In time for Halloween, health care specters arise

It's October, so it seems appropriate to provide an edition of “What Keeps Me Up at Night.” I can tell you right now that it is not the new “Exorcist” movie because there is no way I will go to see that—I still have haunted dreams from the first one! However, when it comes to ACP advocacy and health policy, issues such as the ongoing assault on reproductive health care access; the criminalization of evidence-based health care; the discrimination faced by so many of our fellow citizens due to the color of their skin, their sexual orientation, and/or their gender identity; and the ongoing public health crisis of gun violence are always top of mind and reasons why I lose sleep. However, lately I've been plagued by concern over the state of primary health care in the United States.

The benefits of care provided by internal medicine and other physicians who specialize in primary care are well known at this point. As we discussed in “Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms,” which was published in Annals of Internal Medicine in 2020, “access to primary care has consistently been associated with higher quality of care, lower mortality rates, higher patient satisfaction, and lower total system costs.” Additionally, “increasing 1 primary care physician per 10,000 people in 1 state was associated with a rise in that state's quality rank by more than 10 places and a reduction in overall spending by $684 per Medicare beneficiary.” Yet, the U.S. continues to underinvest in primary care, with primary care spending for all insurance types decreasing from 6.2% in 2013 to 4.5% in 2020. Why is there such a disconnect, and what can we do to address it? This is what keeps me up at night. And while I recognize that it is a multifactorial problem that requires complex solutions, in other ways it is so simple. Primary care needs greater investment across the board in order for those in the U.S. to reap the benefits.

It is not even a partisan issue, given the clarity of the data on the benefits of primary care. Rather, it is unfortunately a situation that pits medical specialties against each other for the stagnant bucket of funds that is made available. The name of this “horror flick” is budget neutrality. You may recall that I spoke about this back in the March 2023 ACP Internist, when I noted that within the Medicare Physician Fee Schedule, any increase in payment for one code or set of codes leads to decreases in payment for others. If the shifts are significant, they can lead to a decrease in the overall conversion factor, meaning that every code would be subject to some sort of reduction.

A significant correction along these lines was scheduled to go into effect in 2020, in part due to the long-sought increases in the outpatient evaluation and management (E/M) codes. This would have led to some major cuts for other medical specialties, particularly those focused on procedures and surgeries, and an overall reduction in the conversion factor. Given that COVID-19 was upon us, and all physicians needed to have stability in their payments, ACP worked with the house of medicine to achieve an intervention by Congress, who added funds into the fee schedule. Since then, Congress has continued to intervene to mitigate the effect of a reduced conversion factor.

Several potential solutions to the challenge of budget neutrality are being discussed across medicine, as simply removing this requirement would likely have unintended consequences, including potentially increased costs in an already tremendously expensive health care system. So, to achieve some stability that would allow for this longer-term effort to occur, ACP and others are advocating for Congress to implement an inflationary update, based on the Medicare Economic Index (MEI). This advocacy effort will continue, but internal medicine and primary care overall have a more immediate issue to address: ensuring that the G2211 code is allowed to go into effect as proposed by CMS.

G2211 is a Medicare-specific add-on code designed to better address the resources and additional costs associated with furnishing comprehensive, longitudinal primary care. When I wrote about G2211 in March, I noted our hope and expectation that CMS would propose the implementation of the code in 2024. G2211 had previously been slated for implementation in 2022. However, to help mitigate the impact of the COVID-19 pandemic on medical practices and offset the cost of stopping cuts to payments for physician services due to budget neutrality requirements, Congress prohibited CMS from implementing payment for this code before 2024. (For more on the specifics of the code, see the Practice Tips column in this issue.)

This time is now upon us, and CMS has responded accordingly. However, even though CMS has made some adjustments to the estimated utilization of this code, it will still have an impact on the conversion factor next year—again, thanks to budget neutrality. As a result, some societies are asking Congress to intervene and further delay or even stop implementation of G2211 entirely.

ACP's position, along with that of numerous other organizations, is that Congress should allow the G2211 code to be fully implemented by CMS in 2024 as intended, as this will ensure that our nation's older adults have access to high-quality, comprehensive, patient-centered care. Implementation of G2211 is long overdue and necessary. Congress should not be providing relief from the impact of budget neutrality on the backs of internal medicine and others who provide primary and comprehensive care. Unfortunately, having to wage this critical battle on Capitol Hill means that we are less able to be united with the full house of medicine. Yet we do still need to work together to achieve an MEI update, even if it is for a limited timeframe.

Another interesting development in the Physician Fee Schedule's proposed rule is that CMS asked for input about the potential range of approaches it could take to improve the accuracy of valuing services. This included a specific question about whether the methods used by the Relative Value Scale Update Committee (RUC) and CMS are appropriate to accurately value E/M and other codes (to learn more about the RUC and other coding topics, you can access our informational webinar series. ACP had been considering this issue even in advance of this inquiry from CMS, so we were pleased to be able to share our thoughts. The College does believe that the RUC survey process should be modernized and that there is a need to identify supplementary or complementary processes to the RUC that transition us away from the one-size-fits-all approach in assigning value. While we were recently able to achieve some increases in payment for E/M services—and the G2211 code will help—more needs to be done to appropriately value and pay for primary care.

Outside of the Physician Fee Schedule, Medicare is implementing and considering alternative models for primary care payment. One of these is the newly introduced Making Care Primary (MCP) model. This model will be tested in eight states—Colorado, North Carolina, New Jersey, New Mexico, New York, Minnesota, Massachusetts, and Washington—starting on July 1, 2024. ACP is strongly encouraged by this model, which takes into account a number of recommendations ACP has made to CMS over the past several years. CMS has also asked for input on the potential of a prospective, population-based payment (hybrid) model that could be nestled within the Medicare Shared Savings Program (similar to ideas proposed by ACP alongside other physician organizations) and the Primary Care Collaborative.

Yet addressing the significant payment issues that keep me awake at night cannot fix the challenges that primary care faces alone. More must be done to improve the pipeline into internal medicine and other primary care specialties and ensure that we continue to provide support to this critical workforce. This is why ACP continues to support both the Resident Education Deferred Interest Act (REDI), which allows borrowers in medical or dental internships or residency programs to defer student loan payments until the completion of their programs, and the Resident Physician Shortage Reduction Act of 2023, which increases the number of Medicare-supported graduate medical education positions by 14,000 over seven years. We are hoping to see one or both of these incorporated into an end-of-year package, as this would go a long way toward alleviating some of the nightmares early career physicians face and ideally offer them a greater opportunity to go into an internal medicine specialty.

If you have already been losing sleep or if this article causes you to do so, know that you can take action to help! I've said it before, and I'll say it again: A key way that you can engage is by joining the Advocates for Internal Medicine Network. This will allow you to be the first to receive alerts to engage your federal or state lawmakers on key policy issues. ACP also offers state health policy toolkits that can enable you to take action, or you can reach out directly to the Washington office for support. We do not want you up at night—unless you've just watched “The Exorcist”! Also, keep an eye out for the 2024 Medicare Physician Fee Schedule final rule, expected to be released just after Halloween. My hope is that the agency will finalize some of the positive policies it has proposed, such as G2211, but we will have to wait and see—and hopefully get some sleep in the meantime.