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CMS Billing Rules Subjugate Family Medicine – Payment for Complexity and Time

July 6, 2014

I’m continuing my series on the reasons there are so few family physicians in the U.S. and why the Center for Medicare and Medicaid Services (CMS) is a root cause of this deficit. My conclusions are based on recent research on the topic.

If you hired an accountant to do your taxes and after she was just about wrapped up with your IRS forms and you found a box of receipts and business expenses you forgot to give her; or if you hired an attorney and asked him to read more documents or talk to additional witnesses or experts, what would you expect their bills for their professional services to look like?

Of course, you wish they would do the extra work and not bill you. Some people might actually be angry that these professionals don’t just give away their services. Most reasonable people would accept additional charges for the additional work. How does CMS handle similar situations for family physicians? CMS says family physicians should just give away their services.

Family physicians have an ethical fiduciary responsibility to their patients, which means they should do the right thing no matter the payment. But CMS has built a payment system where family physicians are asked to do this multiple times a day. Family medicine is drowning in a sea of unfunded mandates from CMS. It’s simply not justifiable or sustainable.

Family physicians I directly observed needed to take extra time to care for their office visit patients about 25% of the time. The extra time was not extensive, about 5 minutes in many cases. But 5 minutes times 25% times 100 visits a week adds up fast. This does not include physicians responding to phone calls, faxes from nursing homes, family members asking questions, etc. Estimates are that 20%-50% of a primary care physicians’ time is spent in unpayable activities because of the CMS rules that practically all insurance companies have adopted as well.

So if you ever asked your family physician to spend extra time reading through a thick stack of old hospital records, and it felt like he or she just skimmed them and merely referred you to another facility or doctor, you’re actually probably right. They’re not paid a dime for doing it or other types of work that required extra time to think, and the CMS fees create no fat to pay for this time in an indirect manner. It’s only human nature to develop work-arounds when a task is unrewarded and family physicians are no exception.

Patients want their doctors to spend necessary time caring for them, but CMS and the complicit insurance companies have created rules that make this fiscally impossible. Patients deserve better.

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