2013 Legislation Could Mean Pain or Gain for Emergency Physicians

As I’ve spoken with ED docs in the last several weeks, many have expressed concerns about potential impacts to their financial livelihood. Medicaid payment cuts, continued growth in managed care, lower negotiated rates with insurers and other factors have led to an overall decline in annual growth of physician earnings for more than a decade now.

It appears as though lawmakers are trying to stem further erosion of physician compensation. Congress passed the American Taxpayer Relief Act in January, which means emergency physicians can breathe a tentative sigh of relief—at least temporarily. The legislation postponed yet again the dreaded sustainable growth rate cuts. In place of the cuts, a zero percent update to the conversion factor used to calculate Medicare Physician Fee Schedule payments was instituted. So, while emergency physicians won’t be seeing an increase in 2013, at least the drastic reduction in reimbursement rates has been averted. The bill also delayed the sequestration issue, but only until March 1. Unless Congress finds an alternative to sequestration, there will be a 2 percent reduction in physician fees, and that decrease will affect emergency physicians.

One program emergency physicians will want to participate in this year is the Physician Quality Reporting System (PQRS) program. 2013 legislation has introduced two Medicare reimbursement-related matters that could cause some pain, but according to the CMS, emergency physicians historically have had the highest PQRS participation rate, so more likely it will result in financial gain.

First, under the program, 2013 results will drive 2015 penalty adjustments.  The 1.5 percent penalty scheduled to take effect in 2015 will be based on 2013 performance, and the penalty will increase to 2 percent in 2016. The good news for ED physicians? None of the new PQRS measures for 2013 are applicable to emergency medicine, and four previous emergency medicine measures have been eliminated for this year’s performance reporting.

The second matter involves group practices that employ at least 100 emergency physicians. The physicians in these practices must participate in the PQRS program as a group if they wish to avoid incurring a penalty in the form of the value-based payment modifier. Individuals do not have to register to participate, but practices need to submit a self-nomination statement before October 15, 2013. There is also an administrative claims option this year that is acceptable for the purposes of the modifier. Unless groups either self-nominate by the October deadline or choose the administrative claims option, they will be faced with a 1 percent value modifier downward fee adjustment in 2015, in addition to the 1.5 percent PQRS payment adjustment.

Although the PQRS program may seem like yet another time-consuming responsibility that interferes with patient care, the incentives can make the effort worthwhile. The average payout in 2009, according to CMS, was nearly $2,000 per eligible professional and almost $20,000 per practice. And, information systems and vendor services can make compliance easier. For example, some electronic health records (EHR) incorporate PQRS metrics in the documentation to ensure the information is captured. If the system captures the metrics discretely, it can produce detailed compliance reports. Some billing vendors automatically capture and report this information because of the impact to a physician’s earnings.

Ultimately, the PQRS program will be the basis for the Value-Based Modifier (VBM) initiative. Under this initiative Medicare will use cost and quality information to calculate payments. By 2017, CMS expects the VBM to be applied to all providers.  But this year, emergency physicians can find opportunities to still benefit from PQRS while participating in the hopeful venture of helping create high-quality efficient healthcare.

— Sunny Sanyal, CEO of Dallas-based T-System, Inc.