Anders Gilberg 0:00
These are actual cuts, not cuts in growth rate, and they, you know, happen at a time when there's an inflation. There's inflation in the industry, so I am concerned about that.

Austin Littrell 0:17
Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell, and the associate editor of Medical Economics, and I'd like to thank you for joining us today. Last week, CMS put out its proposed 2027 Medicare physician fee schedule, and buried in the roughly 1,600 pages is another conversion factor cut: 1.68% for physicians outside an alternative payment model, 1.19% for those in a qualifying one. As the 2.5% bump Congress has patched in year after year runs out, as five straight years of the same fight, and for independent practices paying their own rent and their own staff, the math is getting pretty hard to absorb. That's why in today's episode, Physicians Practice Managing Editor Keith Reynolds sat down with Anders Gilbert, senior vice president of Government Affairs at the Medical Group Management Association to walk through what's actually in the rule. They get into why budget neutrality forces CMS to cut one specialty in order to pay another, why the agency wants to move away from the AMA's valuation process without bringing in new data to replace it, what the sunset of MIPS and the MIPS value pathways will really mean for multi-specialty groups, and the sleeper provision on modifier 25 that could land hard in certain practices, but with all that said, Anders, thank you as always for joining us. Let's get into the episode.

Keith A. Reynolds 1:39
Hey there, folks! Today we're talking to Honors Gilbert, the senior vice president for government affairs at the Medical Group Management Association. Honors, how you doing today?

Anders Gilberg 1:49
I'm great, Keith. How are you?

Keith A. Reynolds 1:50
I cannot complain. It's a beautiful day in the neighborhood when we get to talk to you. So, the final rule for the physician fee schedule is being proposed at this point. A lot of interesting stuff in there. Why don't you give us a real quick rundown? Like, you know, what's you know, what what came down the pike the other day?

Anders Gilberg 2:11
Okay, I mean, I would say there are a few themes I can pick up on. Unfortunately, the one reoccurring theme is the inability for Medicare to keep up with inflation in terms of the payments to physicians. So this year, it's a proposal on the conversion factor. It incorporates the expiration of a two and a half percent bump that that Congress has put in place now for the last five years or so, and so physicians would see a reduction depending if they're in an APM, a qualified APM or not. They'd see a reduction of I have it written down here, 1.19 if they're in an APM, and a reduction of 1.68 if they're outside of an APM. So obviously that's problematic, and the fix there is going to be more on the congressional side. So I can talk about that a little later too. So that's a theme. There's other themes about you know I think like overall the rule is more beneficial towards value-based care, the Medicare Shared Savings Program, and ACOs. So that's positive for ACOs. Something we support, and but it also has a theme in there about which amplifies these budget neutrality requirements that Medicare is under, which tend to exacerbate shifts from one specialty to another when you're reducing or you're often cutting one specialty to benefit another or vice versa. It creates all kinds of political problems as well as you know just care delivery problems when some specialties get cut 10% or more in order to fund primary care, which is very positive. And but we're also pursuing legislative to fix that, legislative initiatives to fix that as well.

Keith A. Reynolds 3:56
All right, so let's dig right in. We're looking at another conversion factor cut, 1.68% for most physicians. You know what are your members saying after five years of just cuts, cuts, cuts? You know what? What are you hearing?

Anders Gilberg 4:09
Well, there's frustration. I mean, some of the cuts have been averted at the last minute, the 11th hour. Is there frustration overall about the state of the physician payment program, the system in Medicare, and you know we just need a reliable system that pays based on inflation. We've seen incredible inflation over the last several years. It tempered a little bit, but picking up again now with the war in Iran, and you know we're certainly not immune to that in this industry, and so the fee schedule doesn't keep up with inflation. So we have practices that are independent, who have to pay their own rent, have to pay their own salaries. They're, you know, they're dependent on the physician fee schedule because that's how they're paid 100% in Medicare at least, and it just isn't keeping up. And so you know, those practices have defined. Alternative revenue sources, or have to subsidize the loss they take on Medicare through private insurance contracts, and you know it's just becoming overly problematic. And you know decisions are often made then when we see consolidation in the industry to like we're going to have to sell our practice, or we're you know the large health system can absorb the losses that our practices incur in order to, you know, secure a referral base or to drive ancillaries into the into the health system, and so all kinds of different things that are just heaping pressure on on physician practices today.

Keith A. Reynolds 5:38
So you know, you mentioned that you know there's been some last minute, you know, corrections on these sorts of things. It seems that Congress is constantly setting up a game of chicken with itself. You know, the the two and a half percent patch dies. You know, december 31 What are we looking at, boss? We looking at a you know permanent fix, or are we stuck in this one year, you know, patch forever? Well,

Anders Gilberg 6:03
one of the like you know more eventful things that's happened this past week is the introduction of the Patients First Act, which is an important bill. It doesn't address the very near term of the cut in 2027 that the fee schedule implements, but it would address some of the things that I know we'll probably touch on, like the budget neutrality rules in the Medicare physician payment system, as well as just dealing with the fact that, you know, we don't have an association in the physician world in the physician payment system in Medicare with inflation and the inflation measure, often in Medicare for physicians is something called the Medicare Economic Index. So I can talk more about that, but those are some of the problems that again are more legislative to fix, but that are resurfacing in this fee schedule.

Keith A. Reynolds 6:58
So yeah, you brought it up. Let's get to it. You know, budget neutrality is what you're drawing. You know, pushing a lot of these cuts. You know, you guys have been fighting against that forever. So, is this the rule that finally fixes it?

Anders Gilberg 7:12
I don't think it fixes it. It like I it further highlights it, right? And you have winners and losers. There's all kinds of different moving pieces in a rule like this, but certainly dermatology is is going to be hurt under this rule. Different surgical specialties would be hurt under this rule, and some of the sub proposals that are going on dealing with practice expense RVUs and some of the legacy things from last year dealing with work RVUs are still affecting the specialties in different ways, and again, it gets amplified by the budget neutrality requirements. Which I would say this is a continued theme where you're going to always have to rob Peter to pay Paul, and you may have a very laudable reason to increase, let's say, primary care, but again, at the expense of surgical or other specialties, it just-it's not a very effective or sustainable system.

Keith A. Reynolds 8:09
So CMS admits that they're working with you know expense data that's 20 years old. Does the rebuild fix it, or just shuffle that around?

Anders Gilberg 8:20
Well, I'm not sure, candidly, if I see them using any new legitimate data sources to justify the proposals that they have in place. For example, dealing with the measures of that are the inputs for the practice expense RVUs. So, just to refresh, so people know what I'm talking about in Medicare, just like in the RBRVS system, the relative value system, you have work RVUs, practice expense RVUs, and then malpractice RVUs, and the vast majority of work goes into physician work, and then practice expense goes into overhead, and you know a lot of this is relative, which is the relative system we have, and it's almost as I see in this fee schedule and other things that the administration has done. They want to move away from the AMA processes, the relative value update committee, the CPT editorial panel, but they don't really have the data to back it up. So in some ways, you know, their criticism of those processes, which I would remind people, they sit at the table and are not the AMA. It's the specialties sit at the table. It's not just one big monolithic entity. It's the specialty organization sit at the table and talk about the relative aspects of these codes. Well, CMS has indicated they want to move away from it. There's an RFI in this rule that talks about that, that it solicits input. But in in justifying their proposals, they don't really have any support data to support what they're trying to do. They just say they don't necessarily like what you know the AMA has come. With in the last couple years, which I find kind of disingenuous, to be honest, and I think you know it's unfortunate that they don't come up with with their own alternative data sources, but are quick to criticize some of the existing processes. So I guess in short, to answer your question, they don't really present a bunch of new data to fix the problem that they perceive to exist. Instead, they just criticize the current system and then go ahead with the changes that don't have a lot of underlying data underneath it.

Keith A. Reynolds 10:34
Sounds like a theme. So, traditional MIPS dies in 2029. MGMA has called it costly, irrelevant, and punitive. You've called it things that are off the record that you know we're going to keep to ourselves. Is this a real win or is this just the same burden in a fancy wrapper?

Anders Gilberg 10:52
Keith is not a win at all. I mean, yes, we've been critical of MIPS, but MIPS was I again feel like historic. I'm like a history professor these days. I mean, it was only meant to be a temporary bridge when we back in the day, 10 years or more ago, when we repealed the SGR to fix and repair the the Medicare payment system. At the time, it was meant to be a bridge, and then a bridge to allow physicians and physicians practices like our members to get into alternative payment models that had a reward for providing high quality care and reducing costs. So unfortunately, MIPS has just been sort of a reporting exercise, a compliance exercise, reporting quality measures, and it can be punitive, and it kind of it benefits those practices that are good at reporting quality measures more than probably necessarily a direct correlation to care. And insofar as this this rule, it does implement sort of along the next several years, the expiration of MIPS into something called MVPs, value pathways. But what are value pathways? They're just MIPs on steroids. So, and you think about like some of the concerns we have that we're still trying to determine. Like for a typical practice, let's say you know practices are larger now, but let's say a 30 physician practice with multiple physician specialties will, under this new value pathway approach, will all of those different specialties within the practice now have to report a MIPS-like measure set? So a practice might have to report dozens of measures, 100 measures, and just exponentially increase the burden that occurred in MIPS without, after you know all this time, moving these practices into actual value-based care. So we are not the biggest fans of the the value pathway approach. And even though it is an alternative to MIPS, we've been working with Congress and some of the physician specialties, as well as the AMA, at supporting legislation that was introduced by Representatives Miller and Meeks that would have more direct reforms in the MIPS program without pushing it into MVPs, which we feel like is just a you know doubling down on a problematic part of the fee schedule. Hey there, Keith Reynolds here, and

Keith A. Reynolds 13:29
welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at k. Reynolds at mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip, we'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. We do love our acronyms in this business, knowing so small and rural practices are always faring worse in these sorts of transitions. What should they do now, and what is MGMA demanding from CMS for these these you know practices?

Anders Gilberg 14:35
Well, I think like when you think about small practices in general, rural or urban or whatever, you often just you look at a rule that 2000 pages long, in its entirety has all these moving pieces. You know there are all kinds of initiatives with this administration to double down on fraud because we you know that want to fix. Fix the healthcare system by dealing with what I consider much more bad actors than a typical small practice, and it just becomes the cumulative effect of all these policies and cuts to physician payment, or moving pieces, or new modifiers, or new changes to the the practice expense RVUs. It just becomes more and more cumbersome to administer for those practices, and so they're being challenged to do more with less. And this rule does not do anything to address the administrative burden for those practices. So it just creates, you know, the ongoing impact of you know our the payment system remains flat, the payments are relatively flat now for many years, and you know there becomes a breaking point when you have to pay staff, pay rent, and you are solely paid under the physician fee schedule. You know they have to make tough decisions about: should we continue to participate in Medicare? Should we sell our practice to a larger health system, you know, it just this this rule does not do much to, I think, help the trajectory that smaller practices have been on now for several years.

Keith A. Reynolds 16:13
All right. So, like you said, it's you know we're looking at two nearly 2000 pages of you know rule here, what's the sleeper provision in this rule that nobody's really watching?

Anders Gilberg 16:28
Well, there are some positive things, so I'm like maybe a sleeper in terms of this conversation because you know I do think that that there is a renewed focus on the Medicare Shared Savings Program. I think that those are going to be things that we support in the end in our comments. Is it a real sleeper? Again, it's the tinkering under under the hood of this engine that it's not a sleeper because we can identify what they're doing, but again, you know, and their end goal might be laudable, but you know, given the budget neutrality rules, given the way the system works, it does create winners and losers. And so, let's just say for your audience, I would be very interested, depending on what specialty physician practices in what what focus that practice has, you know what codes they bill to just pay attention when when CMS makes these under the hood adjustments they can be quite dramatic and you know there's are new proposals again it's not an unknown thing but there's new proposals dealing with the use of the 25 modifier, for example, which would limit payment in circumstances when a practice does an office visit and a a procedure in the same day, and you know that could be substantial for a dermatology practice, for example. And so it's just very important for your readers and listeners to just be aware that these changes can have dramatic effects, but some specialties will get a slight increase, and some will see a dramatic decrease.

Keith A. Reynolds 18:13
Alrighty, so yeah, you mentioned you know the comments; those are due september 14. You know, what do you think CMS would actually be willing to budge on based on feedback?

Anders Gilberg 18:28
That's a great question. I feel like they've often this administration in particular is kind of set in its ways. I haven't seen a lot of movement so far in the last year's fee schedule in terms of the difference between the proposal and the final, I like for example, I thought they would address something from last year's fee schedule called the efficiency index, which has sorry efficiency adjustment, which is on work RVs that has a substantially negative effect on especially surgical other proceduralists, and I thought they might address some of that in this fee schedule. They did not. They tinkered around with some of the practice expense RVU adjustments from last year, and but I don't think they address some of the underlying concerns that, for example, what last year on the practice expense side, it really hurt those practices that are independent. Let's say a surgical practice where a surgeon has its has his or her own independent practice, where you're still seeing patients, you're still doing pre-op, post-op visits, those kind of things, but then going to do your surgery in a hospital or hospital outpatient department that cut payments significantly for those type of physicians, with the notion that somehow they were being subsidized by the hospital itself. And I thought this rule would address some of that, and it did not. So, I have not seen a lot of course corrections so far with the administration. I hope they do listen to us. They, the first Trump administration, and this Trump administration uses enormous amounts of RFI's requests for information. What they do with that information often is a mystery.

Keith A. Reynolds 20:20
You know, last time or last year, the big cliff was the the the ending of the telehealth rules. It was the you know that that is the game of chicken that Congress had set up. So I want to set up a little bet with you. You know, what's the over under on you know the next problem that Congress sets up for themselves that they will veer off of at the the last minute. You know what's what's the one thing that you expect them to chicken out on by the end of the year?

Anders Gilberg 20:52
Well, I'm not entirely sure they're going to act to avert this cut this year. Like I am, I am concerned about it. There is a history if the cut is kind of, you know, the notion of death by 1000 cuts, like there, which is what we feel, but I think we're going to have to double down and make sure that physician practices and physicians do not receive a cut next year, because these smaller cuts sometimes can be overlooked, and but they're real cuts. They're not like these cuts that you often hear, like maybe the managed care plans talk about that they didn't get an increase like they wanted in the MA rule. These are actual cuts, not cuts in growth rate, and they you know happen at a time when there's an inflation. There's inflation in the industry, so I am concerned about that. That will need to be addressed in the lame duck session this year. I don't expect it before the election, but we will have extenders like every year the work RVU, the geographic adjustments on the work RVU, the cut to the conversion factor, not telehealth because that's a two-year extension that's going on through 2027, but there is work to be done, Keith, and we're going to be back at it here at the end of the year.

Keith A. Reynolds 22:06
All righty, honors. It's always a pleasure, man. And I'm going to get you on here sooner rather than later to talk about MIPS. Love

Speaker 1 22:13
Mips.

Keith A. Reynolds 22:13
All right, take it easy.

Anders Gilberg 22:15
Thanks, Keith.

Austin Littrell 22:29
Once again, that was a conversation between Physicians Practice Managing Editor Keith Reynolds and Anders Gilbert, Senior Vice President of Government Affairs at the Medical Group Management Association, or MGMA. And before we wrap up, a quick reminder that CMS is accepting public comments on the proposed 2027 Medicare physician fee schedule through September 14th. My name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching "off the chart" wherever you get your podcasts. And if you like the best stories that medical economics and physicians practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business of medicine podcast, is executive produced by Chris Maslini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai