As they were heading out the door, the Obama Administration decided to scrap a plan to change how Medicare reimburses physicians for administering drugs in their offices. CMS ultimately made the right decision as the changes would have jeopardized patient care and access to life-saving medicines.
While patients are protected from this latest round of price controls, the perverse incentives of Medicare’s reimbursement system are still pervasive with the brunt being passed along to patients in the form of misutilization of resources, restricted access, lengthy wait times, and compromised care. One policy that has produced an array of unintended consequences is that Medicare has historically refused to reimburse physicians for non-face-to-face care.
Non-face-to-face work is an integral part of medicine and is particularly important for primary care doctors such as myself. It includes activities such as speaking with patients on the phone, emailing patients, following up lab results, talking with families, coordinating care, consulting with specialists, refilling prescriptions, completing paperwork.
Primary care physicians (PCPs) spend a considerable amount of time on these tasks. Research in the Annals of Family Medicine concluded that PCPs spend 39% of their work day outside the exam room working on patient related activities. A study in the Annals of Internal of Medicine discovered that every thirty minute visit generated 6.7 minutes of additional work.
These activities are essential to a well-functioning, patient-centered health care system. While lawyers, consultants, and accountants would get paid for this type of work, historically physicians have not.
Ironically, this policy designed to save money can have some costly implications for patients and taxpayers. It means some of these important non-face-to-face activities do not happen as they should or as patients would like. It also means when they do occur, they may happen at a higher, more costly setting than medically necessary.
For example, this policy likely pushes conversations such as a follow up of lab results or follow up of symptoms that could occur over the phone or by email into an office visit. For patients this means they must take time off from work to go to the doctor. This wastes time on travel to and from the doctor’s office, waiting, and the length of the visit, which decrease worker productivity. It also takes away a valuable appointment slot from a patient who needs to be seen in person.
At the same time, this policy likely pushes care that requires urgent subspecialty input that could be managed in the outpatient setting via phone consultation with a specialist or at an urgent specialist visit to the Emergency room.
Research I coauthored, in the American Journal of Medicine explored non-face-to-face medical care and recommended three potential solutions. One possibility would be the creation of Current Procedural Terminology codes for e-mail and telephone encounters. Another would be to let doctors bill insurers for the time devoted to non-face-to-face care. A third option would be to determine the average time per month that a doctor dedicates to each patient outside of the exam room and assign this a per-patient monthly value. The latter would likely be the simplest to implement while the second option would better meet the unique individual needs of patients.
In recent years, CMS has dabbled in reimbursing physicians for non-face-to-face care, but its overly regulated, complex, and stringent approach has limited use and benefit.
Reimbursing doctors for work that they do outside of the exam room is good medicine. It would lead to an increase of email and telephone encounters. This would decrease unnecessary trips to the doctor and eliminate visits that could be handled in other ways. It would also reserve office visits for those who truly need to be seen in person. This would improve patient access and more efficiently use resources. It would also foster a health care system that would be more satisfying for doctors and patients. It would likely attract more young doctors to primary care and also help to alleviate the primary care physician shortage. It could even save the taxpayers money.
Medicare’s recent decision to drop the reimbursement changes was a win for patients. Hopefully, the new administration will look to reform the faulty physician reimbursement and the unintended consequences it has for patients. The reimbursement of non-face-to-face work would be a good place to start.
Jason D. Fodeman, MD, MBA is a practicing primary care physician. He specializes in delivery systems and health policy