Some Good News, Some Bad in Proposed 2021 CMS Reimbursement Changes

The Centers for Medicare & Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule (PFS) rule for 2021 earlier this week, and while there is help for telehealth in the plan, multiple surgical and cardiovascular societies are crying foul over significant cuts to reimbursement for surgical services.

The proposed rule, which would go into effect January 1, 2021, slashes Medicare payments by 9% for cardiac surgery, 8% for thoracic surgery, 7% for vascular surgery, 7% for general surgery, 7% for neurosurgery, and 6% for ophthalmology compared with 2020 rates. However, it adds telehealth services, including a temporary category of reimbursements tied directly to the current COVID-19 pandemic.

“The calendar year (CY) 2021 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation,” according to a CMS statement. The agency will accept comments on the proposed rule through October 5, 2020.

Surgeons React

Speaking with TCTMD, Society of Thoracic Surgeons (STS) President Joseph Dearani (Mayo Clinic, Rochester, MN), said, “The bottom line is that I think it's inappropriate for there to be any cuts to any physicians at the current time given the parallel problem of the pandemic. . . . Now is a poor time to lean into the healthcare system and start cutting reimbursement when many patients already have reduced access to healthcare, and adding this on top of it is just going to make that problem worse than it is.”

Improper treatment or delay of treatment results in death, and so that would be sort of a predictable endpoint with the current approach. Joseph Dearani

With regard to surgical specialties specifically, he stressed that cuts in cardiothoracic surgical care will lead to delays in treatment. “Delay in treatment in our specialty results in mortality, and we've seen this already through the pandemic,” Dearani said. “That's a serious implication for our patient population, because reducing reimbursement is going to further reduce access and the downstream effect will be mortality. That's the problem in our specialty: improper treatment or delay of treatment results in death, and so that would be sort of a predictable endpoint with the current approach.”

Similarly, vascular surgeon Nicolas Mouawad, MD, MPH, MBA (McLaren Health System, Bay City, MI), told TCTMD in an email that “an overwhelming majority of vascular surgery patients are Medicare beneficiaries, and this will affect vascular surgery disproportionately. . . . As healthcare providers and surgeons, we are trying so hard to take care of patients, and it’s already difficult enough with the current COVID-19 pandemic to get patients to come in for care. They are already scared. This is absolutely not the time to decrease any health care resources.”

“We support steps to expand access to care, but this rule takes one step forward and several steps back by disregarding patients’ needs and the surgeons who care for them,” said David B. Hoyt, MD, American College of Surgeons’ executive director, in a statement released by the Surgical Care Coalition. “The middle of a pandemic is no time for cuts to any form of healthcare, yet this proposed rule moves ahead as if nothing has changed.

“The healthcare system cannot absorb cuts of this magnitude,” he stressed. “This proposed rule would move forward with significant payment cuts that will only make the situation worse and harm patients.”

Additionally, the Surgical Care Coalition, which represents more than 150,000 surgeons across the United States, writes that the CMS proposed rule “was ill-informed and dangerous to patients even before the pandemic started but could be even more detrimental as our healthcare system continues to weaken under COVID-19.” The organization is urging Congress to “enact legislation to waive Medicare’s budget neutrality requirements for these [evaluation/management (E/M)] adjustments and to require CMS to apply the increased E/M adjustment to all 10- and 90-day global code values.”

Poor Timing

Samuel O. Jones, MD, MPH (Chattanooga Heart Institute, TN), a cardiac electrophysiologist who chairs the American College of Cardiology (ACC)’s Health Affairs Committee, told TCTMD in an email that the proposed update offers good news and bad. “The ACC is pleased to see CMS propose solutions for some telehealth issues that will be important to the care of cardiovascular patients for the duration of the COVID-19 public health emergency and beyond. Other telehealth aspects require additional work or statutory changes by Congress.”

On the other hand, Jones continued, “it is disappointing that the Agency continues to ignore recommendations from the ACC, the American Medical Association, and other medical societies to adjust RVUs for global surgery services commensurate with increases to E/M services. This shortcoming disruptively amplifies the reallocation of resources across specialties that ensues through required budget neutrality.”

Dearani elaborated on why the timing of reducing reimbursement to surgical specialties right now is especially poor. “Cardiothoracic surgeons have been deployed to other workplaces in the hospital because the skill sets of the cardiothoracic surgeon go beyond just doing either heart or lung surgery,” he said. “We create a situation then where some hospitals and some practices will just not be able to either remain employed or stay and be able to treat this patient population.”

He also supports a congressional act to waive the budget neutrality requirement so that “a pay increase for one specialty does not result in a decrease in another specialty. I just think that that's just inherently unfair in the circumstances.”

The Surgical Care Coalition statement points to results of a member survey taken earlier this year showing that about one-third of private surgical practices were already at risk of closing permanently due to the financial strain of the COVID-19 crisis. “This rule will likely force surgeons to take fewer Medicare patients, leading to longer wait times and reduced access to care for older Americans,” they write.