Curbside Consult with Dr. Jayne 11/15/21

Big news this week, as CMS announced that it would automatically apply the “extreme and uncontrollable circumstances” exception to the 2021 Merit-based Incentive Payment System (MIPS) performance year. Previously, clinicians would have been required to specifically apply for the exception. The automatic exception will be applied for the 2021 performance year and only to those clinicians who are participating as individuals. Those participating as groups, virtual groups, or alternative payment model entities will instead have to apply for performance category reweighting. This can be done on the Quality Payment Program website prior to December 31.

Those who are carefully following how MIPS works will note that the exception reweights the MIPS performance categories to zero, which means that there will be a “neutral payment adjustment” (aka no penalty) for the 2023 payment year. Given inflation, even a neutral adjustment is still a reduction in payments, which adds to physician unhappiness. CMS also reopened the exception application for the 2020 performance year; participants can apply prior to November 29 by submitting a targeted review form.

As physicians consider the ongoing calculus of how they are paid, how they deliver services, and what their patients want them to offer, I’m starting to see more of my primary colleagues considering direct primary care practices. In that model, patients pay a monthly membership fee to see their physician. There is no third-party billing, and the model is designed to delivery quality care at a reasonable cost. The Direct Primary Care Coalition notes that “most DPC memberships / subscriptions cost less than the average cell phone bill” and that patients typically have greater access, shorter waits, and longer appointments with their physician. In addition to reducing administrative burden and costs, the model has the goal of building back the old-school physician-patient relationship and a mutually trusting therapeutic environment.

Many patients are demanding telehealth, especially during hours that aren’t considered traditional office hours. Those practices that remain part of traditional fee-for-service arrangements are continuing to advocate for payment parity for telehealth services so they can be reimbursed at the same rate for virtual visits as they would for in-person ones. On the physician side, the thought is that the visits require the same level of cognitive expertise and also the same amount of time as in-person visits. Opponents of payment parity argue that those visits should be less expensive due to reduced resources, but the reality for most physicians is that they’re still paying rent, they’re still paying staff to assist them and manage patient data, and they’re also paying additional fees for either freestanding video conferencing software or telehealth modules / content from their EHR vendors.

In New Jersey, Governor Phil Murphy recently rejected parts of a bill that would have required payment parity for telehealth services. He noted that the cost to state taxpayers may be “substantial” and that in-person care should be prioritized except when telehealth would increase access and improve patient outcomes. Murphy reinforces the idea that providers should have long-term cost savings with telehealth due to decreased clinical space and support staff. It didn’t sound like he spends a lot of time talking to physicians who are running low-margin practices and working hard to keep the lights on while they are struggling to retain staff in a market where solid clinical personnel are commanding premium salaries. I’ve performed telehealth visits with no support staff as well as those in a model where staff did all the same pre-visit prep as they would in a brick-and-mortar office, and I have to say the latter is much preferred.

Murphy also notes a concern that over the long haul, “pay parity could over-incentivize telehealth, further limiting in-person options” and that it might be “especially detrimental for those in underserved communities.” On the other hand, pay parity might allow those in underserved communities to have consultations with distant primary care physicians without an untenable wait, which is already the case in many rural and underserved communities. It could also provide opportunities to consult with previously inaccessible subspecialists when patients are unable to travel the distance to tertiary care centers. I agree that Murphy has a valid concern that CMS hasn’t fully made up its mind on payment parity, which could create confusion for Medicare and Medicaid beneficiaries.

Murphy goes on to make it clear that he believes that telehealth “was intended as a stopgap to preserve public health during an unprecedented emergency” rather than something that patients and physicians have decided serves both of them well. It’s unfortunate that he sees it as a way to deliver care of last resort as opposed to a rapid evolution in healthcare delivery. The bill received a conditional veto, which allows the senate to potentially incorporate his recommended changes and amendments. Those include a requirement that the state health department would revisit payment parity over the next 18 months and make a subsequent recommendation. In the mean time, payment parity would be in place through the end of 2023 if the recommendations are followed.

As a patient, I enjoy having options. I have two physicians who I see who really need to be seen in person due to the nature of the examinations involved. I see each of those physicians annually, which between the two of them, results in a comprehensive physical examination with a fair amount of overlap every six months. They’re part of the same medical group as my internal medicine physician, who has full access to both their records. When I see my internist in person, 90% of the visit is a discussion – what’s working for me health-wise, what’s not, and a review of laboratory results, my goals, and how I feel. Very little of it is dedicated to the physical exam and that’s OK given my current state of health. In reality, I’m seeing him for his brain much more than I’m seeing him for his exam skills, especially since I monitor the most important indicators of my health at home. As a patient, it would be much better for my schedule to be able to see him virtually and have him compensated fully for his expertise, which is why I value his care.

Time will tell how much cost reduction can really happen with virtual care. I think a lot of it has to do with how integrated various platforms are and how well physicians can learn to work with patients virtually. Will we have it all figured out by 2023? I’m not sure, but I’m committed to trying.

What’s your preference in the virtual versus in-person care debate? Leave a comment or email me.

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