Advocating Against 2021 Medicare Cuts

Update

As part of the COVID relief and end-of-year package, Congress offset the majority of cut to Medicare reimbursement that was expected to take place on January 1, 2021. CMS just published the new Physician Fee Schedule (PFS) conversion factor—which converts code values into dollar amounts—based on that legislation, and instead of that original 10.2 percent cut, a service performed in 2021 will now be paid only 3.3 percent less than what it was paid in 2020. However, because ACEP was able to secure that increase in the code values by CMS for our ED E/M codes, you will likely not see any of that decrease. In fact, you may actually see an increase in your Medicare payments overall (and remember, many private payors base their payments on Medicare rates).

This is the result of years of work ACEP has done to increase the value of certain EM codes, described below. 

Background

One of the leading legislative and regulatory priorities for ACEP has been preventing the cuts included in the final Medicare PFS for 2021, which were set to take place on January 1. This regulation from the Centers for Medicare & Medicaid Services (CMS) sets Medicare payment rates for the coming calendar year (CY), and often serves as the basis for which many private payors set their reimbursement rates. You can find a high-level summary of the final rule here. 

ACEP knew ahead of time that CMS was planning on including these cuts in the PFS and took action. When CMS announced last year that it was seeking to revalue the office and outpatient evaluation and management (E/M) codes for CY 2021, ACEP advocated strongly for corresponding increases for the ED E/M codes—the most commonly billed codes for emergency medicine. These efforts built on our advocacy to the American Medical Association’s RVS Update Committee (RUC). ACEP also provided data and a solid policy argument to directly to CMS and the White House to strengthen our case. That advocacy paid off, and CMS adopted our specific code values for the ED E/M codes, which increases emergency medicine reimbursement by approximately 2 percent for CY 2021.

Unfortunately, a large increase to primary care E/M codes that CMS finalized last year also takes effect in 2021. Because of the existing budget neutrality requirement under the Medicare PFS, any increases in the value of one code means a corresponding decrease in the value of all other codes.  Thus, in the final PFS regulation, CMS cut the conversion factor, which changes code values into a dollar amount, by 10 percent in CY 2021, one of the largest cuts in 25 years. Essentially every specialty got a “haircut,” reducing some codes’ increases and exacerbating other’s decreases.

ACEP’s advocacy for the increase for the ED E/M codes staved off a bigger reduction in value. Basically, ACEP got you a raise, but CMS budget neutrality rules cancelled it out. Overall, instead of a cut closer to 10 percent, CMS estimated that the cut to emergency medicine would be 6 percent. 

A projected 6 percent cut to emergency medicine in 2021 was unacceptable. ACEP worked closely with legislators and other physician and non-physician groups affected by the rule to push for a solution that protected physicians from such drastic cuts–especially when many emergency physicians still face unprecedented financial hardships and instability due to the COVID-19 pandemic.

ACEP Advocacy

• ACEP put out a statement to the press expressing our deep concerns around the final rule, which CMS released on December 1, 2020. 
• Less than 20 hours after CMS released the proposed rule, ACEP sent a letter to Congress requesting that it waive the budget neutrality requirement, since it is the only entity with authority to do so. ACEP’s letter to key congressional committees expresses our strong concerns on this proposed cut and notes the unprecedented strain emergency physician practices already are facing due to the ongoing COVID-19 pandemic.
• ACEP responded to CMS’ proposed rule impacting Medicare physician payments for 2021. (For a summary of ACEP’s comments, please click here, and for ACEP’s full comment letter, please click here.) In our comments, we lay out the specific impact that a -6 percent reduction would have on patients’ access to emergency care, highlighting how COVID-19 public health emergency (PHE) will exacerbate the effects of such a reduction. We also make the following three policy recommendations:
  • To account for the additional expenses that hospital-based clinicians must absorb when treating patients during the COVID-19 PHE, ACEP strongly urges CMS to implement a 20 percent COVID-19 professional services claims-based payment adjustment.
  • ACEP urges CMS to delay the implementation of the add-on code for complexity (GPC1X) to CY 2022 or later or to possibly consider eliminating the code altogether.
  • ACEP recommends that CMS and the Department of Health and Human Services (HHS) utilize its 1135 waiver authority under the COVID-19 PHE to waive the budget neutrality requirement for all of CY 2021.

Prior Legislative Activity

• On December 3, the House Doc Caucus sent a letter to Speaker Pelosi and Minority Leader McCarthy to pass legislation to avoid the cuts.
• Representatives Ami Bera, MD (D-CA) and Larry Bucshon, MD (R-IN) introduced their own bipartisan bill on October 30, the “Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020,” which would maintain physicians’ reimbursement at 2020 levels – if they were otherwise scheduled to receive a payment cut. The temporary, additional payment would be for two years (2021 and 2022). ACEP, along with a coalition of organizations representing physicians and allied health professionals including the AMA, sent a letter to congressional leaders in support of this legislation.
• Introduction of the bill follows a letter spearheaded by Reps. Bera and. Buchson and signed by a bipartisan coalition of 229 House members to Speaker Nancy Pelosi (D-CA) and Minority Leader Kevin McCarthy (R-CA) urging them to blunt Medicare pay cuts scheduled to begin on Jan. With more than half of the House of Representatives signing the letter, this represents a strong showing highlighting the outreach efforts of emergency physicians and other health care professionals.
• On October 2nd, Representatives Michael Burgess, MD (R-TX) and Bobby Rush (D-IL) introduced bipartisan legislation, 8505, to prevent pending Medicare payment cuts by waiving budget neutrality requirements.
• On the Senate side, Sen. Steve Daines (R-MT) sent a letter to Majority Leader Mitch McConnell (R-KY) and Minority Leader Chuck Schumer (D-NY) on Oct. 26 urging them to prevent the Medicare payment cuts as well. He stated his concerns about these cuts placing a further strain on Montana’s health care system and practitioners who are already stressed by COVID.

Congressional Fix

In the year-end package, Congress instituted the following two provisions which will reduce the cut to emergency medicine:

• Added an additional $3 billion to the PFS to increase fee schedules by 3.75 percent in 2021.
• Adopted ACEP’s recommendation and instituted a 3-year moratorium on implementation of G2211 (formerly GPC1X) complex patient add-on code until January 1, 2024 (at the earliest).

These two changes—in addition to the increases in the ED E/M codes that ACEP secured—means that instead of a 6 percent cut on January 1, emergency physicians will see at worst a 2 percent reduction in reimbursement. But depending on their code mix, some may even see an overall positive increase. In other words, the raise that ACEP helped get for emergency physicians in the PFS may actually now come to fruition.