How much of a pay cut for orthopedic doctors are we talking about?
If I’m reading CMS data correctly, then for TKA, the total RVU (ignoring small geographic and other adjustments) is 39.12. A total RVU includes office costs, malpractice costs, and the “work RVU” for the work done by the surgeon on the patient. The 2018 conversion factor (dollar value of one RVU) is $35.996. The work RVU is 20.72. So, $35.996 x 20.72 comes to total surgeon pay of $745.84 for the evaluation, surgery, and the post-op visits in the 90 days after surgery.
The CMS table indicates that the work RVU is divided into 10% for pre-surgery, 69% for the surgery, and 21% for those patient visits in the 90-day post-op period. That calculates to $156.63 in payments for postoperative care to the surgeon (or others paid under the CPT code).
Suppose CMS were to conclude that allfollow-up in that 90 days was not being done under the code (which seems highly unlikely). Then, theoretically, the surgical practice (or hospital) surgeons would be at risk of losing $156.63 (21% of $745.84).
In addition, if CMS were to agree with Anthem that the typical time for the surgery itself is less than the time embedded in current RVUs, then that 69% of the work RVU might also be reduced. To pull a number out of the air: a 10% reduction in that part of the work RVU would take $51.42 from the surgeon.
Even if CMS were to make much smaller reductions in the work RVUs for TKA and THA, the longer-term effect on orthopedics could be much larger because Anthem wants CMS to review every surgical code.
To see these codes and details in a table, go to this URL, click the agreement, input 27447 into the CPT code field, and choose “all” under “type of information.”
Would CMS grant Anthem an RVU windfall?
Yet another question: If specialist RVUs are reduced, would CMS simply let Anthem and other MA plans keep that windfall, or would CMS commensurately cut their flat payments in order to pull those savings into the government’s coffers?
Presumably, over the long run, the federal government would want to capture those savings. However, in order to act, CMS needs to first understand an issue (which might require action from a Congress which has so far been very MA-friendly), then collect data. Once CMS has data, rulemaking moves at a glacial pace. If CMS cuts specialists’ RVUs, MA insurers might see several years of windfall profits at the expense of surgeons before CMS were to catch up.
Is Anthem alone in this?
Apparently, yes, for now.
However, once other insurance companies, especially those with MA plans, get a whiff of the potential profit to be made, chances are that they’ll jump into the fray. There is an initial comment period ending December 31. This comment period might reveal other insurance companies joining the attack.
