Medicare Reimbursement and Patient Care: The trends are heading in the wrong direction
by Louis J. Wilson, MD, FACG
Chair, Legislative & Public Policy Council
Wichita Falls Gastroenterology Associates
Wichita Falls, TX
First: A Brief Review of the Medicare Cuts in 2022
Medicare recently announced yet another slate of reimbursement cuts looming in 2023. Did you know ACG members were already forced into cuts this year? On January 1, 2022, we started with a 0.82% cut. That was part of the aftermath of our hard won “success” in advocating to Congress to stave off more significant cuts that were scheduled for January 2022. Then, our Medicare reimbursement was cut by an additional 1% in April 2022 (Medicare Sequestration). Yet another round of cuts was implemented in July 2022 – another 1% from Medicare Sequestration.
With medical practices reeling from those cuts in the face of the dramatic inflation of the costs of running our practices, now CMS has announced further cuts looming for January 2023.
We need a permanent fix to this broken system. SO, why can’t Congress just pass a permanent fix?
The first main stated reason is that a permanent resolution requires an increase in government spending. Congress may contend they passed a permanent solution in 2015, as part of the Medicare Access and CHIP Reauthorization Act (MACRA), which repealed the Medicare sustainable growth rate (SGR) formula and created a new reimbursement system – the QPP – beginning in 2017. We are told that there is little to no appetite in Congress for a permanent solution. Yet Congress also gets frustrated when it needs to annually pass these temporary patches. Clearly MACRA was not the solution. Instead, it is part of the problem. MACRA provides for a 0% annual fee schedule update through 2025 and eliminated the use of the Medicare Economic Index for inflationary updates!
Secondly, there is no data suggesting a lack of access to specialty care among Medicare beneficiaries. In its March 2022 report to Congress that outlines recommendations related to reimbursement, the Medicare Payment Advisory Commission (MedPAC) notes that our reimbursement appears adequate under current law and that “Overall, beneficiary access to clinician services is comparable to that of privately insured people ages 50 to 64 and comparable to prior years, despite the ongoing PHE. Ninety-three percent of the Medicare beneficiaries ages 65 and over that we surveyed in mid-2021 were satisfied with the quality of the care they received in the past year. Only 10 percent reported forgoing care.”
Thus, Congress has chosen the risky path of temporary fixes without addressing the long-term problems.
These Reimbursement Cuts Come at a Time When COVID is Still Lingering/Screening Rates Lagging
As part of the Cancer Moonshot initiative, the Biden Administration announced in February 2022 that colorectal cancer is among 9.5 million missed cancer screenings in the United States as a result of the COVID-19 pandemic. ACG recently reviewed colorectal cancer screening Medicare claims data and found that in 2020 there was a 37% drop in G0121 compared to 2019 levels, representing almost 60,000 less screenings, and a 21% drop in G0105, representing 45,000 less screenings.
If a polyp is found and removed during a screening, providers use CPT 45380 and/or 45385 as the primary procedural codes. Medicare also instructs coders to use the “PT” modifier, denoting that this procedure started as a screening procedure on an otherwise asymptomatic patient. The PT modifier instruct claims administrators to waive cost-sharing. ACG also reviewed Medicare utilization for CPT codes 45380 and 45385, with this PT modifier. As expected, in 2020, utilization dropped by around 20-25% as compared to 2019 levels for all CPT codes 45380 and 45385 due to the pandemic, representing 151,000 less polyp removal procedures that began as a screening for Medicare beneficiaries.
Yet Congress and the Biden Administration still plan to move forward with the cuts. We must fight for our patients and practices.
Alarm Bells are Ringing! Medical Practice Costs/Inflation Are Increasing Dramatically
Medicare reimbursement cuts also come at a time when practices face high and increasing costs and inflation.
It is unacceptable that GI practices are forced to continue to bear the burden of poor fiscal decisions on Capitol Hill as we face significant financial pressure. Prices grew over 5% just from January 2022 to June 2022! (https://www.bls.gov/data/inflation_calculator.htm). According to the latest KaufmanHall “physician flash report,” while physician productivity, compensation, and revenues rose in Q1 2022 compared to Q4 2021, this also led to higher investments/ subsidies required to support physician practices, as well as continued expense increases as practices contend with inflation and a tight labor market. Our practices must be a dependable place for Medicare beneficiaries. Yet, this Medicare reimbursement system is anti-physician and anti-medical practice.
Of note in the “physician flash report”: “For the first time in two years, the median Investment/Subsidy per Physician Full-Time Equivalent (FTE) surpassed levels seen during the start of the COVID-19 pandemic. Total Direct Expense per Physician FTE continued its upward trajectory, reaching a new 2 year high.”
Thus, ACG and like-minded organizations continue to demonstrate that a permanent solution is the only answer to this recurring problem. We need ACG members to join the effort. Stay engaged for more information in the coming weeks, and please consider joining the ACG NAAN.