Mary Rhee with patient

The proposal to cut physicians’ pay and bring more clinical oversight into nursing homes has not taken into account that critical patient care and therapies will decline, advocacy groups are warning. 

The Centers for Medicare & Medicaid Services received more than 12,000 comments to its July proposal to cut the physician pay rate by 3.3%. The 2024 draft rule would reduce a key annual rate-setting factor by 3.34%, which would affect doctors working in nursing homes and other long-term care settings. It also would significantly reduce pay for therapy services. 

“The ongoing regular reductions to reimbursement under the [Physician Fee Schedule] pose an existential threat to ADVION members’ ability to provide patient access to care across the country, and especially in rural areas,” ADVION said in a deft version of its comments, which were provided to McKnight’s Long-Term Care News on Saturday. “These reductions are not without impact, and we do not see any mention by CMS of the impact on the patient that these reductions will render.”

Congress included a 3% offset to conversion factor cuts for 2023 and planned another 1.25% offset for 2024 in the 2023 Consolidated Appropriations Act. That would still leave a reduction of about 2.1%. The deeper pay cut for 2024 comes as CMS looks to shift more of its overall budget to primary care providers through use of a new complexity code. When primary care docs get more, budget neutrality rules require the agency to reduce spending elsewhere.

ADVION, formerly the National Association for the Support of Long-Term Care (NASL), said it opposes the reduction in the conversion factor and wants the agency to mitigate its reduction. Arguing that “cuts have ramifications,” the association’s comment lays out trend data showing how occupational therapy services have not kept up the cost of inflation since 2013. This is particularly felt in rural and other high-cost areas where providers are faced with accepting steep cuts or pulling back services, the comment noted. 

“We agree that companies should be competing to hire the American workforce — but undercutting the reimbursement that supports that competition has a deleterious effect on our ability to provide needed care,” said ADVION Executive Vice President Cynthia Morton, adding that declining reimbursements make it hard for members and diagnostic testing companies to attract workers and compete against non-healthcare workplaces. 

New training payment

There are some potentially positive aspects of the proposed rule, including the inclusion of three, first-ever payment codes for caregiver training related to certain diseases, including dementia, when provided by a doctor, therapist or other practitioner in skilled nursing settings.

The codes can be used to bill for training when a practitioner “believes the involvement of a caregiver is necessary to ensure a successful outcome for the patient and where, as appropriate, the patient agrees to caregiver involvement,” explained  Renee Kinder, MS CCC-SLP, RAC-CT, who was part of the panel that developed the codes.

The codes cover training for functional performance related to activities of daily living, transfers and mobility, swallowing, communication and more. It includes payment even when the patient is not present.

“During intervention, caregivers are taught how to facilitate the patient’s activities of daily living, transfers, mobility, communication, and problem-solving to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life and assist the patient in carrying out a treatment plan,” Kinder said.

Key review of codes coming

CMS is also planning a revaluation of 19 core therapy codes that were eliminated in fiscal 2018 in an effort to reduce duplication of services. But several therapy groups say that move was made in error and restoring the codes could help blunt the 2024 cuts. 

While that review has to be conducted by the American Medical Association and accepted by CMS, it is unclear whether a correction could be in place by the time the January rates take effect. Still, ADVION said in its comment that the review is worth the undertaking, going so far as to encourage CMS to suspend the Multiple Procedure Payment Reduction until the review is completed. 

LeadingAge, which provided excerpts of its comments to McKnight’s on Friday, cheered the activation of caregiver training services (CTS) codes for the Physician Fee Schedule. 

“Informal, unpaid caregivers are critical members of the interdisciplinary team for older adults and play an increasingly important role in supporting older adults who choose to age at home,” the association said, adding that the agency should expand the codes to include non-billing staff such as social workers and nurses, under the supervision of a billing practitioner.  

Currently, CTS is limited to being used once per year per caregiver, which is insufficient to meet patient and caregiver needs, especially in the event of unexpected hospitalizations and other crises, the group said. It recommends allowing the codes to be billed quarterly or where there is a change in a patient’s care plan, and also adding the codes to the Medicare Telehealth Services List to support caregivers who work full- or part-time jobs. 

LeadingAge also supports CMS’s proposal to add marriage and family therapists (MFT) and mental health counselors (MHC) as eligible providers for Medicare-certified hospices’ interdisciplinary teams but did express concerns with recent agency comments that, it said, contradict the intent of the rule itself. On the August Open Door Forum, CMS staff suggested that hospices would have to employ or contract with all three disciplines: social workers, MFTs and MHCs but the legislative language says the modification allows for MHCs “or” MFTs to be part of the interdisciplinary group.

“The rule does not say that these professions are required or mandatory, which would be a significant burden for hospice providers and nearly impossible to comply with,” LeadingAge said, noting that many states have a limited number of therapists. “We ask that CMS finalize the rule with clear language stating that hospices may use MFTs and MHCs as appropriate but underscore that it is not a requirement to make them available, even when counseling services are in the plan of care.