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Medicare Cuts, Patient Consequences: The Real Cost of Reducing Same-Day Care by 50% · Voices of Otolaryngology

0:01
Welcome to the voices of Otolaryngology.
0:03
I'm your host, Rahul Shah, CEO of the American Academy of Otolaryngology
0:08
Head and Neck Surgery.
0:10
Each episode I bring people from our specialty together
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to talk about the work, the questions and the ideas that move us forward.
0:17
Let's get into it.
0:20
We have a special guest for this episode, our president, doctor Gene Brown.
0:24
And today we're talking about a Medicare proposal.
0:27
That may sound technical, but its impact is enormous.
0:31
CMS wants to pay doctors in full for one service during a visit, and
0:36
then cut payment for additional services that same day by 50%.
0:41
That's not a small change.
0:42
Its arbitrary, it's harmful.
0:44
And it could force practices to make tough choices
0:47
about how they care for patients.
0:48
For the millions of seniors on Medicare.
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The stakes are very real. Gene, welcome.
0:54
Thank you. Rahul, it's a pleasure to be here.
0:57
let's be real.
0:57
You talk with me. What?
0:59
Every other day. Every day.
1:01
But it's always a pleasure.
1:03
Every time.
1:04
Right on.
1:05
Well, today we have a problem Gene and I want to address ahead on.
1:09
And it's called a Medicare physician fee schedule.
1:12
Their proposed cut to reimbursement for Modifier 25.
1:17
Let me just start high up.
1:19
I'm curious, why do we have huge
1:23
mobilization of our specialty at an unprecedented scale?
1:27
Why are our otolaryngologists so upset?
1:31
We've we've absorbed
1:33
cuts in reimbursement for a long period of time.
1:37
While costs have escalated at such high rates
1:42
that collectively we're concerned
1:44
about the viability of our practices moving forward.
1:48
And if our practices are going to struggle to be viable,
1:52
then we don't get to do what we like the most, which is take care of people.
1:56
So I think that collectively, we're concerned that these cuts are going
2:01
to keep us from being able to offer the access
2:04
and the services to patients, which is why we went to medical school
2:08
and trained so we'd be in a position to help people.
2:12
It's very frustrating because I don't think anyone
2:16
is happy about any of the changes that they might have to
2:19
contemplate for their businesses going forward.
2:22
It's just been one hit after another, though, that has stressed
2:28
us to the point where we feel vulnerable and we feel like that
2:32
we're going to have to make changes if they're going to create cuts this deep.
2:38
What did your survey of 1400 otolaryngologists show?
2:42
What were you most alarmed about?
2:44
It was shocking that eight out of ten otolaryngologists
2:47
would stop seeing Medicare, or greatly limit
2:51
the number of Medicare spots in our daily schedules.
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So my job
2:55
is to ask the insightful questions and be provocative.
2:58
And for full disclosure.
3:01
Doctor Brown, we did not prep for this.
3:03
Do you attest to that?
3:06
We're just doing this cold. Yeah.
3:08
Yeah, we're speaking from the heart.
3:10
So I've heard from people that we’re
3:13
bluffing, that were histrionic, that.
3:16
Oh, the surgeons are up in arms again.
3:20
You used a word “viability.”
3:24
Let's get the message out there that this isn't a bluff,
3:27
that a 83 year old widowed lady is not going to have access.
3:31
So can you go a little bit deeper with viability?
3:33
And how does that really affect a practice, Doctor Brown?
3:39
I think that
3:40
this survey that the Academy administered recently,
3:43
which showed that 80% of our members
3:47
would either stop seeing Medicare patients or greatly limit the number of spots,
3:52
probably sent the clearest signal in terms
3:56
of how we might have to adjust to these changes.
3:59
But I think you're correct.
4:00
I think that the the relative decrease in reimbursement
4:05
that's cumulatively approached 33% since the turn of the century.
4:10
We've absorbed these small cuts year over year.
4:14
We've maximized
4:17
our ability to see more, do more,
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try to save here, to do this,
4:26
to keep profitable and keep viable so we can maintain access for everyone.
4:31
But I don't think anybody understands
4:34
how they can squeeze another 10% out of the system.
4:37
The machine is
4:38
is stressed to the point that there's just not that kind of reserve.
4:42
And we're stressed to the point where we realize
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that we're going to have to take larger steps to be able to keep
4:48
our practices, practices open and operational.
4:51
I think it's it's not serious.
4:53
I just don't think any of us
4:54
feels like we can really accept that much of a pay decrease.
4:59
Tell everyone about your practice and who is Stuffy there, as your logo
5:03
right there?
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I mean, it's it's something we we kid about.
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But talk a little bit about your practice.
5:08
Let people know who you represent.
5:10
And then let's talk about why 10% really means almost 30%.
5:14
Doctor Brown.
5:16
So I, I am the CEO
5:19
of a large independent practice in South Carolina.
5:22
We have about 35 physicians who desire to remain autonomous and independent.
5:28
We span from one side of the state to the other.
5:32
We have about 16 offices,
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20 to 25 audiologists and another 20 to 25 APPs.
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So we have a large footprint.
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We serve a lot of the population of South Carolina, a lot of which is rural
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and in small markets, places where other practices
5:52
and other otolaryngologists don't have a footprint in our state.
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We've we've
5:59
grown to this size in an effort
6:03
to create leverage and efficiencies so we could operate.
6:09
And in these competitive times, the rate of physician
6:13
consolidation and employment is skyrocketing.
6:17
Nearly 85% of physicians are employed today.
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15 years ago, that number was like 20%.
6:24
So the pressure is real.
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And as a CEO of a large independent practice,
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I feel the pressure very, very closely.
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It's a hot seat every day.
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I speak to my C-suite staff about how difficult it is and how good
6:41
we have to be to remain in business and to remain independent today.
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And that's important for us, for
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our identity as a practice, because we like being able to sustain
6:55
smaller practices in smaller markets and to provide access
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for those in rural areas, which are things that aren't very -
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That type of access is not robust at all.
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We're seeing people leave rural communities at an amazing rates.
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It's very concerning already for those who are more socioeconomically stressed:
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seniors, people who live in rural markets.
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So when you see Stuffy on my scrubs,
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Stuffy is a symbol of our practice.
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You know, he's cute.
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He's someone that we market around.
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But I think for most of us, he stands for our independence and our ability
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to remain as an independent practice and provide
7:43
care to most of our state.
7:45
All right.
7:46
I want to pull back.
7:47
You said a lot there, and I want to.
7:49
I want to go back.
7:50
So let's start high level.
7:54
Do you mind articulating for those that don't know.
7:57
What is at issue?
7:58
Doctor Brown, let's focus not on the 1500 page Medicare physician
8:02
fee schedule, but on the couple of pages where they talk about Modifier 25.
8:07
Could you explain that to otolaryngologists
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and then maybe to legislators that listen to this and the public.
8:13
So explain the issue. Doctor Brown.
8:17
The issue is that
8:19
circumstances are already difficult
8:22
in margins are already narrowed.
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A 10% cut to top line revenue
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creates even greater pressure on margin
8:33
because it greatly takes away from the profitability.
8:37
So a 10% cut in revenue might translate
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to 30 to 40% cut in profitability.
8:44
You mentioned in the last couple of weeks you've had patients where you provided
8:49
an evaluation management on the same day
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as a procedure, and that I'm not being histrionic.
8:55
I'm not exaggerating. That probably saved someone's life.
8:58
Can you give 1 or 2 of those examples? Sure.
9:01
You know, we live in a market that's probably a smaller
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metro region, and we have a lot of offices around town.
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So we're really gateways to care for a lot of people who live
9:14
in the outlying towns and communities in South Carolina.
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So recently on, two people come to mind.
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One drove from two hours away.
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I was able to see him in the clinic.
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He had been having bad nosebleeds.
9:30
He was on anticoagulant medicines which thin the blood.
9:34
He had already had a blood transfusion.
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His nose had been packed out in a small community hospital.
9:40
Fortunately, I was able to see him and on the same day
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diagnosed where he was bleeding from.
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And then I was able to provide definitive care
9:50
by cauterizing his nose at the same setting.
9:55
So if our services are devalued by 50%,
10:01
first of all, it threatens access for these patients.
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Secondly, it likely affects the ability for this much diagnosis
10:10
and treatment to be provided in the same episode of care.
10:14
Yeah, extremely well said.
10:16
And that's what people are not understanding.
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If there's a 10% cut, you have to see 3 to 4 more patients a session.
10:22
You don't have time.
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You said it yourself to spend with the patient.
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Let's go back to this individual.
10:28
Drove two hours to see you, presumably from a rural
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and let's say underserved because they have to drive two hours.
10:35
Not only did you make the diagnosis of where the bleeding is
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coming from, this was a complicated elderly gentleman.
10:41
You put your thinking hat on and you evaluated and managed them right.
10:46
You talked about anticoagulants.
10:47
Talk a little bit about that.
10:49
You spent time understanding their history.
10:52
Yes. You know, these are some of these patients
10:55
have a lot of comorbid conditions that have to be measured.
10:59
We have to look at all the treatments
11:01
and we have to look at their social situation.
11:03
You know, this was a gentleman who came with two family members.
11:06
He couldn't drive.
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His son had taken off from work the entire day
11:11
to bring him in for this office visit.
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If I had had to see him on a second occasion to provide definitive therapy.
11:19
The son would have had to take in another day off.
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And how many people really have the margin of family to be able
11:26
to lean on people, to bring them to that many appointments over time?
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Also, the fact that the bill
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that the proposed cut
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is going to create these types of economic pressures is going to
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amplify the downstream economic pressures that are passed on to patients
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and families who have even fewer resources to accommodate the stress.
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It's going to it's going to affect everyone - more so patients.
11:55
Yeah, extremely well said.
11:56
And let's carry this vignette out for our listeners who are not otolaryngologists.
12:02
Again I said you you saved this person
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significant morbidity and maybe their life because if they would have gone home
12:09
Doctor Brown they could have bled out again
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and they could have been late to the emergency room.
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They could have fell.
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Can you walk through some stories you see?
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Where nosebleeds just aren't an inconvenience.
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You can lose a lot of blood. Correct.
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You certainly can.
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And when you're an elderly person
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who has these comorbid conditions,
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you don't have the margin to accept medical stresses.
12:35
It does make you weaker.
12:37
It creates balance problems.
12:40
It creates susceptibility to fall and further injury due to falls.
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It puts a strain.
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If you have diminished
12:50
intravascular volume, it puts a strain on your heart and lungs.
12:54
It puts you at a greater risk for heart attack
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or even a stroke in some of these situations.
13:00
So it is very important that we're able
13:04
to diagnose these significant problems and provide treatment.
13:08
Yeah, I mean there's there's aspiration.
13:10
We can think of myriad issues.
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And I think what you're getting at is this flawed,
13:16
arbitrary, capricious, without evidence,
13:19
policy, targets the vulnerable.
13:23
Well, I don't think that if you are sitting in an office
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and you have an administrative position or if you're a political figure,
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you really you just don't have the vantage point or the lens
13:34
to see how this affects patients and their families on an everyday basis.
13:40
You don't understand the stress it puts on them.
13:43
You don't understand how a lack of services is going to further
13:46
complicate their overall health care quality.
13:51
And you don't understand how it's going to affect their quality of life.
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I've got an even better story, Rahul.
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Can I ask you one more thing?
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Because that was very profound.
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Doctor Brown, let's go back to the two family members
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that brought this elderly gentleman to your office.
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I'm going to quote some statistic that says the average
14:09
American worker has about two weeks of PTO.
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That's ten days.
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They spent one of them, one 10% of their time coming to see you.
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And now what you're saying is, look, there's a big burden here,
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not only on the patients, but the caregivers.
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You see a lot of frequent Medicare patients,
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and you must see caregivers with them all the time.
14:29
Can you talk about that then?
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I really would appreciate your second example, Doctor Brown.
14:35
Rahul.
14:35
35% of my practice is Medicare,
14:40
35%. And the fact is,
14:45
unfortunately, looking at it from a business standpoint,
14:48
we're going to have to value the revenue we can produce per block of time.
14:52
So it's going to if we don't,
14:55
we're going to have to decrease spots, but we're also going to have to decrease
14:59
the blocks of time that we can allow
15:02
for seniors in this situation, basically
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due to the revenue pressures, it's going to create challenges.
15:10
It's going to create stresses on family members having to make more trips,
15:14
and it's going to delay treatment for patients.
15:17
It's going to it's going to lead to disease processes
15:21
that progress and are upstaged and more difficult to cure.
15:25
And it's going to lead to other complicating medical problems
15:29
that people are going to become more at risk for because their primary issue
15:34
isn't being treated appropriately in timely fashion.
15:37
If you've got two weeks of PTO and you take a day off this week
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to bring your aging parent two hours away to see me,
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and then I say, I need you to come back in another 2 or 3 weeks.
15:51
How many people can even afford to take that second day off in that situation?
15:55
How many employers can afford for that family member
15:59
to take off all of that additional time?
16:01
It's the downstream effects that administrators
16:05
and politicians and bureaucrats don't understand
16:09
that are really going to profoundly affect
16:11
what we do and the services that our patients receive.
16:15
I really want to hear your second example, but before we go to that, let's
16:19
do some quick math. Two hour drive.
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Let's assume it's 100 miles.
16:23
200 miles each way.
16:24
That family just spent about $70 getting there during that transit.
16:29
Doctor Brown.
16:29
So the affordability really impacts our rural and underserved communities.
16:34
That was just a statement, sir.
16:36
Talk about another example.
16:38
I found that first example about the nosebleeds fascinating.
16:42
Tell us another example of where you see this real life in your practice.
16:46
This was I had a lady
16:48
who came in a couple of weeks ago, and she couldn't breathe through her nose.
16:52
It had rapidly escalated to where she really could not breathe
16:57
out of the left side of her nose over the last month.
17:00
I was able to notice that she had a large obstructive
17:03
mass block - completely blocking the left side of her nose.
17:07
I wasn't sure what it was.
17:10
I wasn't sure what it involved because, you know, we're thinking, well,
17:15
is it a nasal mass? Is it a nasal polyp?
17:18
Could this be brain tissue that's herniated through the skull base?
17:22
Could this be associated with the eye, which is also in close proximity?
17:27
We just don't know. Right.
17:29
So I was able to spend some extra time with her.
17:33
I was able to perform the endoscopy.
17:35
Then I realized I needed imaging.
17:38
Fortunately, I also have imaging in my office.
17:41
I was able to do a CT scan to better
17:44
define the mass and to see where it was coming from.
17:48
I could see it was mostly centered inside of the nose.
17:52
It wasn't eroding into another anatomical location.
17:56
So not only was that able to provide all of this in-depth analysis and diagnosis.
18:01
Next, I brought her back in the room and I was able to biopsy the mass
18:06
with the use of the endoscope to guide the biopsy.
18:09
This biopsy ended up coming back
18:12
from the pathologist as a high grade malignancy.
18:16
So now
18:18
this patient has been in my office for a couple of hours.
18:21
I provided numerous services.
18:24
I looked I took a history and physical examination.
18:27
I performed a preliminary examination, I performed nasal endoscopy.
18:33
Then I performed a CT scan.
18:35
And then I brought this patient back in the room and performed
18:39
a biopsy which showed a high grade malignancy.
18:42
Now, maybe that doesn't seem like a lot,
18:46
but in many different practice locations, that visit could have been accomplished
18:51
in 3 or 4 separate visits that occurred over
18:55
3 to 6 subsequent weeks.
18:58
Not only did that, did that allow the patient to have better access to care,
19:04
but it also decreased our time to diagnosis
19:08
and allowed for us to pursue therapeutic options
19:12
at a much quicker rate, which is even more important for a cancer,
19:17
because if you wait 3 to 6 to 8 weeks, if the diagnosis is delayed
19:23
that long, then the cancer probably becomes less curable.
19:27
It spreads into another part of the body, and that affects
19:32
it affects not only quality of life, but it could affect longevity.
19:36
Doctor Brown, how is that lady?
19:38
It's remarkable that you got her treatment ASAP.
19:42
Same day.
19:43
And the evaluation and management was key to that.
19:47
How is she?
19:49
She's doing great.
19:49
She's in treatment and she's doing very well.
19:52
And, you know, you're commending me for the treatment offer, but this is
19:57
what otolaryngologists are doing in offices across the country
20:01
every day to offer the quality of care that our seniors need and deserve.
20:06
So Doctor Brown you're saying it's going to impact access.
20:11
So a referring doctor might face longer delays.
20:15
A patient being sent from their primary care
20:18
doctor might not be able to get to see you next week.
20:20
They might have to wait longer.
20:22
Is that what you're saying? Oh, definitely.
20:25
They might not be able to be seen.
20:27
They're definitely will be waits.
20:29
There will be delays, but there may not be options for patients.
20:34
What is the primary care doctor going to do?
20:36
They can’t do procedures in their office.
20:38
They're not trained to evaluate the cancer that you found in the nose.
20:42
They might just think it's allergies.
20:45
I think the only thing they'll be able to do is
20:49
be they'll either
20:51
offer suboptimal care, or they'll flood the emergency rooms
20:54
with these patients who don't have access to care in other ways.
20:58
And it's nobody's fault.
20:59
Unfortunately, it was the flawed, arbitrary, capricious
21:03
lack of evidentiary basis CMS proposed rule.
21:06
I've got that down, Doctor Brown, because it comes right out of the heart.
21:10
So, Doctor Brown, what is your ask to CMS to members of Congress?
21:16
What is your ask regarding this flawed proposal?
21:20
Our ask is that CMS completely abandons the discounted fee rates as proposed.
21:26
We just don't have the margin to accept further fee reduction at this time.
21:30
We're not asking for a compromise.
21:32
We're asking for them to completely abandon this pay discount.
21:37
It's arbitrary. It's capricious.
21:40
It's not good for patients’ access or quality of care.
21:45
Doctor
21:45
Brown, there's a table in the proposed Medicare physician fee schedule
21:50
that imputes the impact to otolaryngologists around 10%.
21:56
That's not acceptable, but I'm hearing that it's even larger.
22:01
I look at it in a more simplistic manner.
22:03
Rahul,
22:05
my overhead is nearly 70%.
22:08
What that means is that
22:12
if I see ten patients, the first seven, the revenue
22:16
that I collect from seeing their seven patients goes towards the overhead.
22:21
That leaves 30%.
22:22
The last three patients from that cohort account for all the profitability.
22:28
So let's say that one of those
22:31
three patients I'm not able to see.
22:34
To you, that might seem like a 10% reduction in my revenue,
22:39
but to me that results in a one third decrease in my profitability.
22:44
So this seemingly small cut really cuts at the core of profitability.
22:50
And because we've given on so many other issues and our overhead has risen
22:56
so much, especially since Covid, we just can't afford to accept it further.
23:01
That's why you're seeing the pushback.
23:03
That's why you're seeing so many different people that are being called to arms.
23:07
And that's why we simply can't accept any other solution
23:12
other than this fee cut being completely abandoned by CMS.
23:16
Doctor Brown, we've never seen a response
23:19
from otolaryngologists at this order of magnitude.
23:23
Many call this an existential threat to specialists.
23:27
Where medical students, residents and trainees
23:31
will say, I'm not going to go to that rural, underserved community.
23:35
Why don't we wrap up this podcast?
23:38
Usually I'm chipper and happy, but this is scary,
23:41
and it's not a good time for American medicine.
23:45
Somebody, somewhere believes that redistribution needs to occur.
23:50
Efficiencies need to be arbitrarily cut without evidence.
23:54
Why is the American Academy of Otolaryngology
23:57
Head neck surgery and the same day care coalition
24:01
worried about patient access with this flawed proposal?
24:05
The reality is,
24:08
if this fee reduction does occur,
24:12
that we're not going to be able to see these patients.
24:16
And if we do see these patients, we're going to have to greatly limit
24:20
the amount of time we spend with them, or limit
24:22
the number of these patients that we see in a day.
24:27
So it's going to be a major hit to seniors.
24:31
It's going to greatly affect access, and it's going to greatly affect
24:35
subspecialties where the lack of revenue is going to lead
24:41
to income hits across a specialty, and that's going to dribble down.
24:47
And medical students
24:49
are going to feel the weight of of what they're seeing in the real world.
24:53
And they're not going to pursue subspecialty practices.
24:56
This is going to take away from the highly specialized
25:01
level of care that we administer in America today.
25:04
This is going to take away from the rate at which we can influence and innovate.
25:09
It's going to take away from research
25:12
advances and our ability to do more for patients.
25:17
Doctor Brown
25:17
is president of the Academy this year, you've traveled the world.
25:21
What is the perception of American medicine?
25:23
What have you seen out there?
25:24
Has it made you proud to be an otolaryngologist?
25:28
Yes. It's been a really amazing experience to travel the world
25:33
and to interact with otolaryngologists from so many other countries.
25:37
We are definitely valued as the thought leader,
25:41
thought leaders in medicine around the world.
25:44
We're definitely looked up to as leaders, as innovators,
25:49
and we are where the bar is set worldwide.
25:52
We perform such vital roles for these other countries
25:55
in terms of training, influence, contributions to the literature,
26:01
everyone in other, every, every other part of the world
26:05
is looking to the United States for leadership in medicine.
26:10
Doctor Brown, as we wrap up this informative season
26:13
two episode of Voices of Otolaryngology, let's drive home the point.
26:17
What do you see as our president
26:21
representing an extremely large
26:24
practice of independent otolaryngologists?
26:27
What do you see
26:27
as the impact of this flawed proposal in the Medicare physician fee schedule?
26:33
I'm losing sleep at night in terms of how we can offer
26:37
the same quality of care for seniors in this new system.
26:42
I'm very concerned
26:45
that seniors will not have the access points that they're used to,
26:49
and I'm concerned that I'm not going to have access when I become a senior.
26:53
I'm concerned about the access that my parents are going to have.
26:57
This is going to create a whole new paradigm
26:58
This is going to create a whole new paradigm
27:00
for seniors and quality of care in the United States.
27:02
for seniors and quality of care in the United States.
27:04
So what has to give Doctor Brown?
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Patient access is going to be the pressure valve.
27:10
They're just not going to have the same access
27:14
points to freely engage the system.
27:18
Physicians will have to limit these spots.
27:20
And that's going to greatly offset quality of care.
27:24
Doctor Brown,
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thank you so much for joining us on this episode and telling us how
27:29
seemingly small changes can have enormous impacts for our patients.
27:33
Thank you, Doctor Brown.
27:36
Thank you for listening
27:37
to this episode of Voices of Otolaryngology.
27:40
Subscribe to listen to more of these episodes
27:44
wherever you listen to your podcasts.
27:46
and definitely join us next time
27:47
as we continue these crucial conversations.