By Robert Pear
July
22, 2018
WASHINGTON — The Trump administration is proposing huge changes
in the way Medicare pays doctors for the most common of all medical services,
the office visit, offering physicians basically the same amount, regardless of
a patient’s condition or the complexity of the services provided.
Administration officials said the proposal would radically
reduce paperwork burdens, freeing doctors to spend more time with patients. The
government would pay one rate for new patients and another, lower rate for
visits with established patients.
“Time spent on paperwork is time away from patients,” said Seema
Verma, the administrator of the Centers for Medicare and Medicaid Services. She
estimated that the change would save 51 hours of clinic time per doctor per
year.
But critics say the proposal would underpay doctors who care for
patients with the greatest medical needs and the most complicated ailments —
and could discourage some physicians from taking Medicare patients. They also
say it would increase the risk of erroneous and fraudulent payments because
doctors would submit less information to document the services provided.
Medicare would pay the same amount for evaluating a patient with
sniffles and a head cold and a patient with complicated Stage 4 metastatic
breast cancer, said Ted Okon, the executive director of the Community Oncology
Alliance, an advocacy group for cancer doctors and patients. He called that
“simply crazy.”
Dr. Angus B. Worthing, a rheumatologist, said he understood the
administration’s objective. “Doctors did not go to medical school to type on a
computer all day,” he said.
But, he added: “This proposal is setting up a potential
disaster. Doctors will be less likely to see Medicare patients and to go into
our specialty. Patients with arthritis and osteoporosis may have to wait longer
to see the right specialists.”
Private insurers often follow Medicare’s lead, so the proposed
change has implications that go far beyond the Medicare program.
The proposal, part of Medicare’s physician fee schedule for
2019, is to be published Friday in the Federal Register, with an opportunity
for public comment until Sept. 10. The new policies would apply to services
provided to Medicare patients starting in January.
“We anticipate this to be
a very, very significant and massive change, a welcome relief for providers
across the nation,” Ms. Verma said, adding that it fulfills President Trump’s
promise to “cut the red tape of regulation.”
“Evaluation and management services” are the foundation of an
office visit. Medicare now recognizes five levels of office visits, with Level
5 involving the most comprehensive medical history and physical examination of
a patient, and the most complex decision making by the doctor.
Level 1 is mostly for nonphysician services: for example, a
five-minute visit with a nurse to check the blood pressure of a patient
recently placed on a new medication.
A Level 5 visit could include a thorough hourlong evaluation of
a patient with heart failure, chronic obstructive pulmonary disease, high blood
pressure and diabetes with blood sugar out of control.
“The differences between Levels 2 to 5 are often really
difficult to discern and time-consuming to document,” said Dr. Kate Goodrich,
Medicare’s chief medical officer.
Medicare payment rates for new patients now range from $76 for a
Level 2 office visit to $211 for a Level 5 visit. The Trump administration
proposal would establish a single new rate of about $135. That could mean gains
for doctors who specialize in routine care, but a huge hit for those who deal
mainly with complicated patients, such as rheumatologists and oncologists.
For established patients, the proposal calls for a payment rate
of about $93, in place of current rates ranging from $45 to $148 for the four
different levels of office visits.
“This proposal is likely
to penalize physicians who treat sicker patients, even though they spend more
time and effort and more resources managing those patients,” said Deborah J.
Grider, who has audited tens of thousands of medical records and written a book
on the subject.
Dr. Atul Grover, the executive vice president of the Association
of American Medical Colleges, said, “The single payment rate may not reflect
the resources needed to treat patients we see at academic medical centers — the
most vulnerable patients, those who have complex medical needs.”
While the proposal would redistribute money among doctors, it is
not intended to cut spending under Medicare’s physician fee schedule, which
totals roughly $70 billion a year.
If the new rules really do simplify their work, doctors say,
they will be elated.
“We can focus more on patient care and less on the
administrative burden of documentation and billing,” said Dr. David B. Glasser,
an assistant professor of ophthalmology at the Johns Hopkins University School
of Medicine. “We sometimes joke that it can be more complicated trying to get
the coding level right than it is to figure out what’s wrong with the patient.”
But, Dr. Glasser said, the financial impact of the proposal on
eye doctors is not yet clear.
Documentation requirements have increased in response to growing
concerns about health care fraud and improper payments that cost Medicare
billions of dollars a year.
In many cases, federal auditors could not determine whether
services were actually provided or were medically necessary. In some cases,
they found that doctors had billed Medicare — and patients — for more costly
services than they actually performed.
In a report required by federal law, officials estimated early
this year that 18 percent of Medicare payments for office visits with new
patients were incorrect or improper, about three times the error rate for
established patients.
To prevent fraud and abuse, Medicare officials have repeatedly
told doctors to document their claims. “If it is not documented, it has not
been done” — that is the principle set forth in Medicare’s billing manual for
doctors.
The Trump administration is moving away from that policy.
“We have proposed to move to a system with minimal documentation
requirements for Levels 2 to 5 and one single payment rate,” Dr. Goodrich said.
Doctors now must provide more documentation for higher levels of
care. Under the proposal, “practitioners would only need to meet documentation
requirements currently associated with a Level 2 visit.” That would reduce the
need for audits to verify the level of office visits.
Medicare officials acknowledged that doctors who typically bill
at Levels 4 and 5 could see financial losses under the proposal. But they said
some of the losses could potentially be offset by “add-on payments” for primary
care doctors and certain other medical specialists.
With such adjustments, Medicare officials said, the impact on
most doctors would be relatively modest. A table included in the proposed rule
indicates that obstetricians and gynecologists would gain the most, while
dermatologists, rheumatologists and podiatrists would lose the most.
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