As the coronavirus surges to its highest case numbers since July, the Trump administration is quietly moving to substantially cut reimbursement rates for a long list of surgical services — an action that could reduce patient access to critical health services in the midst of a pandemic.
The Centers for Medicare & Medicaid Services’ (CMS’) proposed fee schedule, announced in August and going into effect January 1, 2021, trims Medicare payments by 9 percent for cardiac surgery; 8 percent for thoracic surgery; 7 percent for vascular surgery; 7 percent for general surgery; 7 percent for neurosurgery; and 6 percent for ophthalmology — compared with 2020.
The public comment period for the proposal closed with little fanfare in early October.
Since the announcement, organizations representing 1.4 million physicians and non-physician practitioners have urged CMS to reconsider payment reductions, warning that the agency has failed to consider concerns from the public and the healthcare community. Indeed, numerous practices are already experiencing sharp cutbacks from insurers, which have reaped dramatic profits during the COVID-19 pandemic.
CMS develops fee schedules used by Medicare to pay physicians, ambulance services and clinical laboratory services, as well as for medical equipment, prosthetics, orthotics and supplies. In announcing its proposed fee schedule reductions for 2021, the agency argued that it is seeking to eliminate “burdensome billing and coding requirements” for Evaluation Management, widely referred to as E/M in the medical community.
“These billing and documentation requirements for E/M codes were established 20 years ago and have been subject to longstanding criticism from clinicians that they do not reflect current care practices and needs,” CMS wrote in a press release. “As a result of this change, clinicians will be able to make better use of their time and restore the doctor-patient relationship by spending less time on documenting visits and more time on treating their patients.”
Under the changes, the agency will impose payment reductions to certain physician, non-physician and institutional providers in order to offset payment increases the agency has proposed for physicians who primarily deliver office-based services.
But a coalition of physician groups — including the American Medical Association, the American Academy of Ophthalmology, the American Association of Neurological Surgeons, the CardioVascular Coalition and the Institute for Critical Care Foundation — called the cuts “unconscionable,” arguing fee reductions will strain a healthcare system already stressed by a pandemic.
The American Medical Group Association (AMGA), which represents group practices, also opposed the cuts, writing in a statement: “While appreciative of the effort to increase support for primary care services, the Physician Fee Schedule’s budget neutrality requirements effectively shift funds from one specialty to another, potentially undermining the team-based approach to care that is the hallmark of the group practice model.”
Should the cuts take effect, they may exacerbate financial pressures the COVID-19 pandemic has already forced on the American healthcare system — as practices furlough or trim staff and others close their doors entirely.
A member survey taken by the Surgical Care Coalition earlier this year, indicated that about one-third of private surgical practices were already at risk of closing permanently due to the financial strain of the pandemic — including due to reduced patient volume — as many Americans remain afraid of contracting the virus when visiting a specialty provider.
Primary care providers may thus have fewer choices when referring patients to specialists if healthcare professionals must close or limit their practices as a result of reimbursement cuts.
The cuts are primed to weaken the practices of a number of healthcare professionals on the frontlines of the pandemic, including anesthesiologists, audiologists, certified registered nurse anesthetists, emergency physicians, neurosurgeons, occupational therapy practitioners, pathologists and surgeons — among dozens of other specialties.
In some cases, the steepest cuts will fall on medical practices that have borne the greatest brunt of the pandemic. Ophthalmology lost more patient volume due to the pandemic than any other specialty, and is facing a 6 percent Medicare pay cut for 2021 in addition to a 9 percent reduction for cataract surgery and 9 percent to 10 percent reductions for retina and glaucoma procedures.
Dr. David Hoyt, executive director of the American College of Surgeons, said of the proposal: “The middle of a pandemic is no time for cuts to any form of healthcare, yet this proposed rule moves ahead as if nothing has changed.”
A September survey from the organization found that one in five surgeons say they may need to stop performing certain procedures, including procedures that are especially complex or risky — a disruption that comes after patients have already faced delayed care due to COVID-19.
Doctors are also expressing concern that cuts to surgical specialties like cardiothoracic surgical care will lead to delays in treatment and, therefore, access to care. Society of Thoracic Surgeons (STS) President Joseph Dearani warned of a “serious implication” for the patient population, “because reducing reimbursement is going to further reduce access and the downstream effect will be mortality.”
“That’s the problem in our specialty,” said Dearani. “Improper treatment or delay of treatment results in death, and so that would be sort of a predictable endpoint with the current approach.”
With the election nearing, there is limited time to enact legislation to counter CMS’ proposed cuts. Should Trump lose, Congress appears poised to lurch through the lame-duck session, as the Senate must dedicate more time on COVID-19 economic relief measures.