Many primary care doctors applaud it. Specialty physicians? Not so much.
Chances are, your physician customers are talking about the 2024 Medicare Physician Fee Schedule proposed rules, published in July by the Centers for Medicare and Medicaid Services. Under the proposal, physicians would see a decrease to the conversion factor of 3.36% on Jan. 1, 2024, going from $33.8872 to $32.7476.
That’s bad news for many physicians. But primary care doctors detect a glimmer of hope in the 2024 Fee Schedule – the proposed addition of add-on code G2211 to HCPCS, intended to better recognize the time and labor associated with longitudinal care of complex patients.
Bronx cheers
An overall cut exceeding 3% was bound to generate complaints from the medical community. And it did.
- The American Society of Anesthesiologists: “The proposed rule underscores how the Medicare payment system is broken, especially during a time when anesthesia groups are faced with continued inflation pressures.”
- The American Medical Association: “The Centers for Medicare & Medicaid Services proposal is a critical reminder that patients and physicians desperately need Congress to develop a permanent solution that addresses the financial instability and threatens access to care.”
- The American College of Cardiology:
“[The proposal] fails to account for significant inflation in practice costs, creates long-term financial instability in the Medicare physician payment system, threatening patient access to Medicare-participating physicians and services.” - The American College of Obstetricians and Gynecologists: “For the physicians who provide care to beneficiaries of Medicaid, this translates to lower payment, which does not cover the cost of providing care. It also puts further strain on practices recovering from the COVID-19 public health emergency and ongoing increases to practice-related expenses that are not immune to inflationary rises.”
Primary care groups had some issues with the proposal as well. “While Congress enacted limited conversion factor relief for 2024, physicians still face untenable cuts, which could threaten practice stability and create barriers to care for beneficiaries,” said Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, president of the American Academy of Family Physicians.
That said, AAFP and some other societies voiced their support for the G2211 add-on. “G2211 is an incremental but meaningful step toward more appropriately valuing and paying for primary care, which will bolster the primary care workforce and protect patients’ continued access to timely care,” Dr. Iroku-Malize told Repertoire. “The G2211 code is a direct investment in these proven services.”
What is G2211?
CMSspeak for G2211 reads like this: “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex condition.”
The American College of Cardiology describes it in simpler terms: “G2211 would generally be applicable to outpatient office visits as an additional payment, recognizing the costs clinicians may incur when longitudinally treating a patient’s single, serious or complex chronic condition.”
The add-on had been scheduled to be implemented in 2021, but Congress delayed it for three years because of its potential cost to Medicare. However, CMS has since decided that the add-on will improve the accuracy of payment for primary and longitudinal care without endangering the financial health of Medicare and should be implemented on Jan. 1, 2024.
The proposed rule – released on July 13 – had a 60-day comment period. Final regulations were expected to be issued around Nov. 1.
Some specialties object to the add-on because of a provision in the Physician Fee Schedule known as “budget neutrality.” If the Centers for Medicare & Medicaid Services projects that net pricing changes for existing services will result in boosting Medicare spending by more than $20 million, the agency must reduce spending elsewhere. Simply put, as more money is allocated to one sector of the medical community, less is allocated to others.
For that reason, there is a chance Congress may once again postpone implementation of the G2211 add-on, as it did three years ago, says coding expert Betsy Nicoletti, MS, CPC, president of Medical Practice Consulting. “Hopefully that won’t happen, but I’m not getting my hopes up.”
A boost for primary care
“Historically, the Medicare physician fee schedule has devalued primary care and other cognitive services as many new procedural codes with higher values were added,” says Dr. Iroku-Malize. “This devaluation has led to lower compensation for cognitive care physicians despite the vital role they play in managing chronic conditions and coordinating patient care across a large team. As a result, the interest in pursuing primary care and other cognitive specialties has declined, exacerbating physician shortages in rural and other underserved areas across the nation.
“Recent efforts by CMS have begun to help address this historic undervaluation of primary care, but evidence continues to indicate that primary care office visits are often more complex than other specialties,” she says. “The existing process for valuing physician services fails to take these complexities into account.”
In a joint letter to legislative leaders in Washington, the American Academy of Family Physicians and the American College of Physicians urged Congress to support full implementation of G2211. “In short, the implementation of G2211 is long overdue, necessary, and will ultimately ensure the Medicare program provides patients with timely access to longitudinal, comprehensive, coordinated, whole-person care,” they wrote, adding:
- G2211 will help promote beneficiaries’ timely access to primary care and other continuous services that promote better health care outcomes and help reduce spending.
- G2211 will advance more appropriate payments for primary care and other longitudinal, continuous care under the Medicare Physician Fee Schedule.
- By advancing fair and accurate payment in Medicare, G2211 will help sustain primary care and other physician practices Medicare beneficiaries rely on and bolster the physician workforce.
A different perspective
Other professional societies and organizations had a more mixed view of the add-on. “ACOG is in agreement with several other surgical organizations highlighting concerns around the practicality and necessity of G2211,” says Lisa Satterfield, senior director of health and payment policy, and Erin Alston, health policy manager at the American College of Obstetricians and Gynecologists. “Implementation of this add-on code would inappropriately result in overpayment for certain evaluation and management services, which will ultimately put even more downward pressure on reimbursement rates due to the nature of budget neutrality requirements under the physician fee schedule.”
Claire Ernst, JD, director of government affairs for the Medical Group Management Association, says that MGMA supports the intent behind the G2211 complexity code, “but Congress must go back to the drawing board to reevaluate budget neutrality requirements. Budget neutrality has consequences that surpass primary care services; any meaningful change to the Physician Fee Schedule will generally trigger across-the-board cuts, making it difficult to implement much-needed policies.
“Medical groups continue to face challenges stemming from inflation and increasing administrative costs, such as prior authorization requirements,” she says. “Physician practices may have to make difficult decisions regarding practice operations to keep the doors open such as limiting the number of new Medicare patients, reducing charity care, and closing satellite locations.”
Without preparation, many physicians may not know how to apply the add-code by Jan. 1, says Betsy Nicoletti. For that reason, she advises primary care physicians and other specialists – including psychiatrists, rheumatologists and other physicians with longitudinal patient relationships – to start preparing today by identifying patient encounters that would merit G2211. CMS estimates the add-on might ultimately be used on up to 54% of claims, but Nicoletti thinks that estimate is low.
Sidebar 1:
Telehealth in the 2024 Physician Fee Schedule
Several telehealth-related provisions would remain in effect until Dec. 31, 2024, if the proposed 2024 Physician Fee Schedule
is enacted, including:
- Temporary expansion of the scope of originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home.
- Expansion of the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists.
- Continued payment for telehealth services furnished by rural health clinics and Federally Qualified Health Centers using the methodology established for those telehealth services during the Public Health Emergency.
- Delaying the requirement for an in-person visit with the physician or practitioner within six months prior to initiating mental health telehealth services, and again at subsequent intervals as the Secretary determines appropriate.
- Coverage and payment of telehealth services included on the Medicare Telehealth Services List (cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes) until Dec. 31, 2024.
Sidebar 2:
Robbing Peter to pay Paul?
One provision in the Physician Fee Schedule continues to draw the ire of many physicians, sometimes pitting physician groups against each other. “Budget neutrality” means that if the Centers for Medicare & Medicaid Services projects that net pricing changes for existing services will boost Medicare spending by more than $20 million, the agency must reduce spending elsewhere.
“The structure and reality of budget neutrality has created a system in which medical specialties are forced to weigh the impact of every action, whether imposed by Congress or CMS, or self-selected through the AMA CPT and RUC process,” say Lisa Satterfield, senior director of health and payment policy, and Erin Alston, health policy manager, American College of Obstetricians and Gynecologists.
“Medicine is an inherently interdisciplinary field and patients often require services from a multitude of specialists for single conditions. Continued decreases in physician reimbursement is detrimental to all medical specialties and work should be done to ‘make physicians whole’ in regard to payment. While news of increases in hospital reimbursement is widely published, the strain of budget neutrality for physicians and other healthcare professions places the entire systems at odds.”
Says Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, president of the American Academy of Family Physicians, “The current Medicare physician payment system pits medical specialties against one another as payment rates become increasingly inadequate and physician practices struggle to stay afloat. That’s why Medicare physician payment reform is needed. This includes an annual inflationary update to help ensure physician payment rates keep pace with rising practice costs. Congress must also address Medicare budget-neutrality requirements, which make it harder to compensate physicians appropriately for the life-saving services they provide.”
The American Medical Association supports a bill introduced in Congress this spring that would tie the Medicare physician payment schedule to the Medicare Economic Index. “By instituting an annual inflation-based update, the legislation would put physicians on equal footing with virtually all other health professionals and organizations paid by Medicare,” according to AMA, adding that physician payment rates have been subject to a six-year payment freeze that will last until 2026.
And in a statement in July, Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, said the proposed 2024 Medicare Physician Fee Schedule “raises significant concerns for medical groups related to its 3.4% reduction to the conversion factor, which further increases the gap between physician practice expenses and Medicare reimbursement rates. The G2211 add-on code for complex patients “highlights CMS’ flawed approach to addressing inadequate Medicare payments for primary care services using a budget neutral methodology,” he added.
“Congress must reexamine existing law to provide an annual physician payment update commensurate with inflation and do away with Medicare’s ‘robbing Peter to pay Paul’ budget neutrality requirements to provide much-needed financial stability for medical practices,” he said.