Becker's Spine Review

13 PRACTICE MANAGEMENT CMS cuts physician pay, adds 5 orthopedic codes to ASC payable list By Laura Dyrda C MS released final rules for the 2024 Physician Fee Schedule and Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Nov. 2, and spine and orthopedic surgeons will see changes in 2024. CMS plans to cut overall physician pay 1.25% in 2024 and the conversion factor will be $32.74, a 3.4% drop from in 2023 despite also recognizing the highest medical practice cost inflation since 2000, with a 4.6 percent increase in the Medicare Economic Index. "CMS' final rule should put to rest how the bureaucracy and leadership view physicians," said Brian Gantwerker, MD, neurosurgeon and owner of e Craniospinal Center of Los Angeles. "e devaluation of healthcare and practice of medicine is proof positive CMS wishes to drive the train over the cliff and drive us into single payer. I think those that welcome the calamity will think otherwise when they have zero say in how their services are valued." Physician groups have also been critical of the decision. "is is a recipe for financial instability," Jesse Ehrenfeld, MD, president of the American Medical Association, wrote in a statement. "Patients and physicians will wonder why such thin gruel is being served. Physicians routinely have faced cuts in the last two decades. Yet, there is nothing routine about the past few years. Physicians have faced the COVID pandemic and subsequent burnout. ey have seen the costs soar for running a medical practice, while Medicare payment updates have offered too little relief." e declining pay could put access to care at risk. While most spine surgeons continue to see Medicare patients, sometimes at a loss to the practice, there could be a tipping point in the near future. "I believe this will accelerate current trends," said Harel Deutsch, MD, co-director of the Rush Spine Center in Chicago. "Physicians in private practice will not be able to sustain a practice treating Medicare patients. ere will be decreased access to care for Medicare patients and generally more treatment through nurse practitioners and physician assistants." In the final rule addressing pay to ASCs, CMS decided to keep aligning the ASC update factor with the hospital outpatient department payments update for the next two years, leading to a 3.1% pay increase for ASCs in 2024. e agency also added 11 surgical codes to the ASC payable list, including the following codes for orthopedic procedures: • 23470 (Reconstruct shoulder joint) • 23472 (Reconstruct shoulder joint) • 27006 (Incision of hip tendons) • 27702 (Reconstruct ankle joint) • 29868 (Meniscal transplant knee with knee scope) n Where spine practices are making, losing money By Carly Behm There are several factors behind what's profitable for a spine practice and what could be putting one in the red. Four spine surgeons told Becker's what's making spine practices money and what's holding back revenues. Note: Responses were lightly edited for clarity. Question: Where are spine practices making money? Where are they losing money? Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): Clearly the main avenue of making money is the outpatient surgery center and facility fees. Practices are likely losing money on patient visits and medicare surgery professional fees. Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Some spine practices are making money by doing more volume. Many practices hire midlevel practitioners to 'amplify' their reach and increase their work productivity. Whether or not this is a winning strategy is debatable, as continued reimbursement cuts administration after administration coupled with inflation, it seems doctors are running harder and faster for the same or less money. Money is being lost in practices on unnecessary employees and expenses. Practices have to look hard at how many full- time employees they employ and decide if you need two FTEs for each physician? Or would one FTE and one part- time employee cover them? Sometimes, physicians need to not be afraid to send their own faxes and answer their own emails. The more costly layers of expenses physicians ladle upon themselves and their business, the more bloat and cost it creates. Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): Spine practices make money when they have adequate insurance contracts with fair reimbursement or if they charge their patients fair price for their services that covers the costs of running the practice and allows for profit. Spine practices lose money when their insurance contracts do not adequately reimburse them. This especially applies to Medicare as they continue to lower physician reimbursements every year. Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Clearly the provider owned surgical clinics and hospitals are continuing their methodologies of money making, based on case mix and insurance base indices. While the non- patient discerning hospital systems have experienced another round of Medicare Physician Fee Schedule and Medicare Sequestration cuts (5% combined) for 2023. A recent internal polling of surgeon-physician patient payor mix revealed a greater than fifty percent Medicare and Medicaid shift among employed providers. The employed neurosurgical pool was even higher in these two underinsured populations. n

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