• In The Trenches

    Fighting the Nuclear Defense

    Any former debaters out there?

    Closeup shot of the numbers on a balance sheet.

    Veterans of high school policy debate will recall the old “going nuclear” play. You insist that your opponents’ case — improving farm subsidies, say — will, if enacted, ultimately bring about World War III. The other side naturally lacks any evidence that government-backed rural assistance, whatever its other ills, will not lead inexorably to a mushroom-clouded doomsday. Meaning you get to argue that your ridiculous point has been conceded.

    It’s hardly an ironclad tactic, but presenting it with just the right newscaster deadpan might overwhelm a judge (while definitely amusing at least one of the two teams slugging it out).

    Besides, hyperbole is a pillar of real-world politicking.

    Right now, for instance, a broadly exaggerated number in the proposed 2021 Medicare physician fee schedule is leading other specialties to go nuclear against long-overdue coding changes that will deliver a significant benefit to primary care.

    A refresher on that benefit: In the proposed rule, to which the Academy responded in detail on Sept. 28, CMS maintains the increase in values for outpatient evaluation and management codes set to go into effect Jan. 1. Together with the new add-on code GPC1X — a welcome acknowledgment of the unique complexity of primary care E/M visits as well as the importance of ongoing care coordination — the change equates to an estimated 13% raise next year for primary care physicians who participate in Medicare.

    The catch is that CMS is required by law to keep Medicare spending the same from year to year. That’s called “budget neutrality,” and it’s why the agency says the 2021 conversion factor is $32.26, down $3.83 from 2020. (The conversion factor is multiplied by the relative value of each code in the fee schedule to determine the Medicare payment rate.)

    Now, the Academy obviously supports the E/M boost and the add-on code, but that reduced conversion factor isn’t good for anybody, and we told CMS that in our letter. Even in a year without a novel coronavirus, that pinch could destabilize any physician who accepts Medicare. But a drop of more than 10% in 2021, following endless months of professional pressure, personal hazard and economic catastrophe? Seems like a good time for Congress to waive the budget neutrality requirement. We said that. Other specialties are making similar calls. And we are urging every AAFP member to do the same here

    Where we — along with our peers in the American Academy of Pediatrics and the American College of Physicians — find ourselves on our own is in defending GPC1X. Which brings me back to that exaggerated number — and a tall tale it seems to have inspired.

    CMS — not the CPT Editorial Panel — created the code and solicited feedback on how it should be defined and used. Even so, the fee schedule seems to assume that the code will be applied to nearly 50% of all E/M claims. Not half of all primary care claims but half of every claim made by an A-to-Z of specialties including cardiology, endocrinology, psychiatry and urology.

    Those estimates come from the agency’s own analysis, which it conducts each year on every fee schedule code to determine the conversion factor. The fee schedule doesn’t reveal what calculus was involved.

    The Academy’s Sept. 28 letter offered a little understatement: “We believe this assumption overstates usage of the code in 2021, which negatively contributes to the downward adjustment in the conversion factor to maintain budget neutrality.”

    In fact, utilization of new codes tends to be much lower than expected in the first year of implementation, and there’s no reason to expect GPC1X to behave differently. Awareness of the code among physicians won’t be universal, and there will be uncertainty about when it’s appropriately used, particularly without the descriptor clarity and regulatory guidance that CMS acknowledges it hasn’t established. Given these factors, it’s hard to imagine more than 25% of claims in 2021 including GPC1X.

    We told CMS that, too, and asked the agency to reconsider its math, which may unfairly suppress the 2021 conversion factor more than necessary to achieve budget neutrality while penalizing physicians who continue to struggle against the pandemic’s financial headwinds.

    For the sake of, as debaters say, “carrying the flow” — of my metaphor, in this case — I’ll single out nuclear medicine as an example of the AAFP’s advocacy headwinds when it comes to your raise.

    In its own recent letter to CMS about the fee schedule, the American College of Radiology said it was “strongly opposed” to implementation of the code: “We are concerned that the ambiguity of this and the implicit direction from CMS that it be added to every, or nearly every, office visit creates program integrity issues for CMS.”

    An argument that turns CMS’ unrealistically high utilization assumption into a GPC1X wild West feels a little like something out of an 11th-grade debate tournament. Sure, there’d be an integrity issue if utilization of one add-on code were so casual. But what’s really at stake is money; estimates suggest that, if the E/M changes remain intact, radiologists could realize an 11% decrease in Medicare reimbursement next year.

    My predecessor and now AAFP CEO/EVP Shawn Martin saw this conflict shaping up almost a year ago. I’ll repeat what he said then: “Game on.”

    Meanwhile, it is no exaggeration at all to say that the 2021 E/M adjustments would correct a historic payment imbalance that has worked against family physicians.

    CMS’ main job is to assign appropriate values to the care that physicians provide to patients. With the slated 2021 E/M update, it has come encouragingly close to capturing the increasing resource costs involved in furnishing high-value primary care and finally correcting a Medicare payment distortion our members have lived with too long. As a bonus, we believe it also would increase the pipeline of primary care physicians, thereby improving patients’ access to care nationwide.

    The GPC1X estimates need to be refined, but the code is critical to ensuring that family physicians are afforded fair compensation for care that is of demonstrably higher intensity than that provided by other specialties during similar E/M visits. Which makes it critically important to the health of Americans — and imperative for CMS to implement in 2021.

    The rule will likely be finalized by Dec. 1. The Academy will continue to press CMS to reduce its utilization estimates for GPC1X. We’re also calling on Congress to pass legislation to temporarily set aside Medicare budget neutrality requirements and keep the conversion factor from dipping while the public health emergency continues.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.