physician with patient
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A proposed 3.3% cut to physician pay would threaten access to care and efforts to bring more clinical oversight into nursing homes, advocacy groups are warning.

A 2024 draft pay rule issued by the Centers for Medicare & Medicaid Services late Thursday would reduce a key annual rate-setting factor by 3.34%. That would hit doctors who work in nursing homes and other settings while also making substantial reductions to therapy pay.

Skilled nursing providers and others are slated to see their pay adjusted for inflation. But neither physicians nor therapists get such accommodation and that creates annual fights to stay afloat.

“That’s at the heart of this: There’s already a shortage of primary care physicians and geriatricians,” Alex Bardakh, senior director of advocacy and strategic partnerships at AMDA – The Society for Post-Acute and Long-Term Care Medicine, told McKnight’s Long-Term Care News Friday.

“It’s very difficult to get physicians and other clinicians to come into the [nursing home] buildings,” he added. “Certainly, cuts to their Medicare reimbursement can only exacerbate that.”

While doctors’ rates would be slashed across the board, those reductions could be felt more severely by those at the bottom of the pay scale. That would include internists and general practitioners who commonly round in the skilled nursing sector, Bardakh noted.

The American Medical Association Thursday called another year of rate cuts “almost biblical” in their impact, adding that Medicare physician pay has declined 26% since 2001 when adjusting for inflation. 

‘Extremely difficult time’

If finalized, the new rates and related rules would go into effect Jan. 1, 2024, adding to an “extremely difficult time” for therapists, said Cynthia Morton, executive vice president of ADVION, which represents therapy and other ancillary service providers in the skilled sector.

“We’re in an inflationary period, and costs have gone up and we can’t find people to work at nursing facilities,” she said. “We can’t minimize the conversion factor cut, and that we’re going to need Congress to help us.”

Congress in the 2023 Consolidated Appropriations Act included a 3% offset to conversion factor cuts for 2023 and planned another 1.25% offset for 2024. That would still leave a reduction of about 2.1%, and Morton and other advocates will again appeal to lawmakers for relief.

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. 

A possible silver lining

CMS said it will allow the revaluation of 19 core therapy codes that were reduced in fiscal 2018 to account for possible duplication of services, a change several therapy organizations believe was made in error. Restoring those cuts could help blunt the impact of 2024 cuts, said Kate Gilliard, director of health policy and payment with the American Physical Therapy Association.

“We don’t really know how much of an increase it’s gonna be, but it could potentially offset the cut to the conversion factor,” she said. “They are the bread and butter of therapy codes: therapeutic activities, therapeutic exercises, neuromuscular reeducation. These are the codes that we bill the most often.”

Gilliard and Morton praised CMS for moving on the review, but because it has to be conducted by the American Medical Association and accepted by CMS, it’s unclear whether a correction could be in place by the time January rates kick in.

New training payment

One “exciting” element of the pay rule, notes Renee Kinder, MS CCC-SLP, RAC-CT, is 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 Kinder, executive vice president of clinical services at Broad River Rehab. 

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,” added Kinder, who was part of the panel that developed the codes.

Gilliard said APTA also had advocated for the caregiver training codes, along with groups representing occupation and speech language therapists. It can be billed at full value, with no deductions for overlapping services if a therapist is also providing a patient session that day.

Overall, Gilliard said the proposed rule was a fairly good one for therapists.

“I have not seen anything negative aside from just the conversion factor, and that’s gonna impact all of our codes. But we haven’t been singled out for anything negative,” Gilliard said. “In fact, aside from the conversion factor cut, almost everything in the rules is positive for therapy.”

That includes the extension of telehealth flexibilities through 2024 as allowed by Congress, a condition that was not a given this rule-making season. CMS could have ended flexibility for therapists working in nursing homes in 2023 or not granted telehealth access in all settings.

“They’ve turned around their interpretation, which is really good news for patients because of the shortage of therapists,” Morton said. “Telehealth is making a difference in terms of continuing access through these services.”