Congress and CMS keep tinkering with physician and other clinician reimbursement in Medicare. The most recent iteration was designed to move more toward value-based purchasing. Congress has required that a regular analysis be conducted of the impacts of the reimbursement method and levels. A presentation at the Medicare Payment Advisory Commission gives a current perspective. (MedPAC Presentation) For the last five years, the reimbursement increases and clinician spending per beneficiary have been very low. The commission staff looked at whether low reimbursement increases were increasing volume and/or intensity, or decreasing it. For basic primary care visits and major procedures, volume has grown at a steady and low rate for the last 15 years. For tests and imaging, the growth was more rapid early in the period and has plateaued. It generally appears unrelated to reimbursement method. Poor reimbursement could affect supply of clinicians, but the number billing Medicare has shown regular growth. Since 2009, the number of primary care physicians billing Medicare has risen about 2% annually, the number of specialty doctors has grown by 1.5% and the number of alternative providers, like nurse practitioners, has increased by 10.1% annually. Supply should be acceptable to provide timely services and there is a shift to cheaper professionals.
Medicare pays significantly less than commercial plans do for the same services. But so far that has not appeared to hurt Medicare access. Beneficiary surveys indicate no greater difficulty than commercial patients experience in getting appointments. Only about 14% of beneficiaries in 2017 reported significant issues in finding a provider. Reimbursement also does not appear to be impacting quality, either positively or negatively. The goal of Medicare reimbursement, according to MedPAC, are to ensure access, maintain good quality of services, and ensure prudent use of federal dollars. According to the current analysis, those goals are being met. If commercial reimbursement, however, falters, there could be bigger demands on Medicare for higher reimbursement. And if the gap gets big enough, access may become a problem. One further area that the commission notes needs ongoing attention is the shift in sites of service, primarily to outpatient hospital departments, which is raising costs.