25 Jul Arcane CMS Formulas Can Over and Under Pay For ENT Surgical Services
MedicalResearch.com Interview with:
Vinay K. Rathi, MD
Otolaryngology Resident | Massachusetts Eye and Ear
Project Manager | Partners Ambulatory Care
MBA Candidate | Harvard Business School
MedicalResearch.com: What is the background for this study?
Response: This study is a secondary subgroup analysis that follows on the heels of a recently published study in The New England Journal of Medicine (NEJM) examining physician reimbursement for surgical procedures in the Medicare Physician Fee Schedule (PFS), which both public and private insurers use to determine payment rates for clinician services.
Although it is widely understood that physician time (i.e., the amount of physician time required to perform a procedure) is perhaps the most important factor used to determine payment rates, the Centers for Medicare and Medicaid Services (CMS) has historically relied upon limited and potentially biased survey data to estimate physician time.
Leveraging time data from American College of Surgeons National Quality Improvement Program, the authors of the recent NEJM study demonstrated that CMS does not appear to systematically misestimate intraoperative times, but there are substantial discrepancies that may result in over- or undercompensation for certain procedures and specialties.
MedicalResearch.com: What are the main findings?
Response: Using supplemental data published with the NEJM study and publicly available Medicare data, we performed a closer examination of our field – otolaryngology (commonly known as Ear, Nose, and Throat). We found that, between 2011 and 2015, CMS did not appear to over- or undercompensate otolaryngologists for commonly performed procedures overall. However, there were substantial discrepancies between CMS-estimated and actual intraoperative times at the procedure level, which may have resulted in overpayment for some procedures (e.g., parathyroidectomy; $1.7 million) and the converse for others (e.g., cervical lymphadenectomy; $-3.5 million).
MedicalResearch.com: What should readers take away from your report?
Response: We hope that this study gives readers greater insight into the somewhat arcane mechanism by which physician payment rates are determined and ways in which certain providers and their organizations may be disadvantaged by this process. In particular, we hope that additional empirical analysis can support the development of policy protections for head and neck cancer surgeons, who disproportionately care for vulnerable patient populations and may already bear the brunt of inadequate risk-adjustment in the era of value-based healthcare.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Our study invites further analysis of potential payment inequity for surgical oncologists caring for high-risk populations. If, for example, surgeons caring for patients with lung or pancreatic cancer are similarly undercompensated on the basis of time, broader refinement of the PFS may be in order.
MedicalResearch.com: Is there anything else you would like to add?
Response: I would like to thank Dr. David C. Chan and his colleagues at Stanford University, who generously published supplemental data with their remarkable study in NEJM. Dr. Chan was additionally very responsive when I approached him about the possibility of secondary data use. This study was possible as a result of his collaborative spirit
Rathi VK, Miller AL, Bergmark RW, Abt NB, Varvares MA. Valuation of Commonly Performed Head and Neck Surgical Procedures in the Medicare Physician Fee Schedule. JAMA Otolaryngol Head Neck Surg. Published online July 25, 2019. doi:10.1001/jamaoto.2019.1943
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