Medicare is proposing across-the-board cuts to what Trump administration officials believe are overpriced medical procedures, scans, and tests — a consequential decision designed to even the score between highly paid specialists and primary care doctors.
The federal Medicare agency justified its action by saying that more than half of the 10,000 billing codes used by physicians have never been reevaluated in the 30-plus years of this payment system. Medicare also criticized the way these services are currently priced — through surveys of physician practices that have unreliably low response rates — and wants to exclude that input going forward.
Among other proposals, Medicare plans to shift the management of several chronic conditions, including type 2 diabetes, chronic low back pain and heart failure to behavioral health specialists who will use non-medical interventions, like practical training in dietary changes, peer support and increasing activity level in patients to delay progression of the conditions
Other changes involve reassigned RVU weighing to treatments and procedures to help level the income differences between primary care providers and specialists, broadening telehealth treatment options for mental health, and changing the payment conversion factor for qualifying vs non-qualifying APM physicians/healthcare systems. (Qualifying APM physicians/healthcare systems get paid a flat fee for managing a patient based on their condition or diagnosis instead being paid per test/patient visit/procedure. If a physician/healthcare system can manage the patient for less than the flat fee, they get to keep the overage. If the patient costs more than flat fee more, the physician/healthcare system has to eat its losses.) The change in conversion factor will greatly reduce payments to physicians/healthcare systems than are fee-for-service.
(BTW, the justification that the billing codes haven’t been revised in 30 years is untrue. Billing codes are revised annually.)
P.S. Apologize for the paywall. No gift links are available.
Medicare reimbursement rates in my profession have been going down and down and down for years .That’s why many in the profession opt out of taking it.
Am I understanding this correctly? If you have T2D for example, you will meet with behavioral health providers (which I interpret as MSW, PsychD, etc) to help you understand why perhaps you make poor choices regarding food or exercise, etc. I definitely think these providers have a place in one’s healthcare.
But don’t you need an MD/DO to look at bloodwork, tweak meds, etc for things like diabetes, heart failure?
You must have a physician or PA for prescribing and interpreting blood test results. So I’m sure that someone beside behavioral health will have to be involved.
But T2 diabetes improvement & prevention thru behavioral health is big push from HHS.
The Health and Behavior Intervention codes (IIRC that’s the procedure code used ), if even covered by Medicare, are billed in 15 minute increments. Wonder how many would be considered necessary per visit?? And the reimbursement is likely to be a pittance.
The 15 minute billing unit will be replace with a block payment to the healthcare system that provides services to the patient. The healthcare system will get one reimbursement for all parts of the patient’s care, including bloodwork, doctor visits, counseling, diet education, peer counseling etc.
Healthcare systems will be evaluated on their “efficiency”-- i.e. at how well they prevent patients from progressing to a more serious status and requiring more costly care.
That reminds me of the old capitated care model, which was awful!! Providers were paid a fixed rate “per covered head” regardless of whether they saw the patient once or 10000X in a year. Awful model.
And I just saw somewhere a 3.5%increase for payment to doctor’s…lol.
One thing that lots of insurance companies are doing is peer to peer for mris. I have never had one rejected. I asked when doing one why in my type of practice (sports medicine injury /surgery) am I even wasting my time. The answer is the pcp ordering them for way too many patients. I totally agree with this. It should be referred out before the mri is ordered.
There is also the issues of ordering tests to protect yourself medically /legally. It’s the you’re dammned if you do or don’t.