"There's no doubt that these work RVU increases are appropriate and necessary," said J. Leonard Lichtenfeld, MD, FACP, the ACP representative to the Relative Value Scale Update Committee (RUC) – an entity that makes recommendations to CMS on relative values. "The physician work involved in furnishing these services has increased significantly in the last 10 years."
Medicare law requires CMS to assess the accuracy of the relative values it assigns to physician services every five years. CMS last changed the work RVUs assigned to the E/M services in 1997. ACP, recognizing that many E/M services were valued too low because of changes in patient characteristics and physician practice, asked CMS in Jan. 2005 to include the E/M codes in this "Five-Year Review." The College was joined in its request by internal medicine subspecialty groups and other organizations that represent cognitive-oriented physicians. CMS agreed, incorporating the following codes in the Five-Year Review:
New patient office visits Established patient office visits
Initial hospital care services Subsequent hospital care services
Hospital discharge services Office consultations
Inpatient consultations Emergency department services
Critical care services
CMS then asked the RUC, made up of physicians appointed by major specialty organizations, to make a recommendation on the appropriate work RVU for the E/M and the other services the agency included in the Five-Year Review. The ACP-led coalition worked with the RUC for about a year – considering national survey data and other information compiled by government and physician-specialty organizations – to determine the appropriate work RVUs for these E/M services. The CMS proposal adopts the E/M recommendations made by the RUC.
"ACP commends CMS for accepting the RUC recommendations," Dr. Lichtenfeld said. "The fact that these recommendations were supported by at least two-thirds of the RUC members shows that the physician community recognizes that these changes are warranted. ACP also believes that the CMS-proposed changes are not only warranted by the evidence, but are essential to at least begin to address other factors at play in our healthcare system, especially the disturbing trend that significantly fewer physicians-in-training are entering into primary care."
"ACP has determined that inadequate and dysfunctional payment policies, including the undervaluation of E/M services, combined with high levels of medical student debt, are key drivers behind the impending collapse of primary care," Dr. Kirk emphasized. "Medicare, as the single largest purchaser of health care in the United States, can lead by replacing policies that are antithetical to primary care with ones designed to encourage and support its importance and growth."
The Medicare law requires that CMS offset the increased Medicare spending resulting from relative value increases, which CMS proposes to do by applying a special adjustment factor that will fully offset the costs associated with the work RVU increases. After the budget neutrality adjustment is applied, physicians who see the most Medicare patients in face-to-face E/M visits will experience significant increases in Medicare payments, while some physicians who provide fewer E/M services will experience payment reductions. Such redistribution will begin to correct long-standing reimbursement disparities that are contributing to the looming crisis in access to primary care and help ensure an adequate supply of internists and other physicians to care for an increasingly aging population.
"ACP encourages CMS to hold the line on its proposal at the end of the 60-day public comment period and include the proposed E/M work RVUs in the final fee schedule to be published by Nov. 1," Dr. Kirk concluded.
The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 119,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection and treatment of illness in adults.