-arthroplasty surgeries as a component of overall operative practice. The decreased reimbursement will be disproportionately felt by arthroplasty surgeons who perform relatively fewer revision TJA procedures and whose office-based productivity makes up a smaller overall percentage of their annual workload.

Projections of the Impact to Arthroplasty Surgeons With Changes to the 2021 Medicare Physician Fee Schedule-A Looming Crisis of Access to Care?

BACKGROUND: The Centers for Medicare and Medicaid Services 2021 Physician Fee Schedule (PFS) includes increases in office reimbursement but decreases in the valuation of total hip arthroplasty and total knee arthroplasty and the conversion factor. The purpose of this study was to determine the financial impact of these changes on arthroplasty surgeons. METHODS: We queried data for 35 arthroplasty surgeons within our practice from 10/2019 to 10/2020 and captured all office and arthroplasty-related surgical procedure codes. We compared the difference in both work relative value units (RVUs) and Medicare reimbursement by surgeon based on the current 2020 PFS to the 2021 changes. We also estimated the impact of several proposals to include office increases to the global surgical package for each code. RESULTS: While the mean per surgeon RVU amount for primary arthroplasty procedures will decrease (6267 vs 6,088, P = .78), the mean office work RVU (2755 vs 3,220, P = .16) will increase in 2021. However, the reduction in surgical reimbursement ($530,076 in 2020 to $464,414 in 2021) far exceeds the gains from the office ($99,456 vs $107,374), leading to an overall decrease in reimbursement ($629,532 vs $571,788), a reduction of 9%. The passage of the coronavirus disease 2019 relief bill delays many of the PFS cuts and will result in an overall reduction in reimbursement of 2.4% ($629,532 vs $612,475, P = .61). CONCLUSION: Arthroplasty surgeons are projected to lose 2.4% of Medicare reimbursement in 2021 with the changes in the Centers for Medicare and Medicaid Services PFS. Further study is needed to determine whether these cuts will limit access to care for Medicare patients.

The Medicare Physician Fee Schedule and Unethical Behavior.

This Viewpoint discusses the Medicare Physician Fee Schedule and its flaws, including how they might be remedied by severing CMS dependence on Relative Value Update Committee estimates of time and intensity.

Medicare Program; Durable Medical Equipment Fee Schedule Adjustments To Resume the Transitional 50/50 Blended Rates To Provide Relief in Rural Areas and Non-Contiguous Areas. Interim final rule with comment period.

This interim final rule with comment period makes technical amendments to the regulation to reflect the extension of the transition period from June 30, 2016 to December 31, 2016 that was mandated by the 21st Century Cures Act for phasing in fee schedule adjustments for certain durable medical equipment (DME) and enteral nutrition paid in areas not subject to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). In addition, this interim final rule with comment period amends the regulation to resume the transition period's blended fee schedule rates for items furnished in rural areas and non-contiguous areas (Alaska, Hawaii, and United States territories) not subject to the CBP from June 1, 2018 through December 31, 2018. This interim final rule with comment period also makes technical amendments to existing regulations for DMEPOS items and services to reflect the exclusion of infusion drugs used with DME from the DMEPOS CBP.

Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) and Fee Schedule Amounts, and Technical Amendments To Correct Existing Regulations Related to the CBP for Certain DMEPOS. Final rule.

This final rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year (CY) 2019. This rule also updates the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). In addition, it updates and rebases the ESRD market basket for CY 2019. This rule also updates requirements for the ESRD Quality Incentive Program (QIP), and makes technical amendments to correct existing regulations related to the Competitive Bidding Program (CBP) for certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). Finally, this rule finalizes changes to bidding and pricing methodologies under the DMEPOS competitive bidding program; adjustments to DMEPOS fee schedule amounts using information from competitive bidding for items furnished from January 1, 2019 through December 31, 2020; new payment classes for oxygen and oxygen equipment and a new methodology for ensuring that new payment classes for oxygen and oxygen equipment are budget neutral; payment rules for multi- function ventilators or ventilators that perform functions of other durable medical equipment (DME); and revises the payment methodology for mail order items furnished in the Northern Mariana Islands. This rule also includes a summary of the feedback received for the request for information related to establishing fee schedule amounts for new DMEPOS items and services.

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Final rule.

This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies such as changes to the Medicare Shared Savings Program, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.