CMS’s proposal to collapse E/M levels will hurt physicians and patients

September 13, 2018

Doctors should never be disincentivized from caring for their sickest patients.

No one likes paperwork, least of all physicians who would much rather spend their time working directly with patients to improve their health and outcomes. In light of that, CMS’s proposed new reimbursement changes that would simplify reporting sound positive, but could these changes hurt physicians, and perhaps even worse, vulnerable patients?

CMS is proposing several new reimbursement initiatives. Most notably, they are seeking to collapse evaluation and management (E/M) levels 2-5 into one reporting category. The goal: take the burden of justifying higher level visits with excessive documentation away by creating just two easy-to-chart levels-Level 1 for non-physician services and Level 2 for everything else.  

Currently, physicians have to justify their coding of patient visits with proper documentation, which can often be cumbersome and confusing. The difference between a level 5 visit, the most complex, versus level 4 is often nuanced and time consuming to document. By combining Levels 2-5 and offering a reimbursement at a rate somewhere in the middle, CMS believes doctors will be relieved from excessive documentation burdens, and as a result, they will gain an extra 50+ hours in their schedule each year.  CMS believes this will impact reimbursement revenue no more than 1-2 percent in either direction. 

That may be true for physicians who see a wide variety of patients at various levels of wellness, but it’s not that cut and dry for most practices. Removing higher E/M levels can have a major impact on physician revenue. Patients with serious, chronic, or multiple conditions take more time and require more systems checks-currently, level 5 visits.  Physicians will no longer be reimbursed for those extra services and checks.  Sure, many doctors will balance this loss of revenue by earning more on patients they spend less time with, but what about geriatricians? Or cardiologists? Or physicians who specialize in the care of some of our most vulnerable seniors? Anyone can see how this could lead to problems.

Doctors should never be disincentivized from caring for their sickest patients. Nor should they be expected to provide the extensive time and attention necessary without proper reimbursement. A generalized rate will only lead to physicians rushing through visits with patients who require more time, or making those patients schedule multiple appointments and focusing instead on the more lucrative visits with the quick patients in better health. This is not how physicians want to practice!

Our most vulnerable patients deserve a physician who can take time with them to explain testing and lab results, who can explore all of their symptoms in one comprehensive visit, and who can provide the personalized care and attention that leads to honest, trustful discourse and adherence to treatment plans.      

And equally important, physicians deserve to be paid for the services they provide. This is the reason for the growth of so many alternative practice models, like concierge medicine. The attempt at streamlining by CMS is nothing more than an opportunity for CMS to save money by not paying doctors in full. It will hurt physicians and patients and could even contribute to physicians avoiding fields that specialize in the care of complex patients.  

Insurance plans tend to follow CMS’s lead. If this proposal moves forward as presented, there is little doubt that insurance plans will follow suit and collapse their payment levels too, further exacerbating the situation for patients and practices.  

Many physician groups are already speaking out strongly against this proposal, and we support them. We favor any attempt by CMS to reduce paperwork and improve efficiencies and outcomes, but patient care should never be the financial burden of the physician. 

Wayne Lipton is managing partner for Concierge Choice Physicians, LLC, and one of the most experienced and successful executives in concierge medicine. Lipton graduated from Harvard College in 1973 with a degree in Biochemistry. He attended the University of Chicago Business School and the Boston Architectural Center. He was formerly a chief operating officer for PhyMatrix, a public healthcare company; chief operating officer for Physicians Choice, a Connecticut IPA and practice management company; and president and principal of Richmond Way Stores, a local chain of drug stores that he operated for 20 years.