The fact that primary care is undervalued by Medicare and other payers has been long understood to be driving the precipitous decline in the numbers of new physicians choosing primary care internal medicine or family practice, and a growing exodus of established primary care physicians.
Efforts to address this undervaluation have traditionally been to, 1) bump up the payments (relative value units) for the office visit codes traditionally billed by primary care physicians; 2) explicitly fund, usually on a temporary basis, higher payments for primary care that do not require offsets from others, like was the case with the two-year Medicaid primary care pay parity program, which expired on January 1 of last year, and the five-year 10 percent Medicare primary care bonus program, which is set to expire at the end of this year if Congress doesn’t continue it; 3) offer higher payments contingent on primary care physicians meeting performance measures (pay-for-performance); and/or, 4) develop and promote alternative payments models, like patient-centered medical homes and accountable care organizations, which offer higher payments in delivery models that require more accountability and risk for quality outcomes and savings.
Each of these approaches is important, and can potentially make a big difference, but each also has its limitations. Under Medicare’s “budget neutrality” rules, bumping up the RVUs for office visits results in across-the-board cuts in all RVUs, which intensifies resistance by other specialties. (Think of it like a pie: a bigger slice for primary care results in a smaller slice for everyone else.) And even the primary care services that are supposed to benefit from the bump end up having to absorb part of the budget-neutrality adjustment. And, because office visits are the most frequently billed services, even a small bump up can result in large across-the-board budget neutrality offsets.
Programs to temporarily fund increased payments for primary care are all well and good, but because they are expensive, they also tend to be time-limited, depending on the willingness of Congress to keep open the funding spigot going past their expiration date. (Good luck with that!) Pay-for-performance programs can potentially increase payments to some primary care physicians but they are a hassle, usually include both penalties and rewards, require a lot of physicians to perform poorly in order for the better-performing physicians to get more (another variation of budget neutrality), and physicians don’t have a lot of confidence in the measures being applied. New payment models may ultimately prove to be the best option to systematically improve payment for primary care, but there is an uncertain track record with them, and the investment in the practice that is required makes for an uncertain and uneasy cost-benefit for primary care physicians.
What if I told you there was another way, already available to primary care physicians, to potentially earn tens of thousands of dollars more from Medicare and other payers, while improving patient care? That is already built into Medicare’s budget neutrality adjustments, so there isn’t any resistance from other specialties? That doesn’t tie pay to performance measures? That isn’t time-limited and temporary, that doesn’t depend on Congress’s “generosity”? That is available within the traditional fee-for-service payment system, not linked to alternative payment models?
What if I told you that there is another way, one that takes a page out of the surgeons’ book? One of the way that surgical specialties have been able to earn higher payments is to constantly create new CPT codes and RVUs for their services, slicing and dicing what they do (pun intended) to create more billable opportunities. Why can’t primary care do the same, creating more codes and RVUs (and with them, more billable revenue opportunities), instead of being stuck with the same old ten codes for office visits for new and established patients?
Well, this is exactly what has happened over the past few years in primary care. Largely because of ACP advocacy, Medicare has approved at least seven new codes that create very substantial billable revenue opportunity for primary care physicians. Practices that bill for all of them can potentially increase their revenue by six figures, or more. (One company has developed a spreadsheet that physicians can use to estimate the potential revenue gains, as well as costs associates with the codes).
What are the new codes? Medicare’s wellness examination, which in 2016 will pay $172.69 for an initial visit, and $116.80 for a subsequent one. Transitions of care management, 14 day discharge, pays $164.81; 7 day discharge pays $232.52. Chronic care management, 20 minutes, pays $40.84. And, brand new, for the first time starting on January 1, Medicare will pay $85.99 for 30 minutes of advance care planning! (These payment amounts are before application of Medicare’s geographic adjustments, and apply to services provided in a non-facility setting).
ACP’s regulatory affairs department has prepared a nice spreadsheet that shows the available payments for these services in both the non-facility and facility settings.
Yet many primary care physicians are not routinely billing for these codes, leaving tens of thousands of dollars at the door. Many say that the documentation requirements are too much, or they might have to hire more staff, so it’s not worth the effort. There is no question that Medicare could make it easier and simpler for physicians to document these services, as ACP has recommended.
At the same time, though, I expect a cost-benefit analysis would show that many primary care physicians and their practices would come out way ahead if they began to bill for these codes, while improving patient care in the process — a real win-win.
So how about it, primary care doctors? Isn’t it time for you to consider taking advantage of the new codes and revenue opportunities available to you, even as ACP and others continue to advocate for more fundamental reforms to improve payment for primary care?
Bob Doherty is senior vice president, governmental affairs and public policy, American College of Physicians and blogs at the ACP Advocate Blog.
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