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Infectious disease care is complex — Medicare reimbursement rules should reflect that
The most pressing question one of my recent patients had for me was about going back to work. But the answer to that simple question depends on the answers to a number of other questions.
After a workplace injury, the patient had come to the hospital with a high fever and Staphylococcus aureus in his blood. These issues led to endocarditis, which is a heart valve infection. Three weeks later, when he was ready to leave the hospital, the patient - a man in his forties - had undergone a heart valve replacement and repair to the vessel that supplies most of the blood to his body.
Now, while his cardiac surgeon monitors his recovery from those procedures, I monitor the balance of five weeks of outpatient intravenous antibiotic therapy to make sure the infection has gone away, stays away and has not affected other organs. This process is essential to gathering the knowledge that I need for our face-to-face encounters, where I evaluate his symptoms and manage his care.
As an infectious diseases specialist, those outpatient evaluation and management encounters are essential to the care I provide, and take about 90 percent of my time. Last month, however, the Centers for Medicare and Medicaid Services released a proposal that would add to the challenges of providing that cognitive (nonprocedural) care, by significantly reducing reimbursement for evaluation and management of complex cases such as the patient I've just described.
The stated goal of the proposal was laudable. It proposed reducing the burden of paperwork for physicians currently documenting five levels of outpatient evaluation and management - from the most complex cases down to routine care for common, readily cured conditions.
The proposal, however, would do this by collapsing reimbursement for evaluation and management from the five categories to just two categories and splitting the difference with increased reimbursement for the simplest cases.
Among the immediate impacts would be a nearly 40 percent reduction in payment for time spent with the patients who need the most complex care. That includes patients with serious invasive bacterial infections, patients living with human immunodeficiency virus (HIV) or with the hepatitis C virus, patients who have undergone transplants, who have antibiotic resistant infections or have psychosocial issues and other challenges to accessing care.
The impacts go beyond the amount of time I can spend with the patient I've described. My time is also spent giving important answers to help avoid an infection from spreading to his kidneys, liver or other organs and doesn't put him back in the hospital. The proposal would inevitably affect the structure of care.
Now, the multiple issues I evaluate and manage with my patient would need to be distributed over a series of short visits in order for reimbursement to reflect or support the time involved. This is not a good approach to infectious disease care, where time is of the essence.
In addition, the precedent set by the proposal and the redefined standard of care it reflects might next be applied to Medicare reimbursements for inpatient cognitive care and by private insurance providers to their reimbursement structures.
With such constraints on best practice and fair compensation, the proposal would strongly discourage future physicians willing to complete infectious disease fellowships. A significant compensation gap between infectious disease (ID) physicians and the average for specialty physicians is already cited as a chief driver of a more than 20 percent decline in the numbers of physicians entering training for the ID specialty from 2011-2016.
The further disincentive of sharply reduced reimbursements that would come with the CMS proposal would have devastating impacts on recruitment into our specialty. It would have adverse consequences on our country's ability to respond to new outbreaks of infectious diseases as well as to treat the "superbugs" that have started to have a significant impact on patient care. The Centers for Disease Control and Prevention already has predicted a shortage of HIV clinicians by 2019.
A proposal that would underpay the skilled, thoughtful and complex outpatient care provided by taking careful histories and performing comprehensive examinations that are critical to infectious disease responses won't just shortchange physicians - it will shortchange everyone.
Dr. Daniel McQuillen is a physician in the Center for Infectious Diseases and Prevention at the Lahey Hospital & Medical Center and an assistant professor at Tufts School of Medicine.