The Washington PostDemocracy Dies in Darkness

Doctors say proposed Medicare fee idea will cut visit times, hurt patients


For those of you who are 65 or older and covered by Medicare, medical care may soon change for the worse, as many doctors see it.

Every year, the Centers for Medicare and Medicaid Services (CMS) presents proposed adjustments to the fee schedule expected to take effect Jan. 1. A recent plan that CMS is considering lays out the most significant changes in over two decades in how much the agency reimburses doctors for office visits.

Medicare now pays doctors a higher fee to do longer office visits. According to the proposed plan, doctors who participate in Medicare will be paid the same flat fee for an outpatient visit whether you go to see them for indigestion or for stomach cancer, and whether you have one chronic medical condition, such as high blood pressure or diabetes, or five.

CMS officials say the plan is an effort to reduce paperwork and give doctors more time with patients, but many physicians are worried that the changes would oversimplify payments and reduce the time your doctor can spend with you.

The present guidelines, established in 1995 and 1997, dictate the rules for what a doctor needs to include in your health record to be reimbursed for a specific level of care. At present, there are four levels of codes doctors use based on the level of medical complexity to bill for new and follow-up patient office visits.

Under the new proposal, CMS intends to collapse the payment rates to just one level.

While we welcome the attempt to reduce regulatory burden and provide us more time for patient care, we are concerned that this will backfire. Doctors who spend time in the office, rather than doing surgery or procedures, fear that their employers will require them to see more people, in much shorter visits, to make up for the lower fees.

For example, in our specialty, neurology, independent American Medical Association experts have determined that these cuts will contribute to overall revenue losses of about 5 percent. In other specialties, it is even higher. This overall loss is misleading, since it lumps together hospital consults and procedures along with office visits. For a practice that takes care of patients in the office and spends time seeing patients rather than performing tests, the reductions may be much higher. This change would end up penalizing doctors for taking the time to figure out what’s wrong with you instead of doing studies.

Medicare also proposes to cut office visit payment by half if a doctor does a procedure on the same day. So, if you have a simple problem such as a pinched nerve, it can probably be addressed in one visit, but your doctor may ask to see you multiple times if you have headaches, diabetic neuro­pathy and stroke. And if you need a procedure, you’ll probably be asked to schedule that for another day.

Currently, most nonsurgical specialty offices set aside 15 to 30 minutes for a follow-up visit and 30 to 60 minutes for a new visit. We often need even more time for complex neurological problems.

Under the new plan, a five-minute visit will pay your doctor the same as a 50-minute visit. That’s like going to fill up your car with gas and being told that, regardless of the type of fuel you want, or how much gas you pump, you will be charged a flat fee of $20. The station owners get to decide how much gas you get, so they are left no recourse but to limit the amounts. If you need to fill up your tank, you are forced to make several stops for a few gallons of gas each time.

Of course, people are not cars and the repeated office visits may be inconvenient, delay treatment and create more travel time, more lost wages and more stress. Patients will have more co-pays for the secondary insurances that pay for the 20 percent, which Medicare does not cover.

Medicare is considering adding small bonuses for primary-care doctors and specialists, but we don’t think this will come close to offsetting the projected losses. Some doctors may simply stop accepting Medicare patients, putting further strain on access to care in many regions already affected by shortages. And if shorter visits become commonplace, there will be little time for conversations about making smart health decisions, discussing alternative treatment plans or listening to your care preferences and engaging in shared decision-making.

Physicians say that they would like to spend less time on their computers checking boxes to meet regulatory requirements, but what they want even less is to feel rushed and provide suboptimal care.

Avitzur is the chair of the Medical Economics and Management Committee at the American Academy of Neurology; Sacco is president of the American Academy of Neurology.

Primary care doctors aren’t so important to millenials

How can you tell whether your doctor is any good?

Diversity in medicine comes at a slow pace