Background – Value of ID Physicians
- A 2014 IDSA study reviewed Medicare data for over 270,000 hospital stays of patients with serious infections to compare stays that involved ID physician intervention with those that did not. After risk adjustment, ID physician care was associated with significantly lower rates of mortality and 30-day readmission rates, shorter lengths of hospital stay, fewer intensive care unit (ICU) days, and lower Medicare charges and payments.
- Other studies have found that ID consultation for patients with Staphylococcus aureus (including MRSA) bacteremia results in lower mortality rates, less antibiotic use, decreased healthcare costs and reduced readmission rates.
- ID physicians also play important public health roles, responding to outbreaks of infectious diseases and other public health emergencies (including the ID impacts of the opioid crisis, hurricanes, and bioterror attacks), and drive innovation in therapeutics, diagnostics, and vaccines.
Background – Workforce Recruitment
- There has been a 21.6% decline in the number of applicants to infectious disease fellowship training programs over a 5-year period ending in 2016.IDSA surveyed internal medicine residents in 2014 and found financial concerns were the chief barrier to pursuing ID.
- The last few years have seen some modest improvements, as IDSA made some administrative changes to the match and has invested heavily in recruitment and mentorship of medical students and residents. But we are reaching the limit of what our efforts alone can accomplish.
Background – Physician Compensation Challenges
- The average salary of an infectious diseases physician (according to IDSA’s 2017 compensation survey) is $100,000 less than the median salary of a specialty physician (according to the 2017 Medscape Physician Compensation Report).
- Average medical school debt is about $200,000 (American Association of Colleges of Medicine), which places pressure on young physicians to pursue more lucrative career paths.
- The chief driver of the compensation gap is the evaluation and management (E/M) codes, which cover more than 90% of ID physician services. E/M codes are undervalued compared to codes for procedures. E/M codes have not been updated in over 30 years.
- New Medicare payment models are based upon these old, outdated codes, thus severely limiting ID physicians’ ability to participate in payment reforms.
Background – Medicare Physician Fee Schedule Final Rule for 2019
- In its 2019 Physician Fee Schedule Proposed Rule, CMS proposed collapsing outpatient E/M codes for new and existing patients from five levels, which are used in billing for non-physician services (level 1) up to physician services for the most complex patients (level 5), down to just two levels regardless of the complexity of a patient’s case, and making reimbursement for complex care equal to payment for more routine, minor conditions.
- IDSA, medical specialty societies, and one quarter of Congress urged CMS to delay the rule and work with stakeholders on an alternative plan that protects patient access to care and the future physician workforce. We are grateful for the significant support of Congress in urging CMS to develop an improved rule—nearly one quarter of Senators and nearly one quarter of Representatives signed letters to CMS on this issue
- CMS finalized the rule on November 1, delaying implementation of the E/M changes to 2021, and maintaining level 5 E/M to account for the most complex patients and visits. We appreciate that CMS was partly responsive to medical societies and Congress, but continue to have serious concerns about the final rule.
- Of great concern, the final rule language still calls for collapsing levels 2-4 E/M codes in 2021, which would result in reductions in payment for the Level 4 E/M. The new code structure of the office/outpatient E/M codes will exacerbate the low value of the codes as they now stand by further diminishing the ability to capture the complexity of care provided by ID and HIV physicians.
- The final rule ignores Congress’s urging to work with the medical community on a revised proposal, and instead advances a policy that may widen compensation gap between ID and other physicians. Because ID physicians care for many of the sickest patients and most complex cases in the country, which are level 4 and 5 visits, the rule may have serious consequences for patient care, ID physicians’ compensation, and the future of our specialty.
- We appreciate that CMS included ID among the specialties that may use a new “complexity adjuster” that may impact payment for the most complex patient visits, but the value of this code is extremely low and is not sufficient to make up for reductions to Level 4 E/M.
- Even though the final rule appears to avoid some of the proposed cuts put forward in the proposed rule, even “doing no harm” would be insufficient because E/M codes were already significantly undervalued prior to this rule. This inappropriate valuation is driving significant compensation, patient access and workforce challenges for ID and other “cognitive” specialties.
Background – President's 2020 Budget Request
- The President’s 2020 Budget Request announced a proposal to create a risk-adjusted monthly Medicare Priority Care payment for providers who are eligible to bill for evaluation and management (E/M) services and who provide ongoing primary care to Medicare beneficiaries. The payment would be funded by a five percent annual reduction to the valuations of all non E/M services and procedures under the Physician Fee Schedule. It is unclear how “primary care” would be defined and whether or not specialists who mostly bill for E/M services would be eligible. Previous temporary primary care payment bumps included all internal medicine subspecialties, so ID was included but many other cognitive specialties were not.
- The strong congressional response to the Physician Fee Schedule proposed rule was essential in securing some changes to the proposal, particularly the delay until 2021 and the maintenance of level 5 E/M. But key concerns (namely the cut to level 4 visits and no action to improve E/M valuation) remain. Continued congressional engagement will be necessary to ensure appropriate policies that protect patient access to care and the future ID workforce.
- IDSA is working closely with other “cognitive specialties” (rheumatology, endocrinology, neurology, etc.) who are also impacted by E/M codes. We are leading voices in both the Cognitive Specialty Coalition and the Cognitive Care Alliance.
- As CMS continues to work on implementation of the E/M changes finalized in the 2019 Physician Fee Schedule, we ask Senators/Representatives to urge the agency to work with medical societies to ensure the appropriate valuation of E/M codes to sustain the ID and HIV workforce.
- SPECIFIC ASK: Ask congressional offices to please support the inclusion of report language in the 2020 HHS appropriations bill encouraging CMS to ensure that changes to E/M reimbursement do not further exacerbate cognitive specialists workforce challenges.