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Doctors Are Managing More Complex Patients,
But E/M Payments Remain Stingy
Old-school E/M levels short-change docs in today's world


Medicare is doling out 1992-style payments for 2005-style evaluation and management services, insists a coalition of 27 physician-specialty societies and other physician organizations.

The Centers for Medicare & Medicaid Services and the Relative Value Unit Update Committee are approaching their scheduled five-year review of the Medicare fee schedule.

The 27 organizations want to see Medicare drastically increase RVUs for most E/M codes. In a Jan. 3 letter to CMS Administrator Mark McClellan, the groups say E/M payments no longer reflect the true cost of patient visits because:

Doctors are expected to be more proactive in preventing diseases as well as diagnosing and treating them. Congress has added a number of screening tests to the Medicare benefit, including the new "Welcome to Medicare" exam.

Doctors have to spend more time on documentation, including jumping through the hoops required by the 1995 and 1997 E/M documentation guidelines.

There's more information and more complex data for physicians to keep track of. Again, doctors have to manage multiple drugs, and there are more clinical guidelines to follow. Doctors have more screening and diagnostic tests to perform and consider in a patient's treatment regimen.

Patients are expecting to be active partners in treating their own diseases. They're surfing the Internet and reading newspaper articles before visiting the doctor, and thus asking more questions and expecting more discussions about treatment strategies.

Patients are expecting to communicate via e-mail and other electronic means.

Physicians must take account of genomics, including the concepts of genetic disease. Because scientists mapped the human genome, physicians have had more information to consider regarding genetic conditions. And physicians are more likely to use genetic information when choosing treatments for a variety of conditions.

Patients in the emergency department are more likely to be higher acuity than before. Also, volume has increased and so have malpractice risks.

The letter also presents data showing that the "intensity" of E/M services has increased. The average patient was older and had more complex diseases in 2002 than in 1992. Patients are leaving the hospital earlier than ever, and they're likely to be sicker when they check out. Patients are able to go home sooner because physicians are orchestrating their post-hospital care.