The road to advocacy's ‘Final Four’

Although ACP achieved major changes to the evaluation and management (E/M) codes, implementation of these changes has not been perfect. There is ongoing work to be done.

It's March, the height of the college basketball season, my favorite and yet most nerve-wracking time of the year. In many ways, it is analogous to how I feel advocating for improvements to Medicare physician payment. Yes, I am that policy wonk who enjoys working on this issue, and yet I constantly feel like I'm “on the bubble” of achieving success—with that “one shining moment” consistently eluding me. And while I'm not a UCLA fan, I am reminded of what John Wooden said: “The most important key to achieving great success is to decide upon your goal and launch, get started, take action, move.”

However, as we work to set those goals and launch, it is important to look back and recognize that while we may not have won it all yet, we have perhaps made it to the Sweet 16. Two years ago, ACP achieved major changes to the outpatient evaluation and management (E/M) codes—increasing their value and reforming the documentation requirements, resulting in reduced burden for our members. Then, in 2023, the inpatient E/M codes followed suit. Both accomplishments were the result of years of ACP advocacy, with input directly from our members. The implementation of these changes has not been perfect; some institutions chose to not allow their physician employees to experience all these benefits, either by not updating their own approaches to documentation and/or by revising relative value unit targets while not increasing compensation. Thus, there is ongoing work to be done.

A side effect of the outpatient E/M changes in 2021 was their impact on the overall Medicare Physician Fee Schedule conversion factor. While the significant valuation increases in the E/M codes were not entirely responsible for decreasing the conversion factor, which resulted from statutorily required budget neutrality, they were a large contributing factor. When budget neutrality is in place, one (or more) things going up leads to others going down—in this case, the conversion factor. This meant that payment for all codes, including those that increased in value, would be reduced in some manner. Internal medicine and other specialties that use E/M codes would still see an increase, just not quite as much as it could have been.

Note that the timing of the outpatient E/M changes also aligned with the ongoing COVID-19 pandemic, when many practices were struggling to stay open, maintain their staffing levels, transition to telehealth, obtain personal protective equipment, and handle many other challenges. Additionally, practices were going to be impacted by the ongoing Medicare sequestration cuts. Thankfully, Congress stepped in and provided additional funds that alleviated these potential cuts. While this was extremely positive, it also began what has now become an annual issue.

In 2022, Congress again stepped in to mostly alleviate potential cuts from budget neutrality and sequestration, as well as some additional cuts due to PAYGO, another sequestration issue triggered by the American Rescue Plan Act. 2023 saw another set of potential cuts for physicians, again due to budget neutrality, sequestration, and PAYGO—this while COVID-19 and now inflation are challenging physician practices. The Medicare Physician Fee Schedule is the only Medicare payment system that is not subject to annual inflationary updates. In fact, according to Medicare trustees data, when adjusted for inflation, Medicare payments to physicians have declined by 22% from 2001 to 2021. Congress yet again included some relief from these cuts in the final 2023 appropriations bill, and while it did not cover the full impact, in the end most internal medicine physicians should still see an overall positive Medicare Physician Fee Schedule update for 2023. Yet, without broader and more comprehensive reform, we will be back in the same place again in 2024.

What does this reform need to include in order for internal medicine—and physicians overall—to become a Cinderella team and get past the Sweet 16? First and foremost, the Physician Fee Schedule must be adjusted for inflation. This adjustment would lead to greater stability so that more comprehensive reforms can be made. The generally accepted methodology for doing this is using the Medicare Economic Index (MEI), a measure of physician practice cost inflation. The Medicare Payment Advisory Commission recently recommended that 2024 physician payments be adjusted at 50% of the MEI, resulting in an approximately 1.25% bump. However, ACP does not believe this to be sufficient, given that physicians and their practices have been faced with decades of flat payments, as well as increased practice expenses, high inflation rates, and staffing and supply shortages. Therefore, ACP is calling on Congress to immediately take on comprehensive Medicare physician payment reform to provide stability for physicians and ensure access to care for patients.

An important side note regarding the 2024 Medicare Physician Fee Schedule is that this is the year when the add-on code G2211, described as “visit complexity inherent to evaluation and management” services, goes into effect. ACP strongly supports the implementation of this code, as it will help internal medicine physicians bill and be paid for the additional work that goes into caring for complex patients. However, as when the original outpatient E/M code changes went into effect, this new code will likely impact the overall conversion factor. Given this, ACP is developing advice for CMS on its implementation.

ACP will also be working to pursue comprehensive reform of the Medicare Quality Payment Program (QPP). The QPP was implemented by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. This law ended the previous annual headache of the sustainable growth rate (SGR) formula and implemented other significant changes to Medicare. Unfortunately, the law has not lived up to expectations and needs reform. Overall, ACP supports payments being aligned to promote high-value patient- and family-centered care, but the QPP and most other value-based payment programs as currently implemented have largely failed to achieve better outcomes at lower costs to patients—and most are also extremely burdensome for participating physicians and their practices.

The basis for our advocacy to improve the QPP and value-based payment overall lies in our 2020 Vision for the U.S. Health Care System, as well as our 2022 paper outlining the need to reform physician payments to achieve greater equity and value. The College defines value “around the patient, including the processes of care they receive, their clinical outcomes, their own health and health care goals, their safety, and their experience and engagement with their care.” We call for a variety of approaches to payment and delivery system reform to be considered, evaluated, and expanded if successful. Payers should prioritize inclusion of underserved patient populations and eliminate inappropriate disparities in payment levels between complex cognitive and preventive services versus procedurally oriented services, as well as unnecessary, inefficient, and ineffective billing and reporting requirements. Performance measures should be aligned across payers, models, and programs and be patient-centered, actionable, appropriately attributed, and evidence based, prioritizing what is important to measure. ACP supports the use of other clinically meaningful measures for quality improvement and calls for health IT to prioritize the needs of patients, frontline physicians, and their care teams.

The College also continues to push Congress and CMS to improve the Merit-Based Incentive Payment System (MIPS) within the QPP and has achieved some success, with CMS choosing to implement two MIPS Value Pathways (MVPs) that were recommended by the College, one focused on chronic care management and the other on promoting wellness. While the agency did not include every measure that ACP called for within these MVPs, CMS did include enough of those recommended by our Performance Measurement Committee that our members can consider them reasonable options for their MIPS participation. Additionally, CMS has removed several problematic performance measures from the MIPS program over the past several years.

ACP has also developed an advanced Alternative Payment Models pathway that, if implemented, would allow CMS to offer more opportunities for internal medicine subspecialists to participate in this program. The Medical Neighborhood Model was recommended by the Physician-Focused Payment Model Technical Advisory Committee for testing since it met all 10 of the HHS Secretary's criteria. We continue to have discussions with HHS and CMS staff regarding testing all or some of the model.

A key component of how ACP is taking John Wooden's advice is by asking Congress to hold hearings on Medicare payment reform, including the QPP, even as we continue to fight for stability in the Physician Fee Schedule. As opportunities arise, we will engage our members via their chapters and grassroots efforts. As Bill Russell, former player and coach for the Boston Celtics, said, “Commitment separates those who live their dreams from those who live their lives regretting the opportunities they have squandered.” While winning it all or even reaching the Final Four of payment reform this year may be a dream, we must take advantage of every opportunity that arises. Happy March Madness, everyone!