Differences in the Complexity of Office Visits by Physician Specialty: NAMCS 2013-2016

The Time Burden of Office Visits in Contemporary Pituitary Care, 2016 to 2019

BACKGROUND

The concept of "time toxicity" has emerged to address the impact of time spent in the healthcare system; however, little work has examined the phenomenon in the field of otolaryngology.

OBJECTIVE

To validate the use of Evaluation and Management (E/M) current procedural terminology codes as a method to assess time burden and to pilot this tool to characterize the time toxicity of office visits associated with a diagnosis of pituitary adenoma between 2016 and 2019.

METHODS

A retrospective cohort study of outpatient office visits quantified differences between timestamps documenting visit length and their associated E/M code visit length. The IBM MarketScan database was queried to identify patients with a diagnosis of pituitary adenoma in 2016 and to analyze their new and return claims between 2016 and 2019. One-way ANOVA and two-sample t-tests were used to examine claim quantity, time in office, and yearly visit time.

RESULTS

In the validation study, estimated visit time via E/M codes and actual visit time were statistically different (P < 0.01), with E/M codes underestimating actual time spent in 79.0% of visits. In the MarketScan analysis, in 2016, 2099 patients received a primary diagnosis of pituitary adenoma. There were 8490 additional-related claims for this cohort from 2016 to 2019. The plurality of new office visits were with endocrinologists (n = 857; 29.3%). Total time spent in office decreased yearly, from a mean of 113 min (2016) to 69 min (2019) (P < 0.001).

CONCLUSIONS

E/M codes underestimate the length of outpatient visits; therefore, time toxicity experienced by pituitary patients may be greater than reported. Further studies are needed to develop additional assessment tools for time toxicity and promote increased efficiency of care for patients with pituitary adenomas.

Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits

IMPORTANCE

Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing.

OBJECTIVE

To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing.

MAIN OUTCOMES AND MEASURES

Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration.

RESULTS

Under MDM-based billing, increased visit length was associated with decreased E/M revenue ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits ($400 432 vs $564 188). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of $846 273 occurred for 10-minute return patient visits under MDM-based billing.

CONCLUSIONS AND RELEVANCE

Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.

How to Pay for Telemedicine: A Comparison of Ten Health Systems

Telemedicine has the opportunity to improve clinical effectiveness, health care access, cost-savings, and patient care. However, payment systems may form important obstacles to optimally use telemedicine and enable its opportunities. Little is known about payment systems for telemedicine. Therefore, this research aims to increase knowledge on paying for telemedicine by comparing payment systems for telemedicine and identifying similarities and differences. Based on the countries' official physician fee schedules, listing all reimbursed medical services performed by physicians, a comparative analysis of telemedicine payment systems in ten countries was conducted. Findings show that many countries lacked tele-expertise and telemonitoring payment, with the exception for some specific payments such as for telemonitoring in patients with cardiac implantable electronic devices. Moreover, a wide variety of benefit specifications were implemented in all countries to specify which type of clinician contact should be used (remote versus physical) in which circumstances. Payment parity between video and in-person visits was established only in a few countries. Furthermore, fee-for-service was the dominant payment system, although two countries used a capitation-based or hybrid system. The results imply several potential payment challenges when implementing telemedicine: complex benefit specifications, payment parity discussions, and risk of overconsumption due to the dominant fee-for-service system. These challenges appear to be less present in capitation-based or hybrid systems. However, the latter needs to be further explored to harness the full potential of telemedicine.