Feds propose single rate for office visits
Bid to slash paperwork could prompt doctors to drop Medicare patients.
The Trump administration is proposing huge changes in the way Medicare pays doctors for the most common of all medical services, the office visit, offering physicians basically the same amount, regardless of a patient’s condition or the com- plexity of the services provided.
Administration officials said the proposal would radically reduce paperwork burdens, freeing doctors to spend more time with patients. The government would pay one rate for new patients and a lower rate for established patients.
“Time spent on paperwork is time away from patients,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services. She estimated that the change would save 51 hours of clinic time per doctor per year.
But critics say the proposal would underpay doctors who care for patients with the greatest medical needs and the most complicated ailments — and could discourage some physicians from taking Medicare patients. They also say it would increase the risk of erroneous and fraudulent payments because doctors would submit less information to document the services provided.
Medicare would pay the same amount for evaluating a patient with a head cold and a patient with
complicated Stage 4 metastatic breast cancer, said Ted Okon, executive director of the Community Oncology Alliance, an advocacy group for cancer doctors and patients. He called that “simply crazy.”
Dr. Angus B. Worthing, a rheumatologist, said he understands the objective. “Doctors did not go to medical school to type on a computer all day,” he said.
But, he added: “This proposal is setting up a potential disaster. Doctors will be less likely to see Medicare patients and to go into our specialty. Patients with arthritis and osteoporosis may have to wait longer to see the right specialists.”
Private insurers often follow Medicare’s lead, so the proposed change has implications that go far beyond the Medicare program.
The proposal, part of Medicare’s physician fee schedule for 2019, is to be published Friday in the Federal Register, with an opportunity for public comment until Sept. 10. The new policies would apply to Medicare services starting in January.
“We anticipate this to be a very, very significant and massive change, a welcome relief for providers across the nation,” Verma said, adding that it fulfills President Donald Trump’s promise to “cut the red tape of regulation.”
“Evaluation and management services” are the foundation of an office visit. Medicare now recognizes five levels of office visits, with Level 5 involving the most comprehensive physical examination of a patient, and the most complex decision-making by the doctor.
Level 1 is mostly for nonphysician services: for example, a five-minute visit with a nurse to check the blood pressure of a patient recently placed on a new medication.
A Level 5 visit could include a thorough hourlong evaluation of a patient with heart failure, chronic obstructive pulmonary disease, high blood pressure and diabetes with blood sugar out of control.
“The differences between Levels 2 to 5 are often really difficult to discern and time-consuming to document,” said Dr. Kate Goodrich, Medicare’s chief medical officer.
Medicare payment rates for new patients now range from $76 for a Level 2 visit to $211 for Level 5. The Trump administration proposal would establish a single new rate of about $135. That could mean gains for doctors who specialize in routine care, but a hit for those who deal with complicated patients, such as rheumatologists and oncologists.
For established patients, the proposal calls for a payment rate of about $93, in place of current rates ranging from $45 to $148 for the four different levels of office visits.
“This proposal is likely to penalize physicians who treat sicker patients, even though they spend more time and effort and more resources managing those patients,” said Deborah J. Grider, who has audited tens of thousands of records and written a book on the subject.