CMS Proposing 6% paycut for EM physicians in 2021

[rokshana]

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You can autofellate yourself all you want, but an NP is a mid-level, regardles of how many fake sequences of letters they put after their name.

Again , I don’t care ...frankly I don’t have to work with them, and I don’t supervise them(unlike many an ED)...you do realize I’m an MD , board certified in IM and Endocrinology...and luckily ( since we make so little) , my field is not overwhelmed with them...they do a lot of the glucose control in hospitals, but at best I can bill that as a level 2...my time is better spent elsewhere.

And again, groove said the exact same thing, yet no admonishment for him...not going to fuss at one of your own?

 

[turkeyjerky]

Yes, I know that...however in states they have licensed independent practitioners (LIPs) mid levels can be and are PCP...meaning they are the primary care for people...we may not like it...and ultimately we as physicians have allowed this to happen...so there are places where a patient’s PCP is a midlevel who is the sole person responsible for that persons care.

And funny you lash out at me and roll your eyes, yet in a few posts above me groove(#27) said exactly the same thing...where is your admonishment for HIM?

Well, as a quick aside (and to beat a dead horse), I would argue that it's actually the multitude of specialists whom the midlevel refer to who are actually responsible for the patients' care. (Cards for their essential htn, endo for their type II DM, neuro for their neuropathy, pulm for their copd, EM for any acute complaint whatsoever)

 

[thegenius]

Well, as a quick aside (and to beat a dead horse), I would argue that it's actually the multitude of specialists whom the midlevel refer to who are actually responsible for the patients' care. (Cards for their essential htn, endo for their type II DM, neuro for their neuropathy, pulm for their copd, EM for any acute complaint whatsoever)

Actually...a midlevel will find some way to proclaim 170/100 in a 65 yo man should go to the ER. Or with a blood glucose of 380. Or a variety of other nonsense things.

I think the only role for midlevels in medicine are in focused, small areas where they can know something small and get good with it. Having them "act" as primary care physicians with only midlevel knowledge is absolutely terrible. They may not make a terrible decision with every patient encounter, but their suboptimal decisions add up over years and decades and patients will inevitable end up with more complications from diabetes, HTN, smoking, and a variety of things that could have been better properly managed by doctors.

 

[Kuratz]

There is a huge variety in the quality of midlevel practitioners. Some come from rigorous structured programs, recognize their limitations and ask questions (just like any resident should), and try to enrich their education outside of work. Others (mostly NPs if I'm being frank) slide through a total nonsense program, don't care to spend time reading real academic articles outside of work, and most importantly possess the hubris to think that medicine is some simple thing that can be easily mastered. The fundamental problem is the bleeping nursing board allowing these garbage online diploma mills while simultaneously pushing for NPs to practice independently. There are some kick ass midlevels but the low quality ones are becoming far too prevalent.

Secondly, it's absurd that we as a profession have to fight against each other for fair compensation because the government dictates that we all draw from the same fixed pot. That's the crux of the issue right there and isn't fair. What other profession has to deal with that? I'm glad Endo/FM etc got a raise, hell even Uro/ENT, but then when I look at what that means for my field (Rads, -11%) it's a total nonstarter to be on board with something like this. This stupid ass policy needs to change so that we can actually fight for each other.

 

[rokshana]

Well, as a quick aside (and to beat a dead horse), I would argue that it's actually the multitude of specialists whom the midlevel refer to who are actually responsible for the patients' care. (Cards for their essential htn, endo for their type II DM, neuro for their neuropathy, pulm for their copd, EM for any acute complaint whatsoever)

There is truth to that...though many times those referrals from the midlevels, I have no clue why they are referring...had one that referred a pt...couldn’t figure out why on earth pt was referred and actually called her...she referred because neurology recommended endocrine referral...smh!

 

[Buckeye1992]

Was recently on PEM service had a patient who was in DKA from new onset DM1. Looked back at her most recent visit from three days prior(a Friday) and saw she was seen by her NP pcp who documented a BG of 550, 3+ketones, and A1C >10 but decided The patient should be good to just follow up with Endo the next week. Lucky that patient did ok.

 

[Groove]

You can autofellate yourself all you want, but an NP is a mid-level, regardles of how many fake sequences of letters they put after their name.

Yeah, yeah... Normally, I would totally side with the physicians on this one and perhaps my ideologic resolution has been compromised by the fact that I'm "sleeping with the enemy" so to speak (after all, I do share the bed with an NP)...BUT...I think it's a lost battle for the acronym of PCP. I mean, c'mon.... nobody says "primary care physician" anymore. The government and insurance companies certainly don't. Hell, the NPs are on the pt's insurance cards these days for crying out loud as "PCP". Half my patients or more see NPs for all their primary needs. It's a lost battle. Better to focus our efforts on retaining the "Dr." title for as long as possible and distinguish our differences in training and experience though I suspect we'll eventually lose the "Dr." fight also. Sigh....

 

[Fart Daddy Smooth]

Exactly. It’s total nonsense. They’ll print trillions to prop up assets and bail out banks insurance companies drum up new social programs but screw the doctors who in the middle of a pandemic are dealt yet another ****ty hand.

As for the others on this board criticizing FP, your just playing the game HHS wants you to play.

Yes, exactly. RN here but you all seriously need to organize and unionize like yesterday. These paycuts, CMGs, and midlevel encroachments are just the beginning. When specialties and even professions (MD vs DO vs NP vs RN vs CRNA etc) fight against each other, we lose sight of the real enemy - the insurance companies, the administrators, and the legislators.

These leeches have been fattening their pockets with our labor for too long. It's time that we unite and fight together for healthcare workers as a whole.

 

[thegenius]

Advice from "Fart Daddy Smooth" 😏

 

[GeneralVeers]

Advice from "Fart Daddy Smooth" 😏

Love the name. Not sold on the advice.

 

[WilcoWorld]

Actually...a midlevel will find some way to proclaim 170/100 in a 65 yo man should go to the ER. Or with a blood glucose of 380. Or a variety of other nonsense things.

I think the only role for midlevels in medicine are in focused, small areas where they can know something small and get good with it. Having them "act" as primary care physicians with only midlevel knowledge is absolutely terrible. They may not make a terrible decision with every patient encounter, but their suboptimal decisions add up over years and decades and patients will inevitable end up with more complications from diabetes, HTN, smoking, and a variety of things that could have been better properly managed by doctors.

While your argument is compelling, this is an empirical claim. The problem is that I'm not aware of anyone on the physician side of the argument having demonstrated it with a well designed study.

 

[deleted941485]

Dealing with CMS is part of the job description for EM, though, considering the amount of ED patients who are either Medicare or Medicaid. Considering the amount of uncompensated indigent care that EDs in this country, I would think it would benefit our specialty if more people were covered under CMS that are currently totally uninsured.

Then I guess you are screwed. Nowadays with states expanding Medicaid your problem is under reimbursement.

Hope you like that knife in your back.

 

[Torsion]

Then I guess you are screwed. Nowadays with states expanding Medicaid your problem is under reimbursement.

Hope you like that knife in your back.

Obviously the ideal world would be one in which everyone was privately insured and reimbursed well but that is not the reality. The reality is that in a lot of EDs throughout the country over half of an emergency physician's time is spent providing uncompensated care. I don't have any data to cite but I would imagine that new Medicaid enrollees are coming from the ranks of the totally uninsured rather than privately insured low-income people. If the law commands that we care for all patients that walk through the door, patients paying 80 cents on the dollar is still more money than patients tying up your time and proceeding to pay 0 cents on the dollar.

Not a long term solution to be certain but in the short term I don't see how it hurts EMTALA bound specialties.

 

[turkeyjerky]

Obviously the ideal world would be one in which everyone was privately insured and reimbursed well but that is not the reality. The reality is that in a lot of EDs throughout the country over half of an emergency physician's time is spent providing uncompensated care. I don't have any data to cite but I would imagine that new Medicaid enrollees are coming from the ranks of the totally uninsured rather than privately insured low-income people. If the law commands that we care for all patients that walk through the door, patients paying 80 cents on the dollar is still more money than patients tying up your time and proceeding to pay 0 cents on the dollar.

Not a long term solution to be certain but in the short term I don't see how it hurts EMTALA bound specialties.

It's funny how this this argument keeps repeating itself. 10 years ago most docs on here thought the ACA was going crush our salaries. Instead, reimbursement.....went through the roof.

Linda like how hospital systems never actually do anything to curtail ED overuse amongst the medicaid set.

 

[Hercules]

Obviously the ideal world would be one in which everyone was privately insured and reimbursed well but that is not the reality. The reality is that in a lot of EDs throughout the country over half of an emergency physician's time is spent providing uncompensated care. I don't have any data to cite but I would imagine that new Medicaid enrollees are coming from the ranks of the totally uninsured rather than privately insured low-income people. If the law commands that we care for all patients that walk through the door, patients paying 80 cents on the dollar is still more money than patients tying up your time and proceeding to pay 0 cents on the dollar.

Not a long term solution to be certain but in the short term I don't see how it hurts EMTALA bound specialties.

If your Medicaid patients pay 80 cents on the dollar, I am wildly jealous.

 

[Raryn]

NPs and PAs would get a 8% increase. Crazy that EM and ID are getting paycuts after being at the forefront of this epidemic.

So I wanted to point out here: This is not a proposed pay increase for NPs and PAs. Not directly at least.

This is the culmination of multiple years of efforts to get outpatient (clinic) doctors paid more - it has been commonly accepted that physician specialties that see patients in the clinic and don't do procedures are (relatively) underpaid. So the codes that describe that work are getting updated - and what that means is primary care doctors and outpatient specialists are going to be paid more. Well, by statute, medicare has a fixed pot of money each year that they project out, so if outpatient evaluation and management codes are paid more, that means everyone else (people who work in hospitals, radiologists, surgeons) gets paid relatively less. One slice of the pie getting bigger means there's less pie for everyone else.

So they projected out what might happen with the distribution of reimbursements based on those changes. Specialties that spend a lot of time in clinic and bill a lot of E&M codes go up in reimbursement, including my own (and I will fully admit endocrinology is supposed to get the largest increase in pay). So do the majority of midlevels. So do PCPs. This is all relative to the codes that have historically been billed by those providers.

But then it's a question of where that money came from. The relative value units for Emergency Medicine codes (or radiology codes, or critical care codes) isn't changing downwards - it's just that medicare is projecting that the *total* RVUs done by *all billing providers* in 2021 will be higher, so each RVU will be worth a smaller number of $, due to the money being divided by a larger number. Because the pot of money is fixed.

A PA billing primarily Emergency Medicine (or critical care, or whatever) codes will see the same proportional decrease as an MD/DO. It's just that PAs are far more common in primary care, so that the overall average PA will see the 8% increase.

 

[maxxor]

I mean the nuts and bolts of the proposal is this:

the Medicare RVU conversion factor is dropping from $37 to $32. If your specialty’s billing codes did not get a >10% increase in their re-valuation, you’re taking a paycut. Radiology got very few codes upgraded, so we are looking at a 10-11% paycut. EM still bills E&M codes, so their hit is less.