One-size-fits-all payment approach won’t work for time spent with patients
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Unable to ignore the crippling joint pain any longer, a patient decides to follow his doctor’s advice and consult a specialist. But there are just a handful of rheumatologists practicing locally, and only one is currently accepting new Medicare patients. The receptionist kindly offers to schedule an appointment – for six months down the road – but promises to be in touch if there are any cancellations.

Meanwhile, the patient’s symptoms continue to worsen and he misses the critical window where his condition might have been treated before permanent disability takes hold.

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This sad and frustrating scenario could soon become the norm for Medicare patients in need of care from specialists such as rheumatologists, oncologists, and neurologists, who are trained to manage their patients’ complex health care needs but require a great deal of time to do so.

This is because a new proposal from the Centers for Medicare and Medicaid Services (CMS) would significantly reduce Medicare payments for specialty care involving complex and time-intensive face-to-face visits. According to a recent report from the Medicare Payment Advisory Commission (MedPAC), doctors are already underpaid for evaluation and management (E/M) services, which include the time clinicians spend diagnosing and managing patients’ chronic conditions, treating acute illnesses, and coordinating care across settings. Under the proposed CMS plan, Medicare reimbursement for outpatient E/M services would be consolidated into a flat payment, regardless of complexity, so that uncomplicated and highly complicated office visits would require similar documentation and receive equal payment. As a result, while payments for many less complex E/M visits would rise, physicians who see a high volume of complex patients or those with multiple ailments would see a reduction in their Medicare reimbursements.

While the proposal was intended to ease doctors’ paperwork and administrative burden, in its current form the policy change would inadvertently penalize specialty providers who serve chronically ill patients with complex needs. For example, rheumatologists could see cuts as high as 10 percent – making it financially difficult for many to continue offering these services to Medicare patients.

The result, experts fear, will be reduced access for Medicare patients and fewer doctors willing to enter already-strained specialties like rheumatology. Current shortages of rheumatology providers already result in long wait times for new appointments, and the documented workforce shortage is projected to increase at a time when more Americans than ever require specialized care.

Nationwide, one in four Americans live with some form of rheumatic disease and it’s estimated that 78 million adults will have doctor-diagnosed arthritis by the year 2040. Rheumatic diseases have become the number one cause of disability in the United States – more than heart disease, cancer, or diabetes – costing the U.S. health care system and economy an estimated $140 billion annually.

The economic and physical toll of rheumatic diseases can be lessened with prompt evaluation by trained specialists. Early diagnosis and treatment, even within the first 12 weeks for some, can prevent damage to joints and other organs, increase the likelihood of achieving disease remission, and improve long-term function. With close monitoring and consultation, rheumatologists can specially tailor treatment by pinpointing those that are most effective – saving patients and the health system money by preventing unnecessary health complications, hospitalizations and surgeries. Ready access to skilled rheumatology providers reduces disability, work limitations, and downstream medical costs like joint replacement surgeries. 

But this high-quality, comprehensive care takes skill and time – and specialists should be compensated appropriately for their work. Instituting policies that penalize this kind of care is not the way to incentivize high value health care.

While we appreciate efforts to reduce excessive documentation, patients and providers are deeply concerned that CMS’ proposed E/M payment cuts will not only compromise patient access to care but also create a disastrous ripple effect throughout our health care system, pushing more medical students into procedure-oriented careers or incentivizing doctors to stop taking new Medicare patients altogether. At a time when many specialties like rheumatology are already struggling with workforce shortages, it will be the sickest and most frail Medicare patients who pay the price with longer wait times, delayed care, and worsening health.

Just as there is no one-size-fits-all solution for patients with complex diseases, policymakers shouldn’t look for a one-size-fits-all approach to physician payment. CMS must reverse this dangerous policy immediately or risk hurting Medicare patients in need of critical care.

David Daikh, MD, PhD, is President of the American College of Rheumatology. Ann M. Palmer is President and CEO of the Arthritis Foundation.