They are the sort of cuts the Society for Vascular Surgery (SVS) says will have a massive impact on vascular surgery practices for years to come. The recently released Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule (PFS) Proposed Rule decreases vascular surgeon work relative value unit (W RVU) and practice expense RVU (PE RVU) by 2 and 5%, respectively, resulting in an estimated reduction of 7% in the total payment for the services vascular surgeons provide.
SVS members may have noticed a recent flurry of attention around the proposed cuts, changes currently scheduled to take effect Jan. 1, 2021.
The stakes are high, demanding we unpack in some detail what these cuts mean to surgeons in practice and what you can do to help support our community in order to work to prevent this looming catastrophe.
On Aug. 3, CMS released the 2021 Medicare PFS Proposed Rule which lays out a series of changes that in aggregate will result in the predicted 7% cut in reimbursement for vascular services administered to Medicare patients.
What will this look like on Jan. 1? The conversion factor (CF), or dollar amount per work RVU, will drop nearly 11%—by $3.83—from this year’s CF of $36.09 to $32.26. Pause for a moment to reflect on the fact that this is less in actual, non-inflation adjusted dollars than we were paid back in 1998. In fact, had 1998 payment levels kept up with inflation over the past 27 years, the CF for 2021 should be $57 per RVU, representing an inflation-adjusted loss of more than 43%. This amounts to an acute collapse layered on top of a long-term devaluation of physician services that has gone on—essentially unchecked— for 27 years.
How did this happen? The failure to adjust reimbursement to keep pace with inflation is a long-term problem but changes to Evaluation and Management (E/M) coding and reimbursement are driving the sharp drop for 2021. This began with a CMS proposed initiative for 2019 to collapse the new and established outpatient office visit levels into one code each, with add-on codes for complexity. The goal was to reduce documentation burden on physicians and simplify the coding system.
This proposal was universally rejected by the house of medicine. The American Medical Association (AMA) then embarked on an enormous undertaking to rewrite the code set for outpatient office visits. The new code set keeps the level structure essentially intact but removes the requirement for history and physical “bullets” to determine visit level. The outpatient office visit level is now determined simply by time or medical decision making (MDM).
The original CMS proposal for consolidation of codes maintained total expenditures and was projected to have relatively little impact on vascular surgery payments. The AMA’s RVU Update Committee (the RUC) then proposed large increases in RVUs for the revised E/M code set that emerged from the AMA CPT panel. The unspoken consequence, however, is that under budget neutrality requirements, those increases must be offset by decreases elsewhere—in this case, through reducing the CF. Those decreases will severely impact surgical procedures as well as radiology, pathology and other services not associated with E/M services. The precise impact on individual vascular surgery practices may vary significantly based on the volume of E/M services provided, case mix and site of service.
For those who hope that reduced payment for surgical services may be a mere oversight, another aspect of the rule underscores the concern that regulators continue to believe Medicare is actually overpaying for surgical services.
Despite strong feedback from the surgical community when the outline of this policy was first introduced a year ago, CMS has elected not to include the increased value for E/M services in the valuation of services that surgeons provide within the 10- and 90-day global periods associated with an operation. In fact, the agency volunteered—when including the increase in payment for maternity care—the opinion that “unlike the 10- and 90-day global surgical service codes … we have never expressed concerns as to the accuracy of the values of the maternity packages.” They note the agency’s prior attempt to reduce payment for the global periods by “unbundling” these services, and reference ongoing activity to investigate whether surgeons are actually providing the postoperative care we are paid for in this period.
So, what can vascular surgeons do to oppose these cuts, stand up for the value of the care we provide, and ensure that we have the resources to continue to do so? The SVS will provide a strong, detailed response to each of the policy points in this proposed rule by the deadline of Oct. 3, 2020. In addition, the SVS has launched its own advocacy effort, marshaling policy and advocacy staff and SVS members to reach out to CMS and Congress on your behalf. In an unprecedented partnership, the SVS has also joined the Surgical Care Coalition, a group formed in response to this challenge that is making a substantial investment to support policy polling, research, and a forceful advocacy campaign to educate surgeons, policymakers, and legislators about the urgency of this matter. Please also take a moment to visit the Surgical Care Coalition’s website, which is located at www.surgicalcare.org.
However, it is clear that this year’s situation requires the full strength of our membership to avert a severe blow on Jan. 1 through advocating for Congressional intervention. In this case, the “ask” is that Congress act to waive the requirement for budget neutrality, which would avert cuts to surgical services while continuing to support the desired increases in payment for E/M services, primary care, telemedicine and others. How can you support this effort? There are a number of important immediate steps that you and your partners can take.
Let your Congressional delegation know what you think on behalf of your patients, practice and profession. The SVS’s easy-to-use Voter Voice platform allows you to quickly identify your legislators and utilize pre-drafted email letters to reach out. Take the time to personalize these with a description of the longitudinal care you provide a medically complex, often socioeconomically challenged population, or how the cuts would impact your practice’s ability to maintain access.
Use Voter Voice’s legislator identification function to find your own representatives and request in-person or (more likely this year, and more easily worked into a surgeon’s schedule) virtual visits with your senators or representatives. SVS staff will gladly provide preparation, supporting material, or virtual support for these meetings and can also help you arrange them. Work to become an advisor to your legislator and his or her staff on matters that impact vascular surgery.
Volunteer to work with SVS and Surgical Care Coalition staff to write and place letters and op-ed articles in your local paper or other key, high-profile publications that will reach critical legislators and policymakers.
Become an SVS Ambassador and help us raise the profile of this campaign on platforms from Twitter and Instagram to Facebook, SVSConnect and LinkedIn.
Give to the SVS Political Action Committee (PAC), which supports events and other meetings with legislators.
This year has brought unprecedented challenges. Please help the SVS work to prevent an additional blow in 2021. Take the time to do one or more of the things listed above and encourage your partners and colleagues to do the same.
Margaret C. Tracci is chair of the SVS Government Relations Committee. Matthew J. Sideman is chair of SVS Policy and Advocacy Council.