The cut included in the 2024 Physician pay rule, which was finalized by the Centers for Medicare & Medicaid Services in November, affects doctors working in nursing homes and other long-term care settings, as well as pay for therapists and other ancillary services. 

In the last few years, Congress has moved to offset similar reductions, which don’t necessarily reflect true costs of physician services but are required if CMS decides to put a greater share of its funding toward other types of care.

The ongoing regular reductions to reimbursement are “an existential threat” to the long-term care sector’s therapists and other providers who bill Medicare Part B, said Cynthia Morton, executive vice president of advocacy group ADVION, earlier this year.

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. But bills that would help make that 2024 change more significant have not moved forward yet this session. 

Morton told McKnight’s Long-Term Care News that the next best opportunity for a fix is  ahead of the government funding expiration on Jan. 19.

“Whatever funding vehicle will be advanced to continue that, we want to have our Physician Fee Schedule patch attached to that,” Morton said. “It’s important that Congress deal with this patient issue in January because the reductions will have already gone into place on Jan. 1.” 

Looking for silver linings

A rate correction could be made retroactive, as has happened in the past.

While ADVION and other provider groups are still advocating for a full 3.7% patch to address the cut, the Senate Finance Committee has so far passed a 1.5% patch and the House Committee on Energy and Commerce passed a 1.25% patch.

Bills that could be a vehicle for the patch are: the Preserving Seniors’ Access to Physicians Act of 2023 (H.R. 6683), which would eliminate the 3.37% conversion factor reduction; and the Strengthening Medicare for Patients and Providers Act (H.R. 2474), which would add a permanent payment update to the Medicare PFS that is tied to inflation, as measured by the Medicare Economic Index.  

There also was a bipartisan letter of almost 200 House members sent to House and Senate leadership asking them to end the 3.37% reduction, Morton noted.

Meanwhile, the American Medical Association, which represents physicians and physician practices, has warned that Congress’ inaction so far could force some providers to cut office hours or forgo treating Medicare patients.

On Monday, the AMA recommended that lawmakers transfer about $1.8 billion from the FY 2024 National Defense Authorization bill to cover the cut. It includes $2.2 billion in money shifted from the Medicare Trust Fund to a Medicare Improvement Fund, which would be more than enough to stop the cuts.

“Facing a nearly 10% reduction in Medicare payments over the past four years and rising practice costs on top of the burdens and burnout of three years of COVID-19, for many physicians, continuing down this road is unsustainable,” said AMA President Jesse M. Ehrenfeld, MD, MPH. 

“These cuts will be felt first and hardest in rural and underserved areas that continue to face significant healthcare access challenges. Medicare physicians do not receive inflationary payment updates, which is why eliminating these cuts is so crucial.”

Many nursing home COVID-19 patients would have benefitted from daily, reimbursed-for physician visits in their skilled nursing facilities, but they were not entitled to them. 

With an epic crisis still at hand, the quickest way to improve performance and public perception of nursing homes is to introduce daily covered visits.

Astonishingly, Medicare and Medicaid suggest that an attending physician visit skilled nursing patients only once every 30 days, generally limiting coverage to that amount. CPT attending codes 99307-10 reimburse approximately $85-$126 for physician follow up visits, depending on the geographic region. Medicaid’s physician reimbursement rates are far lower than Medicare’s physician payment. In California, for example, Medicaid pays a doctor approximately only $38 per monthly skilled nursing center visit.

Medicare and Medicaid physician visitation frequency and reimbursement fees are woefully inadequate. 

Comparing visits over time

The 30-day governmental allocation for physician visits is a relic of the old 1970s model for skilled nursing centers, when residents were predominantly chronic, long-term patients, at low-activity levels, with few changes of condition. By contrast, today the SNF patient population is increasingly at a high-need level. These SNF patients require complex care, as demonstrated by their PDPM scores.

In the 1990s, many of these patients would be at acute hospitals, given their comorbidities. Although patient needs have grown complex, Medicare reimbursement for physician visits remains fixed at only once for each 30-day period.

An acute hospital Medicare reimbursement — the basis for a standard of practice — calls for daily physician visits and the primary driver of patient care is a physician. On the other hand, in skilled nursing, when physicians do not see patients as frequently, more responsibility falls upon nurses. To improve care, Congress or the Centers for Medicare & Medicaid Services need to authorize daily skilled patient physician visits, at the same frequency and reimbursement levels as physician visits in acute hospital settings.

ACOs already allowing daily visits

Notably, managed-care IPAs and ACOs recognize the importance of daily physician visits for nursing home patients. For example, Healthcare Partners, a managed-care pioneer, acquired by OPTUM, initiated a model calling for staff physicians to see each SNF patient on skilled level services on a daily basis as early as 1992. 

The Healthcare Partners model has two distinct advantages. First, daily, on-site physician visits can prevent potentially unnecessary hospitalizations. Second, daily physician intervention does result in shorter patient length of stay and improved outcomes.

Other leading IPAs such as Regal Medical/Heritage have already adopted these practices. Medicare ought to similarly adopt these practices.

Some sophisticated physicians successfully bill for visits several times per month on new admits by identifying change of conditions or creating new face sheets based on secondary diagnosis. While guidelines appear to allow billing in some instances more often than monthly, as a practical matter, doctors have difficulties ever collecting from intermediaries for these extra visits.

The standard medical and billing practices are still based on the monthly visits, particularly for Medicaid patients, who constitute the overwhelming majority of patient census. Some nonprofits and select facilities already have a single staff physician who sees all patients as needed, but even these models would vastly benefit if Medicare and Medicaid reimbursed for such daily visits.

As veteran hospitalist Mohamad Faruki, M.D., of Orange, CA, explains, “During the COVID-19 surge in California, we had no space at the acutes. We successfully provided treatment for patients in skilled nursing facilities, with the same protocols we would have utilized in the acute, except that we were not paid for daily visits. If we could initiate daily visits and be reimbursed for them, we could save Medicare considerable resources and funds by reducing LOS and preventing rehospitalization.”

Medicare and Medicaid already allow daily visits for LTACHS and sub-acutes

Daily physician reimbursement for visits outside the acute hospital is already allowed in some settings. Physicians can bill for daily patient visits at LTACHS. Many patients’ medical profiles at LTACHS closely resemble those of complex patients at skilled nursing centers, leading to incongruous results.

For example, doctors are paid daily by Medicare to visit their ventilator-dependent patients at an LTACH, but only once per month for ventilator-dependent patients at a skilled nursing center. Skilled nursing centers serving complex patients deserve to stand on equal footing with LTACHs. Skilled nursing facilities should also be entitled to reimbursement for daily physician visits, at least for high-need patients.

Another context where physicians are reimbursed for frequent visits is under state Medicaid subacute programs. In California, skilled nursing centers can contract with Medicaid for care of subacute, such as complex tracheostomy or ventilator-dependent patients. Under these programs, Medicaid requires pulmonologist visits several times a week during the initial 30 days after admission and at least weekly intervals thereafter. These specialized programs acknowledge the great value of frequent physician interventions. They recognize daily physician visits pay for themselves by shortening lengths of stay and reducing hospital readmissions.

Daily visits will improve COVID-19 care

Enhanced physician involvement in skilled nursing centers will also raise educational levels and promote learning opportunities for front-line nurses. Importantly, infection control practices and treatment of early-stage COVID-19 disease would dramatically improve. Increased physician visits will also help skilled nursing centers struggling with post-COVID occupancy declines improve their marketability and census, and protect facilities against baseless litigation.

Practical proposals for daily physician reimbursement

Practical proposals for payment of daily SNF physician visits can be implemented through four alternative options under which Medicare and Medicaid would: 

• Pay for all daily visits for skilled level SNF patients at 80% of the allowable acute hospital fee schedule.
• Pay for all daily SNF visits for at least the first 30 days of a covered stay.
• Pay for weekly visits for all patients, including those at custodial levels.
• Pay for daily visits for all higher-level PDPM patients receiving skilled Medicare services.

Politically, the climate has shifted as to COVID-19 relief. The Biden administration appears less inclined to propose direct relief for providers than the previous Republican regime. Indeed, Biden’s $1.9 trillion relief bill largely did not include direct provider assistance. Hence, requesting additional funds for a third-party – not for skilled nursing operators – but for physicians, is an “ask” more likely to be granted. 

Likewise, at the state level, the latest relief bill channels extra funding to Medicaid programs. Some of these new resources should be directed to physician SNF services. ACHA, Leading Age and consumer advocacy groups, as well as the American Medical Association, must unite and form a coalition together to encourage states, Congress and CMS to affirmatively respond: “Yes, the doctor is in.”

Kenneth Lehmann, J.D., is the founder and operating partner of  an 11-facility skilled nursing chain with locations in Californica’s Orange, San Bernardino, and LA counties.

The research, led by a team at the Perelman School of Medicine at the University of Pennsylvania, analyzed Medicare claims by physicians, nurse practitioners and physician assistants to determine how many billed at least 90% of their episodes from a nursing home.

The study’s findings, published Tuesday in JAMA, showed the number of physicians focusing on nursing home care grew by more than a third (33.7%) between 2012 and 2015 — from 5,127 to 6,857. That can be translated from 3.35 specialists per 1,000 occupied nursing home beds to 4.58.

The increase may be spurred in part by providers looking to improve quality in order to adhere to stricter federal guidelines, suggested lead researcher Kira L. Ryskina, M.D.

“Hospitals in recent years have sought to improve care by concentrating it among ‘hospitalist’ physicians who focus on treating hospitalized patients,” Ryskina said. “Twenty years ago, the hospitalist movement started in the same way, wherein hospitals were under pressure to reduce costs, and readmissions. We might be seeing the beginnings of a similar trend in nursing home care.”

In total, 21% of all nursing home clinicians specialized in nursing home care in 2015.

While the study found some regional variation in the increase — around 80% of regions saw increases in nursing home specialists per bed, while 20% did not — the results show the start of a trend that shouldn’t be overlooked, Ryskina said.

“The impact of that trend on patient care may already be considerable, though, because specialists provide a disproportionate share of the care,” she noted.

Whether or not the increase in skilled nursing specialists improves care outcomes or affects the continuum of care will require further study, researchers said.

It is the first senior living community in Tennessee to partner with a medical group and offer a walk-in clinic for residents, according to Dahlen Jordan, the administrator at The Heritage at Brentwood. Services include physicals, electrocardiograms, lab testing, steroid injections, antibiotic prescriptions, suture removals and ear wax cleanings. Additionally, the clinic will offer flu, shingles and pneumonia vaccinations.

Life Care Services manages senior living communities in 29 states.

The news could provide a jolt to any long-term care providers mulling new electronic health record implementation rules. Those using incompatible or uncertified EHR systems by the end of 2018 could face reduced Medicare reimbursements under a bill introduced in late March in both houses of Congress.

More than a million participating physicians received more than $382 million in so-called incentive payments from the PQRS and e-prescribing programs in 2013, according to the CMS report. Among the 460,000 physicians who opted out, nearly half treat 25 or fewer Medicare beneficiaries a year, according  to CMS. Sixty-five percent of PQRS eligible general practitioners failed to participate in the program or meet its requirements, Modern Healthcare reported.

Medicare quality improvement program participants who aren’t meeting meaningful use requirements for EHR systems could face penalties as early as this year.

University of Georgia investigators say they discovered a direct link between elder loneliness and the frequency of visits to physicians, many of whom elders bond closely with to curb their anxiety. Study co-author Kerstin Gerst Emerson, Ph.D., an assistant professor of health policy and management, said she and fellow researchers assumed that elders in declining health fueled greatly by loneliness would naturally have higher numbers of physician visits. The purpose of the study was to determine if those extra visits were made because the elders were actually lonely.

The study was published online in the American Journal of Public Health.

Researchers deliberately avoided studying subjects in long-term care settings. Instead, they worked with data from the 2008 and 2012 University of Michigan Health and Retirement Study, a national survey of Americans over the age of 50, according to published reports. Researchers queried more than 3,500 individuals 60 and over within the surrounding community, focusing on issues about the lack of companionship and feelings of isolation.

The repercussions of those findings are troubling, says Beth Kallmyer, MSW, vice president of Constituent Services for the Alzheimer’s Association. The lack of knowledge likely hinders the impaired patients from actively participating in vital research or critical decisions about care plans, or legal and financial issues, she said.

“These disturbingly low disclosure rates in Alzheimer’s disease are reminiscent of rates seen for cancer in the 1950s and 60s, when even mention of the word cancer was taboo,” Kallmyer said.

Even though the benefits of promptly and clearly explaining a diagnosis of Alzheimer’s have been established in several studies, one prevalent reason for not disclosing diagnoses is a fear among caregivers that the news will create undue emotional distress, the association noted in a public statement on Tuesday.

The “2015 Alzheimer’s Disease Facts and Figures” report can be viewed online or downloaded from the Alzheimer’s Association site.

David W. Baker, M.D., FACP, MPH is the new executive vice president in the Division of Healthcare Quality Evaluation in the Joint Commission. He will oversee the Departments of Quality Measurement, Health Services Research and Standards and Survey Methods. Baker also will oversee the Joint Commission’s biostatistics and data analysis activities, public reporting of performance measurement data, and the development, implementation and maintenance of the performance measures used in accreditation and certification programs. 

After an extensive nationwide search, Baker was chosen to fill the vacancy left by Jerod Loeb, Ph.D., who died in October 2013. He began on Feb. 17, 2015.

Since 2002, Dr. Baker served as chief of the Division of General Internal Medicine and Geriatrics at the Feinberg School of Medicine at Northwestern University, as well as deputy director of its Institute for Public Health and Medicine. In this capacity, he oversaw the largest division of the Department of Medicine, including clinical practices, residents’ continuity of care clinics, and research programs. 

Baker is the chairman of the American College of Physician’s Performance Measurement Committee and serves as its representative to the Measures Application Partnership Coordinating Committee.  

Before Northwestern, Baker was associate professor of medicine and epidemiology-biostatistics at Metro-Health Medical Center and Case Western Reserve University in Cleveland. He also has worked at Grady Memorial Hospital and Harbor-UCLA Medical Center. 

Baker completed his bachelor’s degree at the University of California, and his medical degree at UCLA School of Medicine. He finished a master’s degree in public health at the UCLA School of Public Health. He completed a residency in internal medicine at Harbor-UCLA Medical Center and a research fellowship with the RWJ Clinical Scholars Program at UCLA. 

The mandate is effective March 27.Long-term care providers can now meet workflow requirements such as direct physician sign-off for all prescriptions, the company said. 

Physicians can use a mobile app that lets them look at order requests, view resident information and sign off on orders anywhere.

“The New York State ePrescribing Mandate will be a game-changer for LTPAC and is likely a precedent for complete ePrescribing across the country as the industry moves away from paper prescriptions,” said Steve Pacicco, CEO of SigmaCare. “By offering a complete ePrescribing solution, we can help providers eliminate the likelihood of transcription mistakes, deliver medications more quickly, and ultimately, enhance clinical outcomes through more efficient prescribing processes from admission to discharge.”