‘It’s All Cuts’: Cardiologists React to the 2023 CMS Proposed Rule

The US Centers for Medicare & Medicaid Services (CMS) last week released their proposed rule for the 2023 Physician Fee Schedule (PFS), and many cardiologists and surgeons are not happy.

Among other changes, the more than 2,000-page document proposes cutting the conversion factor from $34.61 to $33.08, which is a result of the recent expiration of the 3% statutory payment increase, a zero conversion factor update, and a budget-neutrality adjustment.

The agency also proposes a 1-year delay through January 1, 2024, before implementing a policy to reimburse practitioners for the amount of time spent with patients during shared visits. Reimbursement for telehealth services, too, will be extended for an additional 5 months.

The proposed rule says nothing about the Medicare Appropriate Use Criteria (AUC) Program for all advanced diagnostic imaging services, but CMS separately published a statement noting that the payment penalty phase of the AUC mandate will be pushed until January 1, 2023, even if the COVID-19 public health emergency lifts sooner.

Speaking with TCTMD, Lyndon Box, MD (West Valley Medical Group, Caldwell, ID), who chairs the Society for Cardiovascular Angiography and Interventions’ Government Relations Committee, said he was not surprised by these “gloomy” changes. “Some of this that we're facing is a cliché of a perfect storm because the continued decreases in reimbursement to try to reduce costs has become the agenda of CMS, and then that's been coupled with the fact that a lot of things were delayed during the pandemic,” he said. “Those delays are now being ended, and so there's other cuts coming to term. It's all coming together at one time.”

What’s worrisome is “this continued trend of taking from the procedural specialties to try to bolster other specialties, which all relates back to the budget neutrality requirement,” Box said. “It pits physicians against each other, and I think that's what's unfortunate about this.”

At the end of the day, “this is not just about interventional cardiologist salaries, it's really about costs to patients and costs to the system,” he added.

We’re trying to make the field of medicine more attractive, not necessarily something that people see fraught with conflict. Lyndon Box

With similar feelings, American College of Cardiology President Edward T. A. Fry, MD, (Ascension Indiana St. Vincent Heart Center, Indianapolis, IN), said in an email to TCTMD: “The proposed rule represents the continuation of a troubling trend for cardiovascular clinicians who care for Medicare patients. The confluence of conversion factor cuts, statutory cuts on the horizon from sequestration and PAYGO rules, as well as a 0% payment update that fails to account for significant inflation in practice costs, creates long-term financial instability for the Medicare physician payment system and CV professionals.”

This is all happening at a time when cardiologists “face lower valuation of CV services that improve quality of life, lower mortality, and reduce long-term healthcare expenses,” he added.

Fry acknowledged that CMS “has limited authority to create lasting solutions” and urged Congress act “to prevent disruption to patients and clinicians.”

Likewise, Joseph C. Cleveland Jr, MD (University of Colorado Anschutz Medical Center, Denver), chair of the Society of Thoracic Surgeons’ Council on Health Policy and Relationships, told TCTMD in an email: "The current Medicare Physician Fee Schedule is broken. It fails to incentivize collaboration and pits doctor against doctor every year.

“It’s crucial that Congress work to address these cuts and create a more sustainable payment system,” he continued. “Failure to do so presents a serious risk to patients during a time of declining access to surgical care and rising prices for services and treatments.”

Other Specialists May Differ

American College of Physicians President Ryan D. Mire, MD, seems to have a more positive outlook. In a press release, he said: “We are particularly glad to see that CMS included the increased value for evaluation and management (E/M) codes used in inpatient settings in the fee schedule. The changes in these codes, combined with the changes made to outpatient E/M codes in 2021, are significant in recognizing the value that internal medicine physicians contribute to their patients and our healthcare system across a variety of healthcare settings.”

He also lauded CMS for continuing to reimburse for telehealth services, as they have “been vital to providing care to my patients during the COVID-19 pandemic [and] can also serve as a tool to better meet the needs of patients in nonemergency times.”

For interventional cardiologists specifically, “it's difficult to find a lot positive,” Box said. “It's all cuts.”

While it would be “wonderful” if Congress passed legislation that would provide even a short-term solution before the end of the year, Box said, “we do feel strongly that the long-term fix is going to be to repeal the budget neutrality mandate because of how that impacts reimbursement. One of the things that's tragic about this is that it really is difficult for private practice cardiologists, because they get hit the hardest by these types of Medicare cuts [since] they don't really have the support of an institution to kind of buffer some of this.”

Ultimately, the system is “flawed,” he continued. “It doesn't really work well, especially at a time when we're seeing an increased demand for physicians; we're looking at shortages for interventional cardiologists. If anything, we’re trying to make the field of medicine more attractive, not necessarily something that people see fraught with conflict.”

The proposed rule is open for comment through September 6, 2022, with the file code CMS-1770-P.