Until They Change The Rules by Pat Conrad MD

“An uncertain policy landscape, ever-changing regulatory requirements, and evolving practice and reimbursement models mean that physicians must constantly stay on top of how they are being paid to ensure they receive what they are owed.”

Doesn’t THAT make you want to leap out of bed, ready for a joyful day of seeing government patients?

CMS is jiggering around again with their Byzantine payment methods including “value-based payments, level of care changes that will impact reimbursement rates, and continued efforts to equalize payments between office- and hospital-based doctors.”

And by participating in the exciting Quality Payment Program, you’ll be eligible for these exciting new updates!  Tell them what they’ve won, Don!

The lucky Medicare doctor will perhaps receive some, all, or none of this deluxe package:

Expanded exemptions. Doc’s who see too few Medicare patients, bill Medicare below $90 K, or deliver below a threshold number of “covered professional services” will be exempt from the QPP.  But wait, there’s more…

– Exempted docs can still opt into the Merit-based Incentive Payment System (MIPS).  However the decision to opt in is “irrevocable” (cue “Hotel California”).  And this all-expense paid (by you) MIPS excursion will have it’s various payment scoring weights fiddled around with so much that the values for “quality,” “interoperability,” and “improvement activities” will be incomprehensible.  And we’re losing “34 quality measures deemed by CMS to be of low value,” whatever in hell that may mean given that quality has never been objectively defined.  And MIPS will require 2015 EHR adoption in 2019, because the vendors were not ready to adopt anything beyond 2014 in 2018.  Does that clear things up?

Physician groups lobbied to reduce the reporting period from 12 to 3 months for “all four performance categories” to reduce burdensome quality data gathering, but CMS said, “Nah, thanks but we really like all that extra data, it gives us something fun to do.”  A rep for the American College of Physicians argued that that “a quarterly report with real-time feedback would add more value to the program for physicians.”  Yep, real-time feedback on an unproven, fluid-definition measure that requires extra staff time to quantify and submit in hopes of keeping up with the rising cost of extra reporting requirements is sooo valuable.

One rep for a capitated physicians group said, “the changes to QPP look to include ‘real action to advance the value movement’ and indicate that MIPS is ‘here to stay.'”

The Medicare Physician Fee Schedule is in for a re-structuring of E/M codes.  CMS wants to smoosh Levels 2-5 into one payment rate, “with add-on codes included to address visits of greater complexity.”  Which is nakedly stating, “We got rid of some codes so that we can pay for more visits on a reduced standard rate, and came up with a bunch of NEW codes for you and your EHR to learn in order to ask for greater payment to perhaps be paid at a later date, once we sort out the decimals.”  The rates for 1-2 will potentially rise, and rates for 4-5 fall.  It is obvious that with the increased demand for documenting complexity, more and more doctors were billing appropriately for Level 4 visits, and this will be a nice way to simply pay them less for the same amount of work.  Ever the suckers, the American College of Physicians supports this move because they think it will result in internists getting paid more.  The ACP actually believes the rhetoric from CMS about documentation streamlining and better pay for more complex patients.  If the ACP would just take a long weekend to Las Vegas and get good and drunk, maybe they would wake up hung over, pockets turned out, and finally realize that the house always wins (and that trying to pay specialists less never actually results in paying primary care more).  Actually there is a difference:  Las Vegas hookers have a higher probability to deliver defined value for payment, unlike CMS.

Medicare is also considering paying for virtual visits via phone, text, or e-mail. (Gee, I wonder if any other payment model already does that?).  Medicare is also proposing to pay even when patients initiate the virtual communication,” at $14 a pop, and hoping for more convenient check-ins.  Can anyone predict what sort of complicated check-in steps will have to be documented each time to submit a claim rapidly dwindling in value?  And pursuant to HIPAA, wouldn’t your smart phone have to be HIPAA-certified?  And since you are communicating with a government patient, doesn’t that make your smart phone and its contents all liable for government audit and inspection?

CMS is also proposing a flat fee for most visits rather that the current Outpatient Prospective Payment System, which basically pays more for visits in hospital-owned practices.  This is obviously a move to stop paying facility fees, which hospitals claim they need for cost-shifting support of things like ER’s and indigent care.  It’s hard to argue with this reform, and we all like seeing Big Hospital take one in the shorts.  But at the same time, a lot of smaller facilities are really harmed whenever a new cost reform rolls out, so cutting some of the pointless federal mandates to balance things out would be appropriate.  Yeah, right.  Sounds like I need a trip to Vegas too.

If you think reading this missive was painful, imagine how painful it was wading through the long article to bring you these observational jewels.  Imagine how painful it is for physicians to have to work through, and under these fluid guidelines that will forever make it impossible to establish a stable business, all the while leaving them potentially guilty of fraud.

A medical school classmate was considering entering the military and asked my opinion (I had gotten out 3 years before).  I said the military was great, providing you understood one simple truth:  they make all the rules, and they can change them at any time.

Fine for the military, but I don’t think that is what any of us thought treating government patients would mean.  For those trapped by their circumstances, I’m truly sorry.  For those who can escape, DPC is your way out.

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