Physician billing guidelines are counter-productive. Will the new CMS rule make things worse?

In a Health Affairs blog and an Inside Angle podcast discussion, the health policy expert, physician and self-styled contrarian, Bob Berenson explains why the Evaluation and Management (E/M) coding guidelines for Medicare physician billing have made electronic records difficult to use, added an immense burden of administrative work to practicing clinicians and have added up to $50 billion in expenses to the U.S. healthcare system.

He says there is wide agreement we need to do something different, but that the CMS rules to flatten E/M payment could create even more problems. In particular, he says the flattened payment structure creates an immense incentive for shorter doctor/patient visits. This will further reward physicians who engage in rapid procedures (e.g. dermatology) while further punishing physicians who need to take more time to understand complex patients and symptoms (e.g. primary care, internal medicine subspecialties).

As most Medicare beneficiaries have multiple and complex conditions, the short-visit incentive is likely to have a negative impact on quality and satisfaction, which in turn is likely to drive up costs in the long run.

In our conversation, Dr. Berenson describes the unfortunate outcomes of a “measure what you can” as opposed to “measure that which is important” strategy.  He describes the unreliability of data in electronic medical records that is perpetuated over time through “cut and paste.”

As part of a larger solution, he suggests CMS expand on time-based billing already in existence for some types of services, as this would provide a more equitable payment structure. 

When I reflect on the current state of U.S. health care compared to the amount of time, effort and expense we have poured into improvement attempts, I think it may be time to consider a contrarian’s view.

L. Gordon Moore, MD, is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.