Page 11 - Modern Healthcare (January 2020)

Medicare
Medicare spent
$2.6 billion,
$2.6B in 2018 on
20% of that on
paper would
post-op visits that
be the patient’s
responsibility.”
never happened
Andrew Mulcahy
Senior health policy
researcher
RAND Corp.
By Tara Bannow “Of the GETTY IMAGES
ment rates are based on physicians’ sur- they provide. And when surgeons pro-
SURGEONS ARE OVERPAID billions vey responses that estimate the number vide visits after the 10- or 90-day fol-
of dollars every year for certain bun- and level of post-operative visits a typical low-up window, they’re allowed to bill
dled procedures, according to a new patient would require. But recognizing for those separately, he added.
CMS-funded study. that there’s no way to verify whether phy- The new report also notes that
The New England Journal of Medi- sicians actually deliver that many visits, post-operative care is increasingly being
cine report found that just a fraction of the CMS now requires certain physi- shifted to hospitalists and intensivists,
post-operative visits the CMS pays for cians and other practitioners in nine who bill separately from the bundled
as part of procedure bundles actually states to report each post-operative visit payment for the initial procedure. “In
take place. The report says reducing the using a “no pay” code. that case, the surgeon is getting paid and
payments accordingly would have saved RAND published initial findings on then the other practitioner that did that
Medicare $2.6 billion in 2018 by decreas- the data in a trio of CMS-funded studies extra visit is also getting paid,” Mulcahy
ing payments for 10- and 90-day global last year. “Up until last year, Medicare said. “So Medicare double pays.”
procedures by 28%. didn’t know how many visits were hap- The study notes that because of
The findings have “huge” implica- pening,” Mulcahy said. “Now they do. Medicare’s budget-neutral payment
tions for physician revenue, but also They’re overpaying.” policy, if the CMS were to lower pay-
for Medicare patients, who face a 20% ments for surgical procedures, it would
co-pay under Medicare Part B, which The data showed that post-operative result in across-the-board pay increases
includes post-operative visits, said An- visits took place in just 4% of 10-day for all other physician services, such as
drew Mulcahy, lead author of the study global periods for minor procedures, evaluation and management. Mehro-
and senior health policy researcher such as a dermatologist removing a skin tra said that would shift a significant
with RAND Corp. tag. For more complex procedures with amount of payments from surgeons to
“Of the $2.6 billion, 20% of that on 90-day global periods, 39% of the visits primary-care physicians.
paper would be the patient’s responsi- that were assumed to have taken place Unsurprisingly, surgeon specialty
bility,” he said, adding that many ben- under Medicare’s payment valuation groups had strong reactions to RAND’s
eficiaries have Medigap or supplement actually took place, according to the first set of studies, and the overall idea
plans to offset that cost. RAND study. that Medicare was overpaying for proce-
Post-operative visits account for Dr. Ateev Mehrotra, an author of the dure bundles.
roughly 25% of Medicare payments to study and associate professor of medi- The American College of Surgeons, for
physicians for procedures with bun- cine at Harvard Medical School, said he example, objected to counting the num-
dled post-operative care, which totaled doesn’t think it’s because patients aren’t ber of “no pay” codes submitted to tally
$9.9 billion in 2017, the getting the post-operative the number of post-operative visits pro-
study found. care they need. vided. Vinita Mujumdar, ACS manager of
The findings are based THE TAKEAWAY “Rather, I think clinical regulatory affairs, said it’s possible doc-
on the volume of post-op- patterns have changed over tors could forget to submit the code or
erative visits reported by Experts believe time potentially, and there- have trouble reporting it due to barriers
clinicians under a 2017 clinical patterns fore that post-operative care in the hospital or inadequate software.
CMS requirement designed have changed and is not necessary,” he said. “There are many steps along the way
the CMS is paying
to strengthen the agency’s for billions of Still, Mulcahy said he where the code could have been pre-
oversight of the number of dollars of post- wouldn’t be surprised if vented from getting to CMS and being
visits actually delivered af- operative care that some doctors tend to round counted,” said Mujumdar, who had not
ter surgeries. isn’t necessary. up in their survey estimates seen the most recent RAND study be-
Medicare’s bundled pay- of how many post-op visits cause it was under embargo. l

January 27, 2020 | Modern Healthcare 9