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Primary Care is Center Stage Again
Congress weighed in on healthcare delivery last week
Dana Prommel Strauss
May 24, 2024
Hi there, friend!
Check out this newsletter I enjoy every week, written by one of the founders of Beehiiv and sponsoring the newsletter:
I’m stuck at Nashville’s airport waiting for storms to pass as I start drafting this. Better than flying in lightening! ✈️🌩️ 🫣
While sitting here, I was scrolling Linked In and I had my daily wake-up call that so many healthcare professionals are heads-down in their work silo and may be missing the big 🖼️.
Dana to the rescue !!🛟
Congress is thinking about some big healthcare issues now. What’s the priority to fix? Fund? Tackle? Extend?
What will they legislate in and perhaps before the lame duck session, and what waits until next year and Congress?
A panelist reminded the audience at a conference today that, besides the healthcare delivery issues I’m tracking, Congress needs to address the SUPPORT Act and PAHPA.
They will hopefully and are likely to extend and fund telehealth, plus extend hospital at home.
Then we have the bipartisan Senate Finance Committee interest in MACRA reform, primary care payment reform, and larger physician payment reform.
Don’t forget about rural payment reform, which Senate Finance had a hearing on last week.
All of these big issues need “pay-fors,” of course.
Why does this matter?
Besides Congress doing this work on a bipartisan basis, the CMS Innovation Center has put out a number of models this year, many aimed at improving primary care provider reimbursement through prospective and enhanced payment, funding e-consults, funding infrastructure growth, and more.
Last year, they added a number of Physician Fee Schedule (PFS) codes that practices can use to be reimbursed for services not previously covered under the PFS like Community Health Integration, Principal Illness Navigation, and Caregiver Training codes.
AND, G2211 was implemented. This is an add-on code for Evaluation and Management visit complexity, which will mostly be used in primary care settings. Note: CMS finalized this policy in 2021, but Congress suspended its use and prohibited CMS from implementing it before 2024.
But Congress didn’t suspend it again, despite strong opposition by organizations like The American College of Surgeons. This is telling.
This code alone had a major impact on shifting spending from other areas of the PFS to primary care.
Below are some samples of the largest impacts to physician fee schedule payment for calendar year 2024, from Table 118 of the PFS Final Rule on the “Estimated Impact on Total Allowed Charges by Specialty.” Caveats: I used a few different data sources (not all information on Indeed.com made sense). These are estimates, averages, nationwide, and should be considered ballparks provided to demonstrate a relative differences in salaries compared to relative increases and decreases.
Also keep in mind that Congress partially “fixed” the conversion factor cut for 2024, so the below are the final PFS cuts before Congress passed a funding patch.
Specialty | Impact of Conversion Factor Cut (allowable charges and RVU changes) | Average Annual Income (source: Indeed.com unless specified, where Indeed didn’t have data) |
|---|---|---|
Clinical Psychologist | +2% | $211,726 |
Clinical Social Worker | +2% | $94,158 (Zip Recruiter) |
Family Practice Physician | +3% | $260,707 |
Nurse Practitioner | +2% | $125,614 |
Interventional Radiology | -4% | $588,471 (source: Chron.com) |
Nuclear Medicine | -3% | $372,031 (source: Salary.com) |
Radiology | -3% | $457,290 (source: Salary.com) |
Vascular Surgery | -3% | $447,231 (Salary.com) |
Physical and Occupational Therapy | -3% | $101,301 and $98,762 (Salary.com) |
As you can see, the second and third lowest-paying provider types on this list both had a 3% cut (PT/OT). Other specialties on the “cut” list all have an “average” salary of over $372,000.
Primary care and behavioral health providers had increases (both are also key members of primary care teams).
The Administration and the bi-partisan members of Congress in arguably the most important Committee of Jurisdiction of healthcare delivery, the Senate Finance Committee (as well as others, including in the House), are interested in “fixing” physician (and those paid in the physician fee schedule) payment in Medicare. And where Medicare FFS goes, other payers follow.
Top Takeaway for healthcare professionals:
It’s a great time to demonstrate your value to primary care providers and practices, and to health systems that employ them.
Healthcare funding is shifting to the primary care space. As it absolutely should be (and as written about several times in other articles) like here and here.
Government-funded programs like the Physician Fee Schedule are inherently budget neutral.
That means shifting dollars in one direction and shifting dollars away from other directions.
If you are a healthcare professional not presently being viewed by policymakers as primary care team members but you believe should be, now’s the time to show that you are and why you are!
In general, healthcare professionals who provide direct access to care in the outpatient setting:
Get. On. The. VBC. Train.
Why am I bringing this up today?
I read and understand healthcare professionals, like those in my own physical therapy profession, lamenting their frustrations online. I hear you. I feel you.
I couldn’t afford to practice as a PT and live in Northern NJ! (And I don’t even have school loans to worry about anymore.)
Therapists are one of the doctorally prepared, non-physician and non-APP health care professionals providing high-value (neuromusculoskeletal, in the case of PTs) care.
Physical fee schedule cuts you saw again this year, PTs?
As I noted above, that was part of the redirecting of budget dollars to primary care services.
This is where you should be focused in advocacy.
Prove your value. Prove it to advanced primary care practices and plan sponsors and employers. We willing to take accountability for the patient outcomes your services help drive.
Show policymakers you should sit on primary care teams (just like behavioral health providers). That you can and should play a role managing patients longitudinally and in reducing total cost of care. For PTs, for example, that you can help address our orthopedic spend, as one glaring example.
Consider this from McKinsey in September, 2023:
Orthopedic care is among the most prevalent, most expensive, and fastest-growing categories in US healthcare. More than one-third of Americans received orthopedic care in 2021, making it the largest expenditure category for beneficiaries of employer-based insurance and the second-largest for Medicare. We estimate that the annual direct cost of healthcare for orthopedic conditions totals $350 billion to $400 billion,1 or roughly 10 percent of total US healthcare spending. And it is on track to grow rapidly in the coming years as the US population ages.
Despite how prevalent orthopedic care is, treatment patterns vary substantially and do not always align with known best practices.2 For example, prior McKinsey research found that roughly half of patients receiving surgery for lower-back pain did so within three months of diagnosis, while evidence-based guidelines recommend surgery within this time frame only in emergency circumstances.3 This variability can have a meaningful effect on patients because care that deviates from evidence-based clinical guidelines can expose patients to the risk of medical complications and increased out-of-pocket costs.4
The best place to address MSK pain and impairments first?
Right in the primary care practice with the right provider at the right time.
It’s not just rehab professionals that can and should be playing a role in:
providing advanced primary care,
supporting accountable care, and
addressing patient needs within the primary care setting.
Pharmacists are another great example of a doctorally prepared healthcare professional type whose value is not nearly being realized.
How did we get here?
Fee-for-service, the American health system hierarchy, public perception, politics, and more.
So to the direct access, often doctorally prepared healthcare professionals reading this:
Redirect efforts and resources in advocacy to demonstrating your value
to expand the primary care workforce.
to contribute to moving from transactional fee-for-service primary care to advanced primary care.
to prevent unnecessary, high-cost specialty care spend.
to collaborate with specialists via e-consult.
in accurately and safely determining when a patient needs advanced imaging (PTs)—the military has demonstrated this already.
to improve access to underserved beneficiaries unlikely, unable, and/or unwilling/resistant to making appointments outside of their trusted primary care practice
to reduce the use of opioid prescriptions to treat pain
and so much more.
Check out my guest appearance on Jerry Dunham’s podcast!
Until next time,
Dana