• In The Trenches

    Budget Neutrality, Not Primary Care, Is Subspecialties’ Enemy

    We were all in this together, until we weren’t.

    physicians in uniforms

    You can’t really sing that to the tune of “Deck the Halls,” but it’s a chorus I’d belt out if I were going caroling in the cul-de-sacs of some medical specialties now lining up on the wrong side of history.

    Before we start choir practice and I start preaching, here’s how the song goes.

    The 2021 Medicare physician fee schedule and Quality Payment Program final rule, which CMS issued last week, delivered great news to the Academy: It confirmed that payment for office-based evaluation and management services will increase as planned on Jan. 1. CMS estimates a 13% increase in total allowed charges for family medicine — the largest increase in primary care reimbursement in decades. In a decision that should have let us all exhale with relief, the final rule also solidified the add-on code acknowledging the unique complexity of primary care E/M visits. The code was first called GPC1X and is now G2211.

    The problem remains, however, that this MPFS does what fee schedules by law must: It abides by its budget-neutrality mandate — meaning CMS can’t improve payment in any area of the fee schedule without cutting it somewhere else. Because the 2021 conversion factor (which is multiplied by the relative value of each code in the fee schedule to determine the Medicare payment rate) has been reduced 10% compared with 2020, specifically to offset the E/M changes, some physicians in other specialties will see their reimbursements reduced next year.

    Surgeons, for example, are unhappy about this. They’re also displeased that CMS decided not to update the values for 10-day and 90-day surgical codes. This is entirely appropriate: A convincing RAND Corp. study and other prior investigations suggest that global surgical codes are overvalued, with clinicians paid under 10- and 90-day global codes performing fewer E/M visits than are included in the global payment rate. Applying the E/M increases to the global surgical codes would levy even more downward pressure on the conversion factor due to budget neutrality rules.

    Again, though, the enemy here is budget neutrality, not family medicine. Accessible, affordable, comprehensive medical care for Americans is not a zero-sum proposition. The Academy, along with other medical specialty societies, has repeatedly asked Congress to waive the budget-neutrality requirement — which, with COVID-19 again burning across every state, has never seemed more coldly punitive.

    One of the bills introduced in Congress this fall fairly addresses our collective concerns with budget neutrality. H.R. 8505 proposes applying unused money from HHS’ Provider Relief Fund to pay for a one-year waiver of the budget-neutrality requirement — equitable relief for every physician practice.

    Not to sound like a Dickens character here, but it’s not too late for you to speak out with us in support of H.R. 8505.

    At least one other piece of legislation, however, would instead provide less relief to family physicians because of the forthcoming E/M boost. (We saw this coming.) H.R. 8702 would keep Medicare payment for non-E/M services at the 2020 rates for the next two years while subjecting some E/M services in 2021 to the lower conversion factor — not only limiting the coming year’s primary care raise but also withholding financial relief simply because this vital systemic improvement happened to coincide with the pandemic.

    The latter bill has the support of a coalition of medical groups that until recently had devoted their lobbying on this front to battling budget neutrality. Why? Because this E/M boost has been under discussion for years — years! — with the support of all physician specialties. And why is that? Because primary care is the backbone of the U.S. health system, and it was broadly acknowledged that office-based E/M services were well overdue for an update.

    Speaking of which, there are a handful of letdowns for AAFP members in the final fee schedule, which the Academy has summarized for members. For one, it’s unfortunate that CMS is not increasing immunization administration payments as it first proposed — an egregious misstep in a pandemic.

    Puzzlingly, CMS also failed to implement a CPT code to cover the additional costs of personal protective equipment — saddling physicians with the full bill as COVID-19 continues to hollow out practices.

    CMS also reiterated that it lacks the authority to waive geographic and originating site restrictions for telehealth beyond the public health emergency. The Academy will continue to lobby Congress to pass legislation ensuring that all Medicare beneficiaries can continue to access telehealth services from home, regardless of location. And we’ll submit comments on a new temporary code covering audio-only telehealth check-ins, which we believe is inadequate.

    This latter handful of CMS’ choices is disappointing but hardly disastrous.

    The big issue in play is whether Congress yields to loud pressure from groups that know better. So let me haunt my own text here by repeating: It’s vital that you raise your voices against that destructive “fix.” Congress must not disrupt, delay or introduce any “phase-in” or other transition period for the E/M increases and G2211. Your representatives need to hear this in the key of Jacob Marley’s chains.

    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.