APA Registers Concerns About Potential Cuts to Medicare Physician Payment

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In a comment letter to the Centers for Medicare and Medicaid Services (CMS) in September, APA expressed concerns about a proposed decrease in the “conversion factor” used to calculate physician payment that would result in an overall cut to physician reimbursement under the Medicare program for 2023.

As part of the 2023 Proposed Medicare Physician Fee Schedule, CMS proposed a decrease of $1.53 in the conversion factor, or 4.42% of last year’s conversion factor. The conversion factor is a variable that is multiplied by the relative value unit (RVU) assigned to every physician service or procedure to derive payment for that particular service or procedure.

A decrease in the conversion factor results in an overall average decrease in reimbursement for all physicians; how it will affect any one individual physician depends on that physician’s practice patterns, geographic location, and other factors.

The decrease is due largely to the fact that a 3% increase legislated by Congress last year will expire. Additionally, there is a further 1.5% decrease to the conversion factor that is the result of budget-neutrality requirements mandating a downward shift in payment to account for increases in utilization and total relative value units.

Legislation to avert the conversion factor decrease, the Supporting Medicare Providers Act of 2022 (HR 8800), was introduced in the House of Representatives by Rep. Ami Bera (D-Calif.) and Rep. Larry Buchon (R-Ind.). APA and many other medical groups are supporting the legislation.

Mental Health Is Biden Priority

In the September letter to CMS Administrator Chiquita Brooks-Lasure, APA CEO and Medical Director Saul Levin, M.D., M.P.A., said proposed payment cuts will only exacerbate the nation’s mental health crisis. Additionally, he urged CMS to take into consideration projected increases in the Medicare Economic Index, which reflect physician practice expenses and medical inflation.

“APA is concerned that further reductions to the Medicare conversion factor forecast for 2023 will have a negative impact on psychiatric practice and in turn access to care,” Levin wrote. “It comes at a time when there is an increase in individuals seeking care and a limited supply of clinicians available to provide treatment. The continuing problem of emergency room boarding reflects both a lack of outpatient services as well as limited inpatient beds. There are not enough psychiatrists to treat all those needing care. Not only is the supply of child and adolescent psychiatrists in short supply, but the numbers of psychiatrists specializing in geriatric psychiatry are even lower, in part due to the difficulty of sustaining a practice serving a large number of Medicare beneficiaries.”

He also pointed out that President Joe Biden has stated that access to mental health and substance use treatment is a priority for his administration. “Without appropriate payment for services, being able to find a psychiatrist will become even harder,” Levin wrote. “APA urges CMS to work with Congress and the physician community to not only address the current constraints related to the Medicare Physician Fee Schedule methodology, including the limitations imposed by budget neutrality, but to develop strategies that support and incentivize access to evidence-based treatments and ensure practice sustainability.”

In-Person Requirement a Barrier to Care

In addition to the conversion factor, the proposed rule covers a range of other issues affecting payment and practice, including evaluation/management (E/M) services; telehealth and other services involving communications technology; and updates to the Quality Payment Program through Merit-based Incentive Payment System (MIPS) activities, methodology, payment adjustments, and other provisions.

In the letter, Levin expressed support for the proposed increase in RVUs assigned to E/M services provided in a facility setting (for instance inpatient care or nursing facility care) and home-based services. APA also supported CMS’s proposal to expand the outpatient coding and documentation guidelines for E/M services to all care settings including inpatient, nursing facility, and home-based care. Once the proposed rule is finalized, physicians will use the same coding and documentation guidelines for all E/M services beginning January 2023 (see pages 10 and 11). Regarding telehealth services, Levin cautioned CMS against requiring in-person visits prior to a telehealth encounter.

“APA appreciates that CMS has allowed some flexibilities regarding the in-person visit requirement; however, we remain concerned about any requirement for an in-person visit prior to a telehealth encounter, regardless of whether the telehealth encounter is conducted via synchronous video or via audio only,” he wrote. “Requiring an initial or subsequent in-person visit for a patient to qualify for a telehealth encounter of any modality will be a barrier to care and disproportionately affect people with low income, the elderly, and those in rural areas. … Data show that telehealth, including audio only, is effective in starting care and retaining patients in treatment. This decision should be based on the clinical decision-making of the clinician.”

Regarding data collection and quality payment programs, Levin encouraged CMS to incentivize the adoption of measurement-based care and implementation of the collaborative care model in accountable care organizations and other federal programs. He also provided feedback on efforts to improve data collection related to social determinants of health, urging CMS to provide adequate funding for screening and interventions that address health disparities.

Finally, Levin asked CMS to provide further guidance on how psychiatrists and other behavioral health specialists can participate in alternative payment models in a way that ensures they are receiving adequate resources and best utilizing their expertise.

The final rule is being issued this month. APA will host an education webinar on the changes to the E/M documentation guidelines in early December. Look for updates in the Psychiatric News Update enewsletter and from APA. ■