CPC+, The New “Better” Physician Reimbursement from CMS

The Centers for Medicare and Medicaid Services (CMS) is constantly coming up with ways to cut payments to physicians in the name of improving health care quality. We had PQRS, then Meaningful Use. Statistical studies have shown that these attempts to reduce payments to physicians under the guise of improving the quality of care have been generally less than stellar. Yet Comprehensive Primary Care Plus (CPC+), and more recently,  MACRA, have been carefully crafted to pay physicians less for the care they provide, especially independent primary care physicians.

Medicare and Medicaid have never been supportive–monetarily–of preventive care.  The kind of care patients get from family practice physicians. CMS often declares preventive care admirable, but in reality, the reimbursement for preventive care is shameful.

Health care payers such as Medicare require physicians sign contracts as a condition for payment. Without such contracts, physicians cannot file claims for the services they provide patients. These contracts require physicians to accept “adjustments” to the charges they submit.  In our rural practice area, this “adjustment” averages 68% of the dollar amount submitted on the claim.

Physicians cannot charge more than the “allowed” cost for their services, but that number on the claim for payment is really just a place holder.  The actual reimbursement for the provided service will be “adjusted down” 68%.

Furthermore, for some reason, CMS thinks it costs more to provide care in metropolitan areas than rural areas. The reimbursement rates in rural states are far less than in urban states. CMS rates the quality of Medicare services provided by state.  North Dakota is always found among the top states in the quality of the Medicare services its physicians provide. Still, Medicare chooses to reimburse physicians in North Dakota at almost the lowest rate in the nation. I suspect large corporations in states with sizable metropolitan areas are in a position to negotiate lesser “adjustments” than small practices in rural areas.

A look at almost any physician reimbursement by Medicare will reveal the severity of the disconnect between the services provided and Medicare’s reimbursement. Managing diabetic patients is a popular topic now. A look at how Medicare handles reimbursement for diabetic foot care can be eye-opening.

Diabetic patients are allowed to have one foot examination every 61 days to check for loss of feeling in their feet, sores on their feet, or toenails in need of care. In the presence of sores on their feet, patients may have foot examinations more frequently.

What services does the physician perform in this foot exam? To be paid for the examination, a form must be filled out documenting that all the parts of the foot exam have been addressed. If the examination indicates the patients qualify for diabetic shoes or inserts for the shoes, there is another set of forms, one for the shoes and one for the inserts.

In our rural area, the allowable charge for this foot exam is $75. For filling out over 5 pages of forms threatening the physician at almost every data entry point. Of course, that’s the charge submitted to Medicare. Medicare’s then “adjusts” the cost down 68% to $51.

Moreover, Medicare will not allow this $75 charge to be included in any claim which also includes an office visit for something else. That’s right.  If the patient in on blood thinners and comes to the clinic to have his coagulation checked, the foot exam cannot be billed on the same day. Just as a woman’s PAP smear may not be billed on the same day as her annual exam.

The only alternative is to have the patient come in another day for the foot exam and settle for a total clinic visit claim of $75.  Of which only about $51 would be paid.

So excuse me if I am a bit chary of Medicare’s latest promotional campaign to provide better primary care physician reimbursement, Comprehensive Primary Care Plus (CPC+).

But note that part of their plan to reward primary care physicians includes further reductions in the office visit payments. There is no clarification as to whether those reductions are in the “face value” of the claim (the $75) or whether those reductions will be in the actual “adjusted” reimbursement (the $51).

CMS, wake up.  Primary care physicians in our area already face a 68% reduction in the claims they submit. Throwing a few more sheckels (and the suggested payments are indeed mere shekels) in the direction of some sort of bundled care while reducing the cost of the office visit hardly seems the way to show real support of primary care.

It’s the old shell game.  Move the pea from under one walnut shell to another and see if anyone can guess where the payment went.

When it comes to physician reimbursement, CMS needs to disassociate itself from the carnival mentality. Most primary care physicians provide very good care to their patients, often under difficult circumstances.

It’s time for Medicare to let go of the notion that physicians are responsible for this country’s expensive healthcare system. Instead, Medicare should be looking for the real reasons the U.S. healthcare system is the most expensive in the world.

According to Forbes, physicians account for only 10 percent of our healthcare costs. The reality is that 90 percent of this country’s expensive healthcare spending resides somewhere else in our horrendously dysfunctional healthcare system. It’s time to stop punishing physicians for their imagined responsibility for the high cost of health care in this country.

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