When a patient is referred to see a specialist, it’s typically to receive highly skilled care from a doctor with very specific medical expertise.
Beyond performing sophisticated procedures, many specialists primarily spend hours each week conducting face-to-face visits with patients to perform examinations, diagnose diseases and coordinate care. These time-intensive services, which are referred to as “evaluation and management” (E/M) services, are crucial to diagnose complex and chronic diseases, help patients keep disease symptoms in check and avoid adverse reactions.
Prompt evaluation by a trained specialist is the first step toward early diagnosis and treatment—which, for many patients, means a lower likelihood of unnecessary complications, hospitalizations and costly procedures down the road.
Ready access to specialist E/M care also reduces disability, work limitations and unnecessary downstream medical costs—a win-win for patients and payers alike.
But despite their indispensability to patient health, E/M services have been sadly undervalued by the Medicare program. Absent adequate reimbursement for time spent on complex patient care, specialists are finding it harder to sustain their practices, creating significant patient access challenges as demand for care is surging.
One study found that Medicare reimburses physicians between three to five times more for procedural care than it does for the same amount of time spent on E/M services. While this is true across the board, certain specialties are under particular strain.
According to a 2018 report (PDF) from the Medicare Payment Advisory Commission (MedPAC), E/M services for specific specialties—including rheumatology and neurology—are significantly underpaid relative to others.
Undervaluing E/M services makes it more difficult for small and rural practices to operate, especially those that have a high volume of Medicare patients. Furthermore, because many undervalued specialties have a lower average annual compensation, it is harder for these specialties to attract new physicians since many recent graduates gravitate toward higher-paying fields in order to pay back medical school debt.
Unfortunately, the strain on the specialist workforce is contributing to a healthcare shortage in already underserved areas across the country. As a result, patients may pay the price in the form of higher wait times, delayed care and possibly worsening health.
According to the American College of Rheumatology’s most recent workforce study (PDF), the U.S. will need an additional 4,729 rheumatologists by 2030 to meet growing patient demand. The American Academy of Neurology’s most recent neurology workforce data (PDF) estimate the U.S. will need an additional 3,380 neurologists by 2025.
In response to these challenges, policymakers are taking steps to address the chronic undervaluing of specialty care. The Centers for Medicare & Medicaid Services (CMS) has begun to recognize the need to more appropriately value the time specialists spend with patients.
In its most recent Physician Fee Schedule proposed rule (CY 2020), the agency suggests increasing Medicare reimbursement for time-intensive E/M services provided by specialists in alignment with recommendations from the American Medical Association. The CY 2020 proposed rule would also replace the CY 2019 proposal to consolidate E/M codes—a change that would have resulted in significant and disastrous cuts to Medicare reimbursements for many specialties.
The CY 2020 proposed changes would be welcome news for specialists and the Medicare patients who rely on their training and expertise. If adopted, they will facilitate sustainability of physicians’ practices and help patients maintain access to these critical services.
We urge CMS to finalize the CY 2020 E/M code changes as they appear in the proposed rule so that the millions of Medicare beneficiaries can continue to receive these vital healthcare services from specialists. These changes would improve access to care while reducing the likelihood of costly complications—a winning scenario for patients.
Paula Marchetta, M.D., MBA, is president of the American College of Rheumatology. James C. Stevens, M.D., FAAN, is president of the American Academy of Neurology.