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Are ObGyns getting “bumped” out of deserved Medicaid reimbursement?
The Medicaid expansion covered approximately 7 million more women in 2014, but not all of them were able to find a doctor. Here’s why, and how...
In each of these reports, the Inspector General also found smaller numbers of cases where surgeons provided more E&M care than was covered under the global payment. In each report, the Inspector General suggests that CMS should do more to identify and correctly value misvalued codes. ACOG Vice President for Health Policy Barbara Levy, MD, who is also chair of the Relative Value Scale Update Committee, or RUC, makes a compelling case that the RUC has identified and corrected many global surgical codes since these reports were issued and is in the process of revising more codes. She also argues that the RUC is the appropriate place to address these issues.
Policy analysis finds that total RVUs would decline
CMS has indicated that it intends to use a formula for converting the 10- and 90-day global services into 0-day services by simply reducing the work relative value units (RVUs) for the service by the number of work RVUs in the postoperative visits. The American College of Surgeons asked Health Policy Alternatives (HPA), a consulting firm, to analyze the CMS decision. HPA found that “systematically convert[ing] all global surgical codes to 0-day global codes by backing out of the bundled E&M services reduces the total RVUs and each component (work, practice expense, and malpractice) for surgical codes. Specifically, for surgical specialties, the impact of this transition on all Medicare reimbursed codes results in the following reductions:
- overall payment decrease of 1.8%
- payment decrease of 0.8% for work
- payment decrease of 2% for practice expense
- payment decrease of 9.2% for malpractice.
This modeling resulted in a total overall payment increase of 0.1% for generalists and a payment increase of 0.3% for medical specialists.”4
HPA’s findings related to the malpractice component are especially interesting for the ObGyn specialty. “Model results demonstrate that this policy results in significant redistribution of malpractice away from the main specialty provider of the surgical procedure into the entire group of providers (surgical and nonsurgical),” notes the HPA report.4 “Most impacted will be specialties with higher malpractice expenses, such as neurosurgeons and cardiac surgeons.”4 We could add ObGyns to that list.
ACOG cites numerous objections
ACOG is deeply involved in opposing this new CMS policy and preventing it from ever going into effect, working on our own, in coalition with our medical organization colleagues and patient organizations, and working closely with the US Congress.
ACOG and 28 other medical organizations, including the American Medical Association (AMA), summarized our opposition in a letter to US House and Senate Democratic and Republican leaders in December 2014, saying that this new policy:
Detracts from quality of care, impedes patient access, and complicates patient copays
- Patients will be responsible for copays on each service, including follow-up visits. This could considerably increase the administrative burden on patients. Worse, it could discourage them from returning for needed follow-up care.
- In the hospital critical care setting, the global payment structure allows the surgeon to oversee and coordinate care related to the patient’s recovery. Without the global structure, care will be fragmented and providers may compete to see patients and bill for the care they provide.
Undermines Medicare reform initiatives
- CMS initiatives for payment are all moving toward larger bundled payments. Deconstruction of the current payment structure for physicians is counterintuitive to the end goal of providing more comprehensive and coordinated care for the patient.
- Current bipartisan, bicameral legislation to repeal and replace the flawed sustainable growth rate formula calls for “a period of stability” in physician pay to allow physicians to transition to alternative payment models. The proposal to unbundle global surgical periods will add new complexities to an already flawed system and stymie progress.
Increases administrative burden
- The administrative burden on surgical practices and CMS (and its contractors) will be significant. Eliminating the global package will result in 63 million additional claims per year, adding unnecessary costs to our health care system.
Obstructs clinical registry data collection and quality improvement
- Surgeons will have less ability to collect information on patient outcomes in clinical registries, undermining many of the most meaningful quality improvement initiatives.5
Additional ACOG concerns
ACOG added these concerns to our opposition to the CMS plan:
- The change will not accurately account for physician work, practice expense, and malpractice risk for services performed.
- Thousands of new codes and/or values will need to be created for postoperative care because the supplies and equipment needed for postoperative care are not included in the E&M codes that will be used to report in-hospital and outpatient postoperative services (TABLE 2).
- Liability costs of a specific service should be derived from those of the performing specialties. Under the CMS plan, the liability costs associated with postoperative work would be removed from the primary service and artificially diluted by the wide mix of specialties performing all types of E&M services. Without global periods, a one-size-fits-all approach to professional liability insurance will be unsustainable and result in great disparities between the actual and realized malpractice costs for many physician specialties.
