Centers for Medicare & Medicaid Services (CMS) is the federal agency that administers the Medicare program and is responsible for the policies within the Medicare PFS. However, CMS also must operate under the requirements set by Congress under the law.

OBFA and other aligned stakeholders are taking our message both to CMS and the Congress to advocate for permanent relief from the cuts that have been so devastating to office-based interventional care for years.

The Medicare Physician Fee Schedule (PFS) is one of several annual Medicare reimbursement regulations. In general, the PFS regulation reimburses physicians, therapists, and other practitioners for the care they provide to Medicare patients under the Traditional Fee-For-Service Medicare program.

It's important to note that while the HOPPS and ASC Fee Schedules include only technical payments (e.g., the high-technology equipment, supplies and other interventions that have been a hallmark of the U.S. healthcare system) for HOPDs and ASCS, the PFS includes technical payments for office-based providers plus professional payments for physicians in all settings (e.g. HOPD, ASC and office). As a result, PFS technical payments currently “budget-neutralize” office-based supplies and equipment to dissimilar items such as professional payments for physician work in the hospital.

These non-sensical reimbursement streams are one of many reasons why the so-called PFS budget-neutrality provision is a significant concern. When the PFS “budget-neutralizes” it does not do so for all professional and technical services in the PFS, HOPPS, and ASC settings. Rather, the PFS only budget-neutralizes for physician work and office-based technical resources, while leaving HOPPS and ASC reimbursement outside of PFS budget-neutrality effects. This dynamic contributes to the significant payment volatility within the PFS.

Included in PFS Budget Neutrality

• Office Technical Component

• Office Professional Component

• Hospital Professional Component

• ASC Professional Component

Not Included in PFS Budget Neutrality

• Hospital Technical Component

• ASC Technical Component

Rationalizing ambulatory payment systems could involve ambulatory (HOPD/ASC/Office) technical payments being paid within a single ambulatory technical fee schedule outside of the PFS and reserving the PFS strictly for reimbursement of professional payments.

There are actually two regulations to keep on your radar. The first is the “proposed” PFS regulation, which is usually issued in the summer and proposes regulations for the following calendar year. The “final” PFS regulation is usually issued on or around November 1.

One key reason is that survey data utilized by the Medicare Payment Advisory Commission (MedPAC), the entity tasked to advise Congress on Medicare payment issues, does not focus on office-based interventional care. For example, in its March 2024 Report to Congress, MedPAC states:

• In a 2022 survey by the American Medical Association (AMA), among nonpediatric physicians accepting new patients, 96 percent reported accepting new Medicare patients; 2 percent said they accepted only new privately insured patients (American Medical Association 2023b).

• A survey that focuses on the subset of physicians who work in office-based settings also found that comparable shares of physicians accepted Medicare and private insurance. In 2021, the National Ambulatory Medical Care Survey found that, among the 94 percent of nonpediatric office-based physicians who reported accepting new patients, 89 percent accepted new Medicare patients and 88 percent accepted new privately insured patients (Schappert and Santo 2023).

There are a number of problems with these analyses:

• In the same report, MedPAC references the study “Recent Changes in Physician Practice Arrangements: Shifts Away from Private Practice and Towards Larger Practice Size Continue Through 2022” . This study validates concerns that private practice physicians are closing their doors.

• The National Ambulatory Medical Care Survey is not an accurate measure of the health of office-based interventional care for a number of reasons:

  • (a) it does not include therapy in any site-of-service,

  • (b) many other provider types of concern (vascular surgery, interventional radiology, interventional cardiology) may not be well represented in the NAMCS survey based on a 2016 public use file for the survey,

  • (c) when an office-based provider no longer accepts Medicare, that typically means they will have closed the center, retired, or migrated to a new site-of-service and, therefore, would not be a participant in the survey,

  • (d) the survey would not reflect the fact that the number of office-based specialists overall is shrinking, and

  • (e) the National Hospital Ambulatory Medical Care Survey will no longer be conducting surveys going forward

• A much better representation of the health of office-based interventionalists is the multi-specialty (SVS, SCAI, SIR, OEIS) survey, which found the following:

  • 94% of respondents say that recent changes to the Medicare Physician Fee Schedule are having a negative impact on their practice.

  • 65% said Medicare changes are having a “very negative” impact on their practice.

  • 26% of doctors said that they are “likely” or “very likely” to close their practice in the next two years.

  • 43% of survey respondents said they were likely to retire in the next two years.