CMS 2023 changes

[DocEspana]

Why isn't anyone (or, really, everyone) getting all excited about this? We are but 4 months away from CM giving us so much **** we have been begging for forever.

Firstly is the changes to midlevel attestations. This was supposed to be the 2022 change but was delayed by a full year (And sort of half-ass implemented in 2022 as a 'lead-up' situation) and will go into effect in 2023. This is already fully confirmed as 100% will-happen and has been as such since the 2022 changes were announced in late 2021. Namely you know how in january we were told to change our phrasing for midlevel attestations to include if you did or did not provide the 'substantive portion' of the exam, but nothing else really changed since you still only had to document 1 element of either HPI, Exam, or MDM alongside it? IDK if billing or legal ever told you (our legal department DEFINITELY did) but that phrase 'substantive portion' probably means *a **** ton* more than you think.

From CMS's perspective if you write that you did the substantive portion, it is assumed *regardless of what you document* that you were the primary person evaluating the patient. Previously CMS had said that you could just prove you saw the patient face to face and they'll give you attending bucks for the chart. But since 2022 it's only counted if you actually were taking care of the patient more than the midlevel did and thats what the phrase means. Now they don't necessarily mean you need to spend more minutes with the patient.... only that you're claiming you did more actual medical practice on the patient and you're attesting that the midlevel truly just sort of "aided" and didn't truly function as the main provider. for nearly all of us, that means that most of our 'substantive portion' statements this year have been a lie - but CMS wrote that for 2022 (and only 2022) they are willing to accept the previous bar of 'give us at least proof you saw them face to face' as how they will decide if its true. And they said for 2022, they will accept that as truth. What changes in 2023 is that CMS now will decide, and as of right now has not been overly specific as to how, who the substantive portion provider is. The only comments we can clearly identify is that they will be deciding this based on "the documentation present." AKA they are going to be looking at the note, seeing how much the mid level stated they did, seeing how much the provider stated they did, and deciding who they feel spent the most time/effort on the patient.

What does this mean functionally? It means that, unless CMS clarifies some easily abusable loophole as to what they are looking for - CMGs likely wont be using midlevels as alternatives for physicians. CMGs care about their bottom line and only that, and the idea that they would use a midlevel on a chart that could potentially be upcoded if a physician saw it is simply unacceptable to them. And since, it would seem, the only way to get full credit for the chart is for the attending to actually see the patient and actually document a reasonably thorough MDM (more on this in a second) midlevels seeing anything outside of the fast track area is a money loser for them. They could run the risk of letting the midlevels do everything except the MDM and letting attendings write the MDM on the note, but that runs into a dual issue where I doubt many attendings would be comfortable writing high level MDMs without also seeing the patient and I don't know if CMS will always automatically accept that the MDM by definition is more substantive than the HPI, ROS, past hx, and PE combined.

The second part of the changes (and this is highly highly HIGHLY likely to go into effect but hasnt been officially approved, only proposed without any significant backlash) is that CMS is no longer going to require 'elements of complexity' to decide billing level. Or at least they wont require complexity of the HPI, ROS, PE, or past history. They state that they feel a provider can decide how complex they feel all of these above elements need to be and that they will no longer make any billing/payment decisions based on them. They will be doing it entirely on the MDM section where they will assign a complexity score to 1) how numerous and how complex the issues you state you are addressing are 2) how many different modalities you 'interpret' to make your medical decisions and 3) how complex you assess the patient's risk of morbidity/complications to be, including any assessment of socioeconomic factors at play. They will then take the total of the two highest of those three elements and that will decide billing level for the chart.

CMS has quite literally spelled out that they feel HPI, ROS, past history review, and PE need only be as thorough as you deem is necessary for your own ability to make a functional/intelligible chart of the encounter +/- any medicolegal concerns you may have. This, frankly, changes the way ED charts work completely. Instead of complex HPIs (particularly ones with check boxes meant to make billers happy) you only need to document what the actual issue is. ROS is essentially useless and can be excluded. PMhx is also only useful if you think the positives are *actually* pertinent. PE can essentially be a macro that says 'unremarkable' for stuff you'll always do and you just plug in the abnormals you find, and you don't need to worry about documenting systems that you probably didnt really check but always found some stupid statement that felt 'true enough' (lymph? You really noticed no grossly enlarged nodes? Technically true, but, come on!). Now I do notice a lot of my co-workers find the MDM their laziest section (you do need to actually *comment* on the results. copying and pasting the lab results without comment or the radiology read without comment gets you zero credit). But people can learn.

Thoughts, fellow long-suffering EM peeps?

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[TysonCook]

...got an email about it last week. The MLP portion we'll see how it goes, but the new "charting" portion is going to be a bunch of verbal diarrhea that nobody will find medically useful (except billing). This is what IM does on their admission H+P, not EM seeing 2-3pph...

"Things that will be associated with a higher level of care that you should document in your MDM going forward:

- Speaking with a consultant, and their suggestions
- History from a family member or a facility
- Reviewed the medical record and what you learned from it
- Considered their chronic illnesses in your treatment
- Method of arrival
- Considered a test, but the patient refused
- Spoke with the radiologist about a study you ordered

These are just to name a few of the items that will be looked at in your MDM to determine level complexity."

 

[EctopicFetus]

Why isn't anyone (or, really, everyone) getting all excited about this? We are but 4 months away from CM giving us so much **** we have been begging for forever.

Firstly is the changes to midlevel attestations. This was supposed to be the 2022 change but was delayed by a full year (And sort of half-ass implemented in 2022 as a 'lead-up' situation) and will go into effect in 2023. This is already fully confirmed as 100% will-happen and has been as such since the 2022 changes were announced in late 2021. Namely you know how in january we were told to change our phrasing for midlevel attestations to include if you did or did not provide the 'substantive portion' of the exam, but nothing else really changed since you still only had to document 1 element of either HPI, Exam, or MDM alongside it? IDK if billing or legal ever told you (our legal department DEFINITELY did) but that phrase 'substantive portion' probably means *a **** ton* more than you think.

From CMS's perspective if you write that you did the substantive portion, it is assumed *regardless of what you document* that you were the primary person evaluating the patient. Previously CMS had said that you could just prove you saw the patient face to face and they'll give you attending bucks for the chart. But since 2022 it's only counted if you actually were taking care of the patient more than the midlevel did and thats what the phrase means. Now they don't necessarily mean you need to spend more minutes with the patient.... only that you're claiming you did more actual medical practice on the patient and you're attesting that the midlevel truly just sort of "aided" and didn't truly function as the main provider. for nearly all of us, that means that most of our 'substantive portion' statements this year have been a lie - but CMS wrote that for 2022 (and only 2022) they are willing to accept the previous bar of 'give us at least proof you saw them face to face' as how they will decide if its true. And they said for 2022, they will accept that as truth. What changes in 2023 is that CMS now will decide, and as of right now has not been overly specific as to how, who the substantive portion provider is. The only comments we can clearly identify is that they will be deciding this based on "the documentation present." AKA they are going to be looking at the note, seeing how much the mid level stated they did, seeing how much the provider stated they did, and deciding who they feel spent the most time/effort on the patient.

What does this mean functionally? It means that, unless CMS clarifies some easily abusable loophole as to what they are looking for - CMGs likely wont be using midlevels as alternatives for physicians. CMGs care about their bottom line and only that, and the idea that they would use a midlevel on a chart that could potentially be upcoded if a physician saw it is simply unacceptable to them. And since, it would seem, the only way to get full credit for the chart is for the attending to actually see the patient and actually document a reasonably thorough MDM (more on this in a second) midlevels seeing anything outside of the fast track area is a money loser for them. They could run the risk of letting the midlevels do everything except the MDM and letting attendings write the MDM on the note, but that runs into a dual issue where I doubt many attendings would be comfortable writing high level MDMs without also seeing the patient and I don't know if CMS will always automatically accept that the MDM by definition is more substantive than the HPI, ROS, past hx, and PE combined.

The second part of the changes (and this is highly highly HIGHLY likely to go into effect but hasnt been officially approved, only proposed without any significant backlash) is that CMS is no longer going to require 'elements of complexity' to decide billing level. Or at least they wont require complexity of the HPI, ROS, PE, or past history. They state that they feel a provider can decide how complex they feel all of these above elements need to be and that they will no longer make any billing/payment decisions based on them. They will be doing it entirely on the MDM section where they will assign a complexity score to 1) how numerous and how complex the issues you state you are addressing are 2) how many different modalities you 'interpret' to make your medical decisions and 3) how complex you assess the patient's risk of morbidity/complications to be, including any assessment of socioeconomic factors at play. They will then take the total of the two highest of those three elements and that will decide billing level for the chart.

CMS has quite literally spelled out that they feel HPI, ROS, past history review, and PE need only be as thorough as you deem is necessary for your own ability to make a functional/intelligible chart of the encounter +/- any medicolegal concerns you may have. This, frankly, changes the way ED charts work completely. Instead of complex HPIs (particularly ones with check boxes meant to make billers happy) you only need to document what the actual issue is. ROS is essentially useless and can be excluded. PMhx is also only useful if you think the positives are *actually* pertinent. PE can essentially be a macro that says 'unremarkable' for stuff you'll always do and you just plug in the abnormals you find, and you don't need to worry about documenting systems that you probably didnt really check but always found some stupid statement that felt 'true enough' (lymph? You really noticed no grossly enlarged nodes? Technically true, but, come on!). Now I do notice a lot of my co-workers find the MDM their laziest section (you do need to actually *comment* on the results. copying and pasting the lab results without comment or the radiology read without comment gets you zero credit). But people can learn.

Thoughts, fellow long-suffering EM peeps?

Counter. unless commercial insurers and medicaid follow CMS who cares. MLPs see no one over 65. Problem solved and keep using your MLPs as is.

The 2nd change is nice BUT one thing you didnt mention is there will not be any 99281s and most of the 3s are moving to 4s. In the end though this is all billing stuff. a chart still needs to tell the patient story and stand up in a court of law when you get sued.

Helpful yes... life changing i dont think so.

 

[RustedFox]

I'm going to read this three times before I consider opening my mouth.

 

[DocEspana]

Counter. unless commercial insurers and medicaid follow CMS who cares. MLPs see no one over 65. Problem solved and keep using your MLPs as is.

The 2nd change is nice BUT one thing you didnt mention is there will not be any 99281s and most of the 3s are moving to 4s. In the end though this is all billing stuff. a chart still needs to tell the patient story and stand up in a court of law when you get sued.

Helpful yes... life changing i dont think so.

immediate counter: commercial insurances literally have almost always mimicked CMS rules in essentially every way except sometimes (like observation) they are actually *nicer* and more lenient than CMS requires. And have pretty much always done so almost immediately upon CMS doing so. Also.... do you think medicaid would not be following the center for medicare and MEDICAID services?

snarky counter: you see people with commercial insurance?

Still think its odd that the second change has been known for about 1 year now and no one is talking about it and the first change has been proposed for a month or so and will be announced officially in the next few days and no one has been chatting about it.

 

[DocEspana]

I'm going to read this three times before I consider opening my mouth.

Decent article on the second set of changes. The 2023 Physician Fee Schedule Proposed Rule: All E&M Is Going to MDM or Time

the first one is all over the CMS website, but since the announcement is a year-ish old by now its hard to find articles discussing it specifically on the google algorithm any longer because all of the terms are so common that it pulls up lots of stuff thats more recent but irrelevant to us. I'll try to go look and find an article summarizing it nicely.

 

[southerndoc]

Commercial insurers generally follow CMS (a year or two later before they adopt).

Be careful... this may not be what we wished for. It may be that MDM must be several pages long to justify a 99285 patient. I've read before that CMS thinks a chest pain admission should be a 99284 visit and not 99285. I'm no expert in billing, but I worry that this will have unintended consequences.

 

[EctopicFetus]

immediate counter: commercial insurances literally have almost always mimicked CMS rules in essentially every way except sometimes (like observation) they are actually *nicer* and more lenient than CMS requires. And have pretty much always done so almost immediately upon CMS doing so. Also.... do you think medicaid would not be following the center for medicare and MEDICAID services?

snarky counter: you see people with commercial insurance?

Still think its odd that the second change has been known for about 1 year now and no one is talking about it and the first change has been proposed for a month or so and will be announced officially in the next few days and no one has been chatting about it.

The 85% reimbursement for MLPs has always been the case for medicare. Medicaid and most commercial insurers have no followed. Exception being BCBS in Alabama.

Dont see it changing. Our MLPs dont see anyone over 65. Where it matters with with MLPs in the ICU and on the floors. Much less useful.

 

[EctopicFetus]

Commercial insurers generally follow CMS (a year or two later before they adopt).

Be careful... this may not be what we wished for. It may be that MDM must be several pages long to justify a 99285 patient. I've read before that CMS thinks a chest pain admission should be a 99284 visit and not 99285. I'm no expert in billing, but I worry that this will have unintended consequences.

I have spent a lot of time taking with our billing company and others in the RCM space. There is concern some 5s will move to 4s. The details are out and some things will generally weigh heavily.

Lots of details but just importing the labs and CTs give you credit without need to interpret. To be honest the win is we will actually get paid for effort and not so much based on final diagnosis. Also important to note they released rules protecting PLP standard.

Its not all sunshine and daisies but seemingly the changes are beneficial and reasonable. Also we wont really know until claims start getting kciked back and specific questions can be asked and answered.

Again, the lower reimbursement for MLPs has been the standard forever with medicare but medicaid and commercial insurance hasnt followed. The difference is that the physicians cursory hello wont cut it anymore and it did before but the concept of lower pay for MLPs isnt new, just the standard for the doc to be involved has increased.

Also since MLPs make less than 85% of physician money it doesnt make docs cheaper than MLPs. Just a financial consideration.

 

[RustedFox]

Commercial insurers generally follow CMS (a year or two later before they adopt).

Be careful... this may not be what we wished for. It may be that MDM must be several pages long to justify a 99285 patient. I've read before that CMS thinks a chest pain admission should be a 99284 visit and not 99285. I'm no expert in billing, but I worry that this will have unintended consequences.

This is precisely why I am reading and thinking long and hard.

 

[RustedFox]

Quick takeaways:

1. ROS needs to die. This seems like it allows it to die.

2. PLPs need to be relegated to quick and easy dispos. I like to say: "they need to play second base and simply gobble up easy ground balls and flip to first for simple force outs". This seems like it encourages this to happen.

3. Forcing additional MDM seems like it can be a good thing in terms of getting some of my coworkers who are retar-, erp... I mean... ostriched to actually give a eff and write a coherent chart (This is a big peeve of mine), AND can be automated easily with macros.

 

[EctopicFetus]

Quick takeaways:

1. ROS needs to die. This seems like it allows it to die.

2. PLPs need to be relegated to quick and easy dispos. I like to say: "they need to play second base and simply gobble up easy ground balls and flip to first for simple force outs". This seems like it encourages this to happen.

3. Forcing additional MDM seems like it can be a good thing in terms of getting some of my coworkers who are retar-, erp... I mean... ostriched to actually give a eff and write a coherent chart (This is a big peeve of mine), AND can be automated easily with macros.

ROS, PE and HPI and past medical history (if not tied to their complaint) is dead. Even as such not more downcoding for missing these things.

 

[RustedFox]

ROS, PE and HPI and past medical history (if not tied to their complaint) is dead. Even as such not more downcoding for missing these things.

Yeah. I'm not arguing.
ROS is just bearing the brunt of my ire, as I feel that HPI is critical, PE is critical, but less so, and that ROS is for retar-, I mean... Ostriches.

 

[VA Hopeful Dr]

I can't speak to EM charting, but we've been on this system in outpatient since last year. Its been great. My HPI is what I want it to be, I'm not trying to hit bullet points. My ROS is only stuff I want there (often times its blank). Very targeted physical exams.

I often do have to flesh out my MDM a bit, but honestly not by much 99% of the time.

 

[Siggy]

As long as they continue to allow split-sharing critical care time for easy -92s...

 

[southerndoc]

As long as they continue to allow split-sharing critical care time for easy -92s...

Split sharing?

 

[Siggy]

Split sharing?

You can now combine time (called split/share) between the PLPs and physicians. So if my NP does 35 minutes of work and I do 40 minutes (for a total of 75 minutes), I can bill both a 91 and a 92. Who ever billed the most time gets to bill, however at 85%, a 91 and a 92 under a PLP is still more RVUs than a 91 under a physician.

Prior to this year you couldn't split/share critical care time.

This also sets the night team up for an easy 92 because it's not hard to justify 10 or 15 minutes per provider.

 

[thegenius]

...got an email about it last week. The MLP portion we'll see how it goes, but the new "charting" portion is going to be a bunch of verbal diarrhea that nobody will find medically useful (except billing). This is what IM does on their admission H+P, not EM seeing 2-3pph...

"Things that will be associated with a higher level of care that you should document in your MDM going forward:

- Speaking with a consultant, and their suggestions
- History from a family member or a facility
- Reviewed the medical record and what you learned from it
- Considered their chronic illnesses in your treatment
- Method of arrival
- Considered a test, but the patient refused
- Spoke with the radiologist about a study you ordered

These are just to name a few of the items that will be looked at in your MDM to determine level complexity."

Ha! More templates and macros for the notes!

 

[thegenius]

immediate counter: commercial insurances literally have almost always mimicked CMS rules in essentially every way except sometimes (like observation) they are actually *nicer* and more lenient than CMS requires. And have pretty much always done so almost immediately upon CMS doing so. Also.... do you think medicaid would not be following the center for medicare and MEDICAID services?

snarky counter: you see people with commercial insurance?

Still think its odd that the second change has been known for about 1 year now and no one is talking about it and the first change has been proposed for a month or so and will be announced officially in the next few days and no one has been chatting about it.

Everything I do is macro these days anyway. The ROS, PE, etc. I just changed a few things here and there.

I usually write a 2-5 sentence MDM depending on complexity. If it's going to be focused on more, then I'll probably make a template out of it.

The midlevel stuff? Is there more legal protection? All I want is legal protection. I don't really care about anything else. I can't stand signing their notes.

Here's the deal breaker:

If I can write a 2-5 sentence note AND THAT'S IT!!!!! then I'll get excited.

 

[RustedFox]

Ha! More templates and macros for the notes!

I mean, 6 out of 7 of those things go in my HPI.

Patient arrives via private vehicle, reports concerns regarding a 2-3 day history of abdominal pain with the following characteristics. Family adds "xxxx" and "yyyy". Review of prior notes reveals multiple similar visits with strong history of alcohol abuse. Patient refuses additional CT imaging, I feel this is reasonable, as patient denies any dissimilar characterisrics to their symptoms during today's visit. Patient denies any/all other complaints/symptoms at the time of initial H&P.

 

[thegenius]

Commercial insurers generally follow CMS (a year or two later before they adopt).

Be careful... this may not be what we wished for. It may be that MDM must be several pages long to justify a 99285 patient. I've read before that CMS thinks a chest pain admission should be a 99284 visit and not 99285. I'm no expert in billing, but I worry that this will have unintended consequences.

I think a routine chest pain admission should be a 4, but if there are EKG changes, rising troponins, gtt's ordered, or other signs of instability, then it should be a 5.

CMS knows we put little thought into a routine chest pain admission. They are not maximal complexity.

 

[RustedFox]

Everything I do is macro these days anyway. The ROS, PE, etc. I just changed a few things here and there.

I usually write a 2-5 sentence MDM depending on complexity. If it's going to be focused on more, then I'll probably make a template out of it.

The midlevel stuff? Is there more legal protection? All I want is legal protection. I don't really care about anything else. I can't stand signing their notes.

Here's the deal breaker:

If I can write a 2-5 sentence note AND THAT'S IT!!!!! then I'll get excited.

I swear, most of their notes are completely ostriched.

 

[thegenius]

I don't even know what ostriched means.

 

[RustedFox]

I don't even know what ostriched means.

That's cause you're an ostrich.

Lol. Just kidding. I'd never call you an ostrich

 

[thegenius]

That's cause you're an ostrich.

Lol. Just kidding. I'd never call you an ostrich

I still don't know what ostriched means!

You cannot define a word by calling me that word.

Now go away and stick your head in a dirt hole.

 

[thegenius]

On another note.

I would like to see a before 2023 and after 2023 note comparison to get an idea of how our work might change.

 

[BoardingDoc]

What does this mean functionally? It means that, unless CMS clarifies some easily abusable loophole as to what they are looking for - CMGs likely wont be using midlevels as alternatives for physicians. CMGs care about their bottom line and only that, and the idea that they would use a midlevel on a chart that could potentially be upcoded if a physician saw it is simply unacceptable to them. And since, it would seem, the only way to get full credit for the chart is for the attending to actually see the patient and actually document a reasonably thorough MDM (more on this in a second) midlevels seeing anything outside of the fast track area is a money loser for them. They could run the risk of letting the midlevels do everything except the MDM and letting attendings write the MDM on the note, but that runs into a dual issue where I doubt many attendings would be comfortable writing high level MDMs without also seeing the patient and I don't know if CMS will always automatically accept that the MDM by definition is more substantive than the HPI, ROS, past hx, and PE combined.

You are optimistic about this for precisely the reasons I'm pessimistic about this change.

Agree that based on these changes, it seems like PA patients will now be billed as PA patients and not as Doc+PA patients. This means 85% instead of 100%. This means that everyone collecting money is going to collect less of it.
-In my case as a group where we keep what we kill (and what the PA kills under our supervision), I will be getting paid a decent chunk less now.
-In the CMG case, profits go down. That won't fly, so they need to cut costs. There's an upcoming glut of EM docs coming. Do you really think that they're going to keep paying docs the same? I don't.

 

[southerndoc]

I think a routine chest pain admission should be a 4, but if there are EKG changes, rising troponins, gtt's ordered, or other signs of instability, then it should be a 5.

CMS knows we put little thought into a routine chest pain admission. They are not maximal complexity.

I disagree. There are a lot of high-risk possibilities with a chest pain patient.

 

[DocEspana]

You are optimistic about this for precisely the reasons I'm pessimistic about this change.

Agree that based on these changes, it seems like PA patients will now be billed as PA patients and not as Doc+PA patients. This means 85% instead of 100%. This means that everyone collecting money is going to collect less of it.
-In my case as a group where we keep what we kill (and what the PA kills under our supervision), I will be getting paid a decent chunk less now.
-In the CMG case, profits go down. That won't fly, so they need to cut costs. There's an upcoming glut of EM docs coming. Do you really think that they're going to keep paying docs the same? I don't.

From how you're phrasing your post, I assume you're not at a CMG. Most (though clearly not all) have been trending towards, and largely accomplishing, taking the mid-level out of the fast track/low acuity area and saying that there should be no practice distinction between a mid-level and a physician. Both Envision and Schumacher have made it priorities to pull mid-levels out of the fast track and make "all patients seen by everyone". I imagine the other groups are doing it too, but I have no insight into their leadership. Unlike some connections, I have moderately to significantly high up in the other groups. The goal is to democratize care, but it's not coming from an altruistic place.

What this really means, in a brass tacks sense, is that they don't want the mid levels stuck in the low acuity area because they would much prefer them working on the high acuity patients to essentially demonstrate there is no difference in care, so there should be higher utilization of the cheaper revenue source. I think the argument is that having them there is a proof of concept that they don't really need actual physicians there if nothing goes terribly wrong over the next few months and years as they create policy that "democratizes" who sees the above average acuity patients. They view it as an argument to continue to hire fewer doctors and likely convert some physician jobs to mid-level jobs. Essentially, arguing that physicians truly only need to be there to run the highest of high acuity patients and that mid-levels can handle basically anyone who is not immediately perimortem or already pulseless.... So why ever staff more than 24 hours total physician coverage (This argument to eventually cut physician coverage down to 24 hours. Essentially, universally was explicitly stated, though sadly not put down in writing, at an Envision meeting about two years ago per a person I trust who was there). As long as it takes minimal actual effort to turn a medleville chart into an attending chart, why do you need multiple attendings signing mid-level charts? Of course, if it actually takes legitimate input, documentation, and proof of interaction for that mid-level chart to become billed at a full level - they might be driven by proifts but they also know what they realistically can whip a single person into doing

The second the payment is not identical for a mid-level in a position, this entire end-stage capitalism logic falls apart because 15% off a lot of charts very quickly ruins the entire premise that you can simply replace currently employed physicians as long as mid-levels don't actively kill belly pain patients and non-descript chest pain complaints.

 

[BoardingDoc]

From how you're phrasing your post, I assume you're not at a CMG. Most (though clearly not all) have been trending towards, and largely accomplishing, taking the mid-level out of the fast track/low acuity area and saying that there should be no practice distinction between a mid-level and a physician. Both Envision and Schumacher have made it priorities to pull mid-levels out of the fast track and make "all patients seen by everyone". I imagine the other groups are doing it too, but I have no insight into their leadership. Unlike some connections, I have moderately to significantly high up in the other groups. The goal is to democratize care, but it's not coming from an altruistic place.

What this really means, in a brass tacks sense, is that they don't want the mid levels stuck in the low acuity area because they would much prefer them working on the high acuity patients to essentially demonstrate there is no difference in care, so there should be higher utilization of the cheaper revenue source. I think the argument is that having them there is a proof of concept that they don't really need actual physicians there if nothing goes terribly wrong over the next few months and years as they create policy that "democratizes" who sees the above average acuity patients. They view it as an argument to continue to hire fewer doctors and likely convert some physician jobs to mid-level jobs. Essentially, arguing that physicians truly only need to be there to run the highest of high acuity patients and that mid-levels can handle basically anyone who is not immediately perimortem or already pulseless.... So why ever staff more than 24 hours total physician coverage (This argument to eventually cut physician coverage down to 24 hours. Essentially, universally was explicitly stated, though sadly not put down in writing, at an Envision meeting about two years ago per a person I trust who was there).

The second the payment is not identical for a mid-level in a position, this entire end-stage capitalism logic falls apart because 15% off a lot of charts very quickly ruins the entire premise that you can simply replace currently employed physicians as long as mid-levels don't actively kill belly pain patients and non-descript chest pain complaints.

Interesting. You are correct that I do not work for a CMG, and as such I don't really have the pulse of the issues you described above. If that is what is happening, your POV makes a bit more sense to me now. My concerns may or may not remain true in the scenario you describe. On a purely selfish level, I'm not thrilled about the likely paycut that this legislation poses for me.

 

[DocEspana]

Interesting. You are correct that I do not work for a CMG, and as such I don't really have the pulse of the issues you described above. If that is what is happening, your POV makes a bit more sense to me now. My concerns may or may not remain true in the scenario you describe. On a purely selfish level, I'm not thrilled about the likely paycut that this legislation poses for me.

Oh if the mid levels work for you and are a reasonable way for you to Make sure that all of the labor is accomplished at an affordable price... I get it. I also work under the assumption that group's like yours are using mid levels in a way that is respectful of the importance of physician at the head of care and all of the other things that I'm sure you can assume I want to say positively about what mid-levels could be. So it sucks that this likely takes money out of your guy's pockets, cuz you're doing it the right way.

I love most of the mid-levels I've worked with, but (except for a short stint with a true doctor owned/ran group doing travel medicine) I've always worked with CMGs and I've always had to swallow and increasingly more uncomfortable prominence of mid-levels as the axis that the care paradigm turns on. I'm optimistic to see something that actually derails the crash course that anyone with eyes can see the companies are putting the CMG physicians on

 

[BoardingDoc]

Oh if the mid levels work for you and are a reasonable way for you to Make sure that all of the labor is accomplished at an affordable price... I get it. I also work under the assumption that group's like yours are using mid levels in a way that is respectful of the importance of physician at the head of care and all of the other things that I'm sure you can assume I want to say positively about what mid-levels could be. So it sucks that this likely takes money out of your guy's pockets, cuz you're doing it the right way.

I love most of the mid-levels I've worked with, but (except for a short stint with a true doctor owned/ran group doing travel medicine) I've always worked with CMGs and I've always had to swallow and increasingly more uncomfortable prominence of mid-levels as the axis that the care paradigm turns on. I'm optimistic to see something that actually derails the crash course that anyone with eyes can see the companies are putting the CMG physicians on

Yeah, I think that doing it in the CMG model would be absolutely soul crushing. We hire (and fire as needed) all of our midlevels. We do not hire NPs period. We have a solid small group of PAs who work under the docs and function more or less as residents. They present each case. Buck stops with the attending. They are all really good at proactively picking off the lac repairs, social nightmare / whatever patients to free us up to do the other stuff. Staffing is such that we run doc heavy and staff PAs only as needed to keep the volume moving. Doc : PA ratio (in terms of who is working every day) is 1.75 : 1

 

[alpinism]

I’ll openly admit I’m not an expert on the proposed CMS requirements however it’s my understanding that while midlevels can bill only 85% for a chart they also make about 45% of doctors salaries.

In that case even with reduced collections they’ll get better profit margins from midlevels instead of doctors.

 

[thegenius]

I disagree. There are a lot of high-risk possibilities with a chest pain patient.

I guess your definition of routine is different than mine. By definition routine chest pain doesn't have any high risk features, because if it had high risk features it wouldn't be routine.

Most chest pain we see in the ED is low risk. Even the chest pain we admit, as a group, is majority routine low-to-medium risk chest pain.

 

[Rekt]

I guess your definition of routine is different than mine. By definition routine chest pain doesn't have any high risk features, because if it had high risk features it wouldn't be routine.

Most chest pain we see in the ED is low risk. Even the chest pain we admit, as a group, is majority routine low-to-medium risk chest pain.

Most chest pain shouldn't be admitted at all.

 

[RustedFox]

I guess your definition of routine is different than mine. By definition routine chest pain doesn't have any high risk features, because if it had high risk features it wouldn't be routine.

Most chest pain we see in the ED is low risk. Even the chest pain we admit, as a group, is majority routine low-to-medium risk chest pain.

Not at my shop, amigo.
Most chest pain that I see is in a fat senior with all the risk factors.

I swear, "Florida" is a risk factor.

 

[southerndoc]

I guess your definition of routine is different than mine. By definition routine chest pain doesn't have any high risk features, because if it had high risk features it wouldn't be routine.

Most chest pain we see in the ED is low risk. Even the chest pain we admit, as a group, is majority routine low-to-medium risk chest pain.

I guess my use of routine chest pain admit is the person with risk factors. The vast majority chest pains I send home.

 

[GatorCHOMPions]

From how you're phrasing your post, I assume you're not at a CMG. Most (though clearly not all) have been trending towards, and largely accomplishing, taking the mid-level out of the fast track/low acuity area and saying that there should be no practice distinction between a mid-level and a physician. Both Envision and Schumacher have made it priorities to pull mid-levels out of the fast track and make "all patients seen by everyone". I imagine the other groups are doing it too, but I have no insight into their leadership. Unlike some connections, I have moderately to significantly high up in the other groups. The goal is to democratize care, but it's not coming from an altruistic place.

What this really means, in a brass tacks sense, is that they don't want the mid levels stuck in the low acuity area because they would much prefer them working on the high acuity patients to essentially demonstrate there is no difference in care, so there should be higher utilization of the cheaper revenue source. I think the argument is that having them there is a proof of concept that they don't really need actual physicians there if nothing goes terribly wrong over the next few months and years as they create policy that "democratizes" who sees the above average acuity patients. They view it as an argument to continue to hire fewer doctors and likely convert some physician jobs to mid-level jobs. Essentially, arguing that physicians truly only need to be there to run the highest of high acuity patients and that mid-levels can handle basically anyone who is not immediately perimortem or already pulseless.... So why ever staff more than 24 hours total physician coverage (This argument to eventually cut physician coverage down to 24 hours. Essentially, universally was explicitly stated, though sadly not put down in writing, at an Envision meeting about two years ago per a person I trust who was there). As long as it takes minimal actual effort to turn a medleville chart into an attending chart, why do you need multiple attendings signing mid-level charts? Of course, if it actually takes legitimate input, documentation, and proof of interaction for that mid-level chart to become billed at a full level - they might be driven by proifts but they also know what they realistically can whip a single person into doing

The second the payment is not identical for a mid-level in a position, this entire end-stage capitalism logic falls apart because 15% off a lot of charts very quickly ruins the entire premise that you can simply replace currently employed physicians as long as mid-levels don't actively kill belly pain patients and non-descript chest pain complaints.

My current EM gig is part time with an SDG that has more MLP than doc coverage. Also more non-partner doc hours than partner doc hours. I wouldn’t necessarily call them malignant, they do it because they can. CMG vs SDG, humans are humans and are looking out for their own interests and bottom line. It’s just slightly more obvious with the former, and with the latter you may have an outside shot at profit sharing…eventually, after making below market rate and working all nights for an undetermined time period.

 

[DocEspana]

I’ll openly admit I’m not an expert on the proposed CMS requirements however it’s my understanding that while midlevels can bill only 85% for a chart they also make about 45% of doctors salaries.

In that case even with reduced collections they’ll get better profit margins from midlevels instead of doctors.

15% loss on 2-2.5 charts per hour per midlevel adds up quickly and overtakes that 45%, especially when you then start adding in more dififcult to pin down things - like physicians can probably do that 2-2.5 on actual sick patients not just on low acuity patients, so there is not a 1-to-1 manpower replacement if you are moving them into the main floor.

Regardless, the people at the companies have already done the math on this and figured it out. We will know what their calculations were if there is a relatively quick adjustment to their 'grand plan' come january.

 

[Mount Asclepius]

Chest pain admits should be moderate to high risk. Where as low risk chest pain should be discharged home. Moderate to high risk chest pain is worthy of a level 5 code. Some low risk chest pain also deserving especially if receiving more extensive evaluation with CTA imaging in addition to standard ACS workup. We occasionally forget that what is routine or easy for us with our advanced training still has a decent amount of risk and complexity.

 

[RustedFox]

Excuse me, but as long as missed MI is in the top batch of high med-mal payouts, then "chest pain" should be a level 5 chart, and paid accordingly.

 

[Rekt]

Must be regional. I'd say about 75% of the CP I see each day walks around at a moderate heart score. I have to send home multiple >65 y/os s/p previous stents/CABGs or my admission rate would be like >50%. Unless your trop is elevated beyond your baseline or you have new ECG changes or look like hot caca then you're going home.

 

[RustedFox]

Must be regional. I'd say about 75% of the CP I see each day walks around at a moderate heart score. I have to send home multiple >65 y/os s/p previous stents/CABGs or my admission rate would be like >50%. Unless your trop is elevated beyond your baseline or you have new ECG changes or look like hot caca then you're going home.

Maaaaan.
I must work in the Capital Of Ostriches.

Me, to 58 year old: "Do you have a cardiologist?"

Yes.

Who is it? What is their name?

Hurrrrr.....

What medicines do you take?

Oh, I uhh, take thaaaaa.....

- and if I sent these ostriches home, entrusting them to follow up, they'd all say: "but the ER doctor said I was fine."

 

[Mount Asclepius]

Must be regional. I'd say about 75% of the CP I see each day walks around at a moderate heart score. I have to send home multiple >65 y/os s/p previous stents/CABGs or my admission rate would be like >50%. Unless your trop is elevated beyond your baseline or you have new ECG changes or look like hot caca then you're going home.

Agree. COVID-19 partially changed things as well as we just didn’t have hospital room to admit negative testing moderate risk chest pain. They even shut down the cardiac observation unit only doing formal admits. I send home a lot of moderate risk chest pain with negative testing. I perhaps didn’t phrase my comment as well as I could have above. Mainly implying we don’t admit low risk chest pain. The ones we do admit should be level 5 charts. Even a decent amount of moderate risk chest pain going home should be a level 5 chart concordant with the complexity and risk.

 

[CoolDoc1729]

Maaaaan.
I must work in the Capital Of Ostriches.

Me, to 58 year old: "Do you have a cardiologist?"

Yes.

Who is it? What is their name?

Hurrrrr.....

What medicines do you take?

Oh, I uhh, take thaaaaa.....

- and if I sent these ostriches home, entrusting them to follow up, they'd all say: "but the ER doctor said I was fine."

For me the answer to the cardiologist question is always “it’s the one on XYZ road”. XYZ road literally has three office parks full of doctors offices in addition to many individual offices. The kicker : 1/3 of the time it’s not even one of the 25 cardiologists on XYZ road 🤦🏻‍♀️

 

[GonnaBeADoc2222]

For me the answer to the cardiologist question is always “it’s the one on XYZ road”. XYZ road literally has three office parks full of doctors offices in addition to many individual offices. The kicker : 1/3 of the time it’s not even one of the 25 cardiologists on XYZ road 🤦🏻‍♀️

Even more amazing is when the lemmings don't know the name of the surgeon who literally cut into them.

I still remember the name of the ENT I saw when I was 8 years old.

 

[NYEMMED]

Must be regional. I'd say about 75% of the CP I see each day walks around at a moderate heart score. I have to send home multiple >65 y/os s/p previous stents/CABGs or my admission rate would be like >50%. Unless your trop is elevated beyond your baseline or you have new ECG changes or look like hot caca then you're going home.

Heart score pathway much?

Don’t take risks, your employer and hospital will throw you right under the bus when you get sued.

 

[Mount Asclepius]

I feel like the standard of care is moving away from the HEART score in the age of high sensitivity troponin testing and a premium on inpatient beds.

 

[EctopicFetus]

I feel like the standard of care is moving away from the HEART score in the age of high sensitivity troponin testing and a premium on inpatient beds.

May be on the path but not there yet. Med mal lawyers need To eat and will screw you sideways to get filet in lieu of a juicy in n out burger.

 

[RustedFox]

May be on the path but not there yet. Med mal lawyers need To eat and will screw you sideways to get filet in lieu of a juicy in n out burger.

If this is the idea; then they need to give us reasonable numbers for the clinical decision making pathway.

12 or less and a delta of 3 is what is on our laminated quick reference sheets.

If that were true; I'd admit so many, many more.

Even healthy young people roll a 22 on their first hsTnI.