Cuts to Medicare: ‘As vascular disease complexity increases, reimbursement for complex care decreases’

Kellie Brown

Outgoing Midwestern Vascular Surgical Society (MVSS) President Kellie Brown, MD, has seen fundamental changes to the way vascular surgery is practiced during her 20 years as a surgeon. The advance of endovascular techniques. The arrival of the electronic medical record (EMR). An increasing move toward quality metrics.

She has also borne witness to the challenges that have ensued as the specialty has evolved.

Now, with vascular surgery approaching another crossroads as impending cuts to Medicare draw into the near distance, Brown is facing up to another looming threat to the profession: As the complexity of vascular disease that surgeons treat increases, “reimbursement for that complex care decreases—particularly in the office-based or OBL setting, which is actually one of the most efficient, cost-effective centers with high patient and physician satisfaction,” Brown told attendees of the recent 2021 MVSS annual meeting in Chicago (Sept. 9–11).

She was speaking during her presidential address, entitled “Challenges to the health of vascular surgery,” in which she also drew attention to the dangers posed by an aging vascular physician workforce, how burnout is affecting the specialty, and the progress of diversity, equity and inclusion in shaping the future of the profession.

“As I reflected on what I wanted to address today, I thought about all the challenges facing vascular surgery, including changing demographics, reimbursement pressures and burnout,” she told attendees.

“At least at our center,” explained Brown, a professor in the division of vascular and endovascular surgery at the Medical College of Wisconsin, Milwaukee, “the vascular volume seems to keep growing, and the patients seem to keep getting sicker. It feels more overwhelming than it did 20 years ago.”

She drew attention to an array of data points to illustrate the point: by 2030 there will be 82 million people in the United States who are 65 years and older, she said—rising to 88 million in 2040 and continuing to increase until at least 2050, according to the U.S. Census Bureau. “This means more patients with vascular disease and therefore more volume for us to take care of,” Brown continued. “In addition, currently 80% of people aged 65 and older have at least one chronic condition and nearly 70% have two or more. This means that vascular disease is likely to increase in prevalence as many of these patients have hypertension, hypercholesterolemia and diabetes, conditions that carry with them a high risk of vascular disease.”

Obesity, too, is also on the rise, Brown said. “I don’t need to tell you that increasing prevalence of comorbidities and obesity, along with increasing age, leads to higher complexity and possible complications. It’s no surprise then that vascular surgery volumes are increasing.”

Against this backdrop come the proposed Medicare cuts for 2022. The percentages confronting vascular surgery in particular are stark. As a whole, the specialty faces an 11.4% drop in physician fee schedule payments. Some outpatient services—such as those performed in the office-based lab (OBL) setting—are staring down as much as 22% in cuts.

In tandem with these types of percentages, Brown put a figure on the increased vascular volume she has witnessed during her time in practice in the form of mean number of work relative value units (wRVUs): up 55% since the beginning of the millennium.

“So, with increasing complexity, what is happening to reimbursement?” she asked the MVSS gathering. “This should be no surprise to any of you: While hospital and skilled nursing facility reimbursement has increased since 2000, physician reimbursement has not … and this may be about to get even worse.”

The cut will hit three areas, Brown went on: Recent updates to the office-based evaluation and management (E/M) codes shuffled money from procedures to E/M. The second decrease comes from an adjustment to the supplies and equipment data. And a pricing update to the clinical labor staff payment rates increases the payment to practices for their staff—“which should be a good thing,” she said, but “given the budget neutral mandate for Medicare physician payments, this increase to all physician practices came at the expense of areas with high direct practice expense, i.e. office-based procedures.”

Referring to the perils of the aging vascular surgeon population, burnout among its practitioners and the looming payment cuts, Brown implored: “We have an issue with high work hours, workforce shortages, threats of decreasing compensation, increased administrative burdens and high prevalence of burnout. So what can we do about it? I would contend that just keep swimming is not an acceptable answer. Certainly, these are not all individual issues—many stem from institutional or systems problems. And they are all interrelated. Burnout is related to increasing complexity in our work lives, which leads to increased work hours, which increases burnout, which then increases attrition, harms recruitment and leads to more burnout.”

She offered a series of solutions—in the case of the threat of cuts to Medicare with a call to action. “Reimbursement for the vascular surgeon is primarily dependent on the government as most of our patients have some type of governmental insurance claim,” Brown said. “The only way to combat these declining reimbursement numbers is to educate your government officials about the importance of vascular surgery to the population at large, and how these cuts adversely affect our ability to care for patients.”

The most effective avenue would be through a political action committee (PAC), she argued. “Unfortunately, lobbying via a PAC is really the way government works. In addition, or as an alternative, you could contact your representatives in Congress and the Senate about your concerns. These contacts have most effect when they’re part of an organized campaign. However, efforts to educate your representatives and their support staff around your concerns can be done at any time, and I highly recommend writing, calling or visiting your elected officials in effort to educate them about the role of the vascular surgeon and the effect the declining reimbursement has on our patients and our practices.”


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