Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep187: Medicare's plan to pay half for same-day care, with Anders Gilberg of MGMA
Transcript
- Anders Gilberg 0:00 Unfortunately, with this proposal, you could be in situations where patients were going to have to be asked to come back the next day in order to get these secondary procedures that are related to that E and M. Austin Littrell 0:23 Welcome to Off the Chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Physicians Practice Managing Editor Keith Reynolds sat down with Anders Gilbert, senior vice president of government affairs at the Medical Group Management Association, or MGMA, where his public comments closed on Medicare's proposed 2027 physician fee schedule. Anders explains why MGMA is fighting a provision that would cut payment when an office visit and procedure happen on the same day, and he sizes up the odds that Congress fixes next year's Medicare pay cut. And a quick note before we get started, a week from today, medical economics, physicians practice, and obviously Anders will be at the MGMA annual conference. This year's show is being held in San Antonio from September 27 to the 30th, where MGMA is celebrating its 100th anniversary. So, congratulations to all our friends at MGMA, to everyone listening. We hope to see you there. And Anders, thank you as always for joining us. With that, let's get into the episode. Keith A. Reynolds 1:29 Hey there, folks! Today we're talking to Honors Gilbert, the Senior Vice President of Government Affairs for MGMA. Honors, how you doing, buddy? Anders Gilberg 1:37 Great, Keith. How are you? Good to see you again. Keith A. Reynolds 1:39 It's always a pleasure, buddy. It's always a pleasure. I'm great. It's always good. So let's get right into it today. Little housekeeping. Today we are talking. It's on September 14th. Comments for the 2027 fee schedule close today. What's the one change? The one big change MGMA has told CMS to make. Anders Gilberg 1:59 There are a lot of things in the fee schedule that I think our letter is 32 pages. In fact, I have it sitting right here, Keith. And after this, I'm going to approve it, and we're going to send it out. But certainly, the major issue, which I don't think CMS can change on its own, but an important issue is the fact that this year, once again, there is a cut to the conversion factor. It's slightly mitigated if you're a qualified participant in an advanced APM, but it's 1.19 for qualified participants and 1.16 if you're in a. I'm sorry, if you're a non-qualified participant and not in an APM. And so again, not only are we not keeping up with inflation, but the conversion factors cut, and that's largely as a result of expiration of things that Congress has done now, year after year, since some adjustments were made in about five years ago to E and M codes. But outside of that, something that they can do, we've been very concerned with a proposal. We're part of a coalition called the Same Day Care Coalition. It has to do with cutting services if you have an office visit at the same time as a procedure in certain cases that they would cut one of those by 50% and that is something that concerns us a great deal, and this is why. So, for example, a dermatologist-you go in for an office visit, you go in for an exam, and there is a small procedure that needs to be done. Something is identified by the dermatologist. You know there are codes in place that allow you to do that same day, get paid for it. It's not-you know-we're not talking about excessive amount of money, but it's certainly convenient for the patient and good care to get that done immediately. Unfortunately, with this proposal, you could be in situations where patients were going to have to be asked to come back the next day in order to get these secondary procedures that are related to that E and M offices, and so this was something that was proposed in 2019 and rejected. But we're concerned that this could once again rear its head here in the final rule. And the one thing I'll say about this administration that is a little bit disappointing is there haven't been a lot of give and take with their rules, a lot of the proposals get pretty much finalized in in their totality, and so it's something that we've had meetings with our coalition, White House meetings, congressional meetings, and we're hoping that this will be something that won't prevail in the fee schedule. Keith A. Reynolds 4:41 Alrighty. So you know you were talking about the cuts when we talked back in July. You said that Medicare can't keep up with inflation. The cuts are a big part of that. You know, has anything shifted in the past couple months that might you know mitigate that at all? Anders Gilberg 4:58 Well, there's one very. Significant development, but it's up on the hill. It's the introduction of something, a legislation called the Patients First Act, and it's largely been coalesced around by the doctors' caucus, the physicians up on the hill, both parties, who are advancing some of these important legislative proposals. One of the important things in that would be to at least align future adjustments to the Medicare physician fee schedule annual updates with the Medicare economic index, and you know at least associate it with the Medicare economic index. It would also reform budget neutrality rules that have become quite antiquated. We can talk more about that. Reform some of the MIPS program and quality reporting, but all in all, we're very pleased to see action on the Hill on some of the very, very important kind of macro issues and position payment, and this is one of them. Keith A. Reynolds 5:56 Okay, so you know we not to belabor the point on cuts, but it's you know that's the name of the game these days, and not to repeat yourself back to you too much. But last time we talked, you mentioned the rob Peter to pay Paul, you know way that we do healthcare in this country. You know this budget neutrality keeps pitting specialties against one another. Why can't CMS just fix that on its own? Anders Gilberg 6:25 Well, the budget neutrality rules are pretty simple. They are they kick in when, let's say, CMS makes a change in the equation to the RVU side of the equation. If that change is increases spending by 20 million or decreases spending by 20 million, then a budget neutrality adjustment kicks in on the conversion factor, which is the multiplier to create the dollar value to pay a service. That's in law, and that's why we're pursuing it on the congressional side. CMS can't change that on their own, but it has a huge implication. I'll give you an example of another thing in the Patients First Act. There were changes dealing with some coding changes in the utilization of a certain code, an add-on code for complex services back in 2024, and CMS estimated that utilization would be three times what it turned out to be, and in essence made a $1 billion error in its estimates, which then caused a reduction in the conversion factor that year. But CMS can't go back and change that, so physicians were hurt as a result of the estimates of that add-on code really causing Medicare spending to get quite high in that one situation, and was intended to offset that, but then that never occurred, and so we got the offset without the spending for the add-on code that year. So this bill would also address some of the retroactive aspects of budget neutrality, so we can correct some of those errors. Keith A. Reynolds 8:06 Okay, so you know, sort of the quiet part of this this proposed rule is the practice expense methodology. You know, why should an administrator care about that? Anders Gilberg 8:18 Administrators like physician physicians and administrators, practice administrators. I mean, it's it's a key component of the how physicians get paid in an ambulatory setting. So you have a situation where you've got work RVUs, practice expense RVUs, and malpractice RVUs, and the practice expense RVUs are meant to deal with the overhead costs and the relative values of those costs to the practice, and you know, obviously, we're in a situation in the last several years, and right now, as we speak, inflation, interest rates are rising. Inflation is still is still growing as it has for several years, and you know, practices need to keep the lights on. So, pretty much any administrator, practice administrator, is going to be keyed in on that, very much focused on that, and we need those type of reimbursement elements in the RVUs to keep up with inflation. And that's the bottom line: you got to keep the lights on in the practice, you got to pay the staff, you have to buy the supplies. So that's what practice expense covers. Keith A. Reynolds 9:19 So you mentioned ambulatory, you know, practices. The ambulatory specialty model starts on january 1. Mandatory. What are you hearing from your members? Are they ready? Anders Gilberg 9:31 They're not ready because the actual list of physicians, in this case, physicians that deal with like low back pain, has yet to be published. I mean, we have had conversations, MGMA, my staff, and has had conversations with CMS. They've got some talented people working on it, and we've appreciated their outreach. But physicians dealing with low back pain, orthopedics, others are have yet to be notified. And one of the things that we're concerned about is the notification process. They are like right now. My understanding is there's going to be a portal, and that individual physicians would need to go and look and see what they're you know if they're subject to being part of this mandatory model. And as opposed to you know what we're thinking would be the most efficient way is like having a group practice administrator being able to access the physicians within their practice to understand kind of the dynamics of the entire practice. But now they're going to be relying on individual physicians to identify you know whether they're in or out of this program. So you know having individual providers or physicians, in this case, setting up accounts and then having the administrator as a secondary to that account is just going to cause a lot of administrative hassle. So we're working to do our best to help get the word out with this. And but the bottom line is they're not ready because they don't know we don't know which physicians are in or out at this point. Keith A. Reynolds 11:10 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. So it's that time of year again. Congress is going to come back after the midterms with a cut already on the books. What do you think the odds are that they fix it in the lame duck? Anders Gilberg 12:13 I think it's going to be tricky. There's going to be a lot of different things. It's not just the cuts this year. The cuts are relatively modest, and you know, in my experience dealing with the SGR over the years, one of the problems we had when the cuts were small is you could get the death by 1000 cuts, you know, versus the big cuts of 10, five, 10% you know, that would get a lot of eyes on it. So something we're working very hard on. Obviously, the the doctors' caucus is keyed in on some of the larger issues as well. There are other issues too. There's the Gypsy floor, the Geographic Price Indices floor that for the work RVUs. That once again we got to go back and deal with. There's the alternative payment model incentive bonus, and that will expire at the end of the year, so once again, we're dealing with a lot of physician extenders, as we call them. Healthcare extenders are outside of physicians too, so the hospitals will have different policies in the game as well. So it's really hard with this Congress. This has been the least well, could have been. I don't know. It's competing with last Congress, but you know, it's the least productive Congress in the history of the Congress, and so there's not much getting done. Yeah, and so it's very hard to predict. But we will be; it'll be a priority for us. Keith A. Reynolds 13:32 It reminds me of the the Simpsons line of you know, this is the worst day of my life, and Homer comes. It's the worst day of your life so far. This is the least effective Congress so far. Anders Gilberg 13:44 So far, that's true. Keith A. Reynolds 13:45 We'll see what happens next year. All right. So you know what else is sitting in that lame duck pile that practices should be keeping an eye on? Anders Gilberg 13:53 Yeah. As I mentioned again, the if you're in a rural area or underserved area, or actually it's not just rural. I think the whole state of North Carolina or Indiana it has a geographic price indice below one on the work RVU, meaning that the physician work in those states is valued below other states, and this adjustment is meant to equalize that. So there are some pretty big ticket items in there, and the last thing we want to do is have this spill into the new year and have it retroactively applied, and we've done that before. Don't want to do that. Also, you know, we have a huge focus on alternative payment models, getting physicians into alternative payment models. Even the adjustments on the conversion factor, as I mentioned, are adjusted based on whether you're a qualified participant in an alternative payment model or not, and so like you know, the incentivizing physicians-it's not just about the money, but helping them get from fee for service into models which really talk about, in many cases, reducing. Reimbursement back to the practice, and you know potentially not allowing them to bill fee for service, and it could be a hit when you're in two different models: one where you're you're compensated based on you know fee for service, another based on total cost of care and population health management. So again, if you can't incentivize people to get into APMs, then you know the the differential and the conversion factor and the like will just hurt practices even more, especially smaller ones that you know can't take the risk that a large entity could take. Keith A. Reynolds 15:38 All right. So sort of switching gears here, you know the the big again. We were recording this on september 14. There was a lot of big AI news over the weekend and this morning, even before we started chatting. So in the past, MGMA has asked HHS for sort of guardrails on AI use in Medicare, or not Medicare, but medical care. These are two different things. What does a guardrail look like that actually would help sort of a 12 physician, you know, practice group? Anders Gilberg 16:10 Well, I think in many ways, you think about this issue. It's not just about healthcare right at the moment. I mean, we've been hearing these apocalyptic predictions over the last week, and AI and the president, I'll just let it stand on its own, has tweeted about this or put it out on social media that we may not need certain guardrails on the all over AI. That and so I think this is a societal debate. That said, I guess what I would maybe refocus your question on and think about like what practices can do within their own sphere of influence. You know, at this point in time, AI can be an incredible enabler. It can help physicians. It can help with scheduling. It can help with scribe dictation, reducing the overhaul overhead for staff to have to do certain things, administrative tasks. It could be part of your electronic medical record in some degree. And you know, the one thing that we would say is that you know practices need to have some degree of governance in their practice, and it's important that there are policies in place that you you know you don't want some physicians using maybe ChatGPT to query about some HIPAA protected information about a patient only to then get an incorrect or a hallucination and be liable for that hallucination, so setting up kind of like how are we going to use AI in the practice? What are the parameters? What kind of you know what is AI? There are different kinds of AI. There's embedded AI. There's AI on the administrative side, but then there's kind of the wild west of the large language models, and you know a lot of physicians are interested in this stuff and are looking stuff up on you know things up on their phone might have their own personal accounts, and like any business, that there needs to be guardrails within the practice to just make sure that you know investment in new tools that use AI interfaces that they're done in a way that is that protects the practice. I mean, HIPAA liability from malpractice. A lot of existing laws. There's no AI compliance per se. It's the existing laws that you can go sideways with pretty quickly. And there is probably a government role in you know helping people understand how AI will impact healthcare and the human element. And retaining the human human element is very important as well, making sure that it doesn't override or interfere with the physician patient relationship. So those are some of the things off top of my head. Keith A. Reynolds 18:51 All right, I think that's all the questions I've got for you. Is there anything else you want to add? Anything you think I'm overlooking? Anders Gilberg 18:58 No, I think stay tuned. The final. So we're submitting comments today, and then we expect the final physician fee schedule. Let's say november 1, approximately on or about november 1, and that gives a short period of time for practices to prepare. So just kind of be on the lookout for the calendar. You're not going to hear anything like in terms of whether or not some of these things, like the 25 modifier, the same day cut is finalized until the kind of the 11th hour. So you know whether you're a member of MGMA or another physician association in your practice, your physicians are part of those. Like be very, very much on guard to make sure you understand what's in the final fee schedule to share. Keith A. Reynolds 19:39 All righty, thank you so much, Anders, and I'll see you in a couple of weeks down in San Antonio for the MGMA Leadership Conference. If you are not there, you are already square. Anders Gilberg 19:50 Yeah, and I can't wait to see you there. And we would encourage all of your listeners and readers and your passionate, you know, base of. Folks that physician practice and medical economics and all the good stuff that you do are are involved with, and we we we love to have you down there representing them and their interests. And I'm sure there'll be some really interesting stories for you to to pick up on. For Keith A. Reynolds 20:16 sure, we're sending down a whole crew. We're going to try and find Pee Wee's bike in the basement of the Alamo. Anders Gilberg 20:22 Okay. Keith A. Reynolds 20:23 All righty, Anders. Thank you so much. Anders Gilberg 20:25 Thanks, Keith. Austin Littrell 20:36 Once again, that was a conversation between Physicians Practice Managing Editor Keith Reynolds and Anders Gilbert, senior vice president of government affairs at MGMA. Anders expects the final 2027 physician fee schedule on or about November 1st, so that's when practices will learn whether the same-day payment cut is in it. But with all that said, my name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business and medicine podcast is executive produced by Chris Masolini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you. Transcribed by https://otter.ai