Mount Sinai professor: Why Medicare should pay physicians more for treating sickest patients

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CMS' plan to change Medicare payments to a flat rate per visit regardless of a patient's sickness could have harmful consequences for severely ill patients, a professor of medicine argues in a STAT op-ed.

Five insights from the op-ed, written by Timothy Sullivan, MD, an assistant professor of medicine in the Division of Infectious Diseases at the Icahn School of Medicine at Mount Sinai in New York City:

1. Dr. Sullivan discussed one patient with a complicated condition who had a comprehensive visit at his infectious diseases clinic that lasted over an hour. Dr. Sullivan billed the patient's insurance, Medicare, at the high rate for the most complex patients.

Medicare currently pays physicians $211 for a new visit with a complicated patient like the one Dr. Sullivan mentioned, compared to $76 for the simplest cases, but under the proposed changes, slated to start in 2019, the payment will be $135 for all new visits. "That means I would be paid the same for spending a few minutes caring for a patient with a runny nose as for treating [the complex patient]," Dr. Sullivan says.

2. "The effects of this policy could be catastrophic," Dr. Sullivan says. "Doctors will be pressured by clinic administrators to see more patients each day to maintain revenue, which will encourage them to treat more patients with simpler problems and fewer with complex, time-consuming health issues."

As a result, Dr. Sullivan says some physicians may send their sickest patients to emergency rooms as opposed to addressing their issues in the clinic, and others may stop seeing Medicare patients altogether.

3. Physicians who still treat the sickest Medicare patients may see lower incomes, Dr. Sullivan says, and medical students with hefty debt may be drawn away from lower-paying jobs in primary care. "Medicare's flat-rate plan, by contributing to a decline in income among physicians who treat complex patients outside of the hospital, would … discourage trainees from pursuing much-needed careers in primary care," Dr. Sullivan says.

The policy shift could also result in fewer available physicians, longer appointment waits and less time spent with the physician at every visit, Dr. Sullivan writes.

4. Medicare should therefore pay more, not less, to physicians who treat the sickest patients to improve care for vulnerable patients and encourage more trainees to enter primary care, Dr. Sullivan says. "By increasing payments for these visits, Medicare may still be able to cut overall costs," he writes. "Allowing doctors to spend more time with the neediest patients can prevent hospital admissions and other costly complications."

5. Paying physicians more for complicated visits may also encourage young physicians become primary care physicians while motivating existing physicians to give necessary treatment for the most complex patients, Dr. Sullivan says.

"Instead of broadly reducing reimbursement rates, Medicare administrators should consider how to better structure physician payments to help patients, reduce costs and foster a sustainable Medicare system," Dr. Sullivan writes.

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