Expected Changes in Physician Outpatient Interventional Practices as a Result of COVID-19 and Recent Changes in Medicare Physician Fee Schedule.

OBJECTIVE: To examine the economic and practice effects of COVID-19 and decreased Medicare physician payments on outpatient vascular interventional procedures.
METHODS: A 21 point survey was constructed and sent electronically to the physician members of the Outpatient Endovascular and Interventional Society and the American Vein and Lymphatic Society. Survey responses were converted to a Likert scale and statistical analyses performed to examine the association between the response variables and the characteristics and practice patterns of the physician respondents.
RESULTS: A total of 165 physicians responded to the survey of which 33% were vascular surgeons, 18% were radiologists and 15% general surgeons. Slightly more than half (55%) had their interventional practice limited to the office setting while the others also performed procedures in an OBL, ASC or the hospital. Almost all performed superficial venous interventions with slightly more than one-third also doing either deep venous procedures and/or peripheral arterial interventions. The COVID-19 pandemic impacted 98% of practices with staff shortage reported by 63%. The most established physicians, those with more years since completion of training, were least likely to have experienced staff shortages. Almost all, 94%, expect that the recent Medicare payment changes will have a negative effect on their practice. Physicians with only an office-based practice are less likely to add a physician associate as compared to those with an OBL (P=0.036). More than one quarter think it likely they will close or sell their interventional practices in the next two years while 43% plan to retire early. Anticipated ameliorative responses to the decreased Medicare physician payments include adding wound care (24%) or other clinical services (36%) to their practices, alternatives being considered more by younger physicians (P=0.002) and non-surgeons (P = 0.047). Only 10% expect to convert their practices to an ASC or hybrid ASC/OBL (16%).
CONCLUSIONS: The emotional and economic effects of the COVID-19 pandemic and decreased Medicare physician reimbursement rates for vascular outpatient interventionalists have been significant. Even greater challenges for the financial viability of office practices and OBLs can be expected in the near future if additional further planned cuts are put into effect.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the treatment of patients with vascular disease. Nationally, 91% of vascular surgeons reported elective surgical procedures being cancelled at their hospitals during the pandemic. On the other hand, nationally 49% of office-based laboratories (OBL) stayed open with regional variability ranging from 69% staying open in the Southeast to only 20% in the Midwest, As multiple hospitals cancelled elective surgical procedures for weeks at a time, OBLs, ambulatory surgery centers (ASC) and physician offices provided care for both elective and emergency procedures. This off-loading of patient volume to outpatient centers provided critical health care access for patients with previously demonstrated comparable efficacy and high patient satisfaction. , However, a large decrease in the number of surgical procedures and office visits, associated with higher expenses required to mitigate COVID-19 transmission, caused a significant financial challenge to vascular practices. In addition, the COVID-19 pandemic had a substantial mental health impact on vascular surgeons, who are already at high risk for burnout, have low career satisfaction and quality of life.

In addition to the continuing medical impact of COVID-19, physicians with outpatient vascular interventional practices have sustained further financial challenges with significant reductions in reimbursement by the Centers for Medicare and Medicaid Services (CMS) which were implemented in 2022. Although the initial proposals would have had a 13.75% decrease in physician reimbursement, Congressional action on December 9, 2021, provided additional funding which reduced the proposed cuts to 3.75% by the end of 2022. Nonetheless, the final effect on vascular surgery is still estimated to be an overall decrease in reimbursement of 7.4% by July 1, 2022, and cuts to arterial revascularization and outpatient venous procedures reimbursement in the office and OBL setting of over 20% in the same time period. A combination of budget neutrality for physician payment under Part B of Medicare and impact of inflation has already had a cumulative effect of a 20% decrease in procedural reimbursement for vascular procedures over the past decade, and an even greater decrease of 42% for venous procedures.

We undertook this study to examine the economic and practice effects of COVID-19 and the decreases in the Medicare physician fee schedule on interventionalists performing vascular outpatient interventional procedures and expected changes in their practices. A survey for this purpose was designed and sent to the members of two societies primarily involved in outpatient vascular interventions, the Outpatient Endovascular and Interventional Society (OEIS) and the American Vein and Lymphatic Society (AVLS).

Materials

A 21 point survey was created (Online Supplement 1) and sent electronically via a Doodle poll (Doodle.com; Zurich, Switzerland) on February 1, 2022, to the physician members of the OEIS (n= 350) and the AVLS (n= 815). Non-physician members and physicians in training were excluded. Emails were sent to the registered email address of the members. Physicians who were members of both societies (n=27) were electronically limited to only one response and linked to the society through whose request they first responded. Repeat email requests were sent to non-responders for a total of five requests during a two-week time period. All responses were anonymous and confidentially was maintained throughout the survey process. The survey was reviewed and approved by the Research Committee and the Executive Committee of the OEIS. Informed consent and Institutional Review Board review were not deemed necessary due to the anonymous nature of the survey.

Methods

Statistical analyses were performed with SAS software, version 9.4 (SAS institute Inc; Cary, NC). Multivariable logistic regression was used to examine the association between the response variables and explanatory variables, which included the characteristics and practice patterns of physicians. Survey responses were converted to a Likert scale of 1 through 5: Very likely=5, likely=4, Neither likely nor unlikely=3, unlikely=2, very unlikely=1. The final multivariable logistic regression model selected was based on stepwise selection. The p-value for the Hosmer-Lemeshow goodness of fit test was 0.44 indicating that the model adequately fits the data. The same set of explanatory variables were included in a series of multiple linear regression models with the response outcome variables, which included COVID impact, Medicare payment impact, adding physician associates, closing practice, selling practice, becoming employee, retiring, converting to ASC, converting to ASC/OBL, adding wound care, adding other services and a summary score of future personal and practice change. The final models for each response variable were determined by the significance of the model and the model selection criteria, Akaike information criterion (AIC). All the explanatory variables were included in the initial model and then removed based on the model AIC. The final models satisfied the assumptions of normality and constant variance. The descriptive data is expressed as mean + standard deviation. The analytical results were considered to be significant when p-values were less than or equal to 0.05 or the 95% confidence intervals (CI) for odds ratios (OR) did not contain 1.

Results

Physician and Practice Characteristics

A total of 165 physicians (14%) responded to the survey taking 5.8 + 0.0 min for its completion. Of the respondents, 3 declined to identify their society membership, 23% (38) belonged to the OEIS, 77% (124) to AVLS with 10% belonging to both societies, reflecting a representative distribution of the societal physician memberships, 350 and 815, respectively. Those who were members of both societies were listed among the society through which they responded to the survey. The plurality of respondents, 33%, were vascular surgeons while 18% were radiologists and 15% general surgeons (Figure 1 ). The 16% self-described as Other included 15 vein/phlebology specialists, 4 cardiothoracic surgeons, 3 emergency medicine, and 1 each in vascular medicine, cosmetic surgery, preventive medicine and obstetrics-gynecology.

Figure 1

Specialty of physician respondents to the survey.

Slightly over half of the respondents (90/165; 55%) had their interventional practice limited to the office setting while 12 (7%) did procedures solely in an OBL, 2 (1%) just in an OBL/ASC and 1 (0.7%) solely in the hospital outpatient setting (see also Table 1 ). Multiple practice locations were reported by 60 (36%): 38 (23%) being office + OBL, 22 (13%) office + OBL/ASC, 26 (16%) hospital + OBL or OBL/ASC, and 3 (2%) being office + hospital. Reflecting the majority of office-based practitioners, more than half were single-physician practices. Almost all, 99%, performed superficial venous interventions with slightly more than one-third doing deep venous procedures and arterial interventions (Table 1). Almost half of the respondents, (71/165; 43%), performed more than one intervention type with the most common being superficial venous in combination with both deep venous and peripheral arterial (51/165; 31%) while superficial venous and cardiac interventions were performed by 3% (5/165) or with deep venous by 4% (6/167) or with other combinations by 5% (9/165).

Table I

Practice and Physician Characteristics

	Number	Percentage
Highest InterventionalPractice Type∗
Office-based Practice	90	55%
OBL	46	28%
Hybrid OBL/ASC	24	15%
Hospital Outpatient	4	2%
ASC only	0	0%
Physicians in practice
1	81	53%
2	25	16%
3	11	7%
4	6	4%
5	8	5%
6	22	14%
Clinical Practice
Venous - Superficial	164	99%
Venous - Deep	63	38%
Peripheral Arterial	60	36%
Cardiac	12	7%
Employment Model
Practice Owner	125	76%
Private Practice, but not the Owner	23	14%
Multi-specialty Group Employee	9	5%
Hospital Employee	8	5%
Years since training
1-5 years	9	5%
6-10 years	7	4%
11-15 years	29	18%
16-20 years	23	14%
20+ years	96	59%
Years in interventional
1-5 years	16	10%
6-10 years	24	15%
11-15 years	37	23%
16-20 years	30	18%
20+ years	56	34%

For physicians performing interventional procedures in multiple locations, highest level of practice location was ranked as OBL/ASC > ASC > OBL > Hospital > Office.

Reflecting the memberships of the two societies that were surveyed, 90% of members were in private practice as owner or partner, more than half were more than 20 years out of training with 16 years or more of experience with interventional procedures (Table 1).

Survey Results

A staff shortage was reported by 63% (103/163) of respondents with 70% of them facing specific difficulties in hiring and retaining nursing staff (50%), administrative office staff (31%) and vascular technologists (28%) mostly due to salary expectations. The COVID pandemic was felt to have impacted the respondents’ practice in 98% of cases with 2 of the 4 who felt it had no impact being hospital-employed physicians (Figure 2 A). Similarly, 94% of physicians expect that the recent Medicare payment changes will have a negative or very negative impact on their OBL practice (Figure 2B). Two thirds (112/165; 68%) thought it unlikely or very unlikely to add physician associates to their practice in the next two years. On the other hand, more than one quarter felt it likely or very likely to close or sell their interventional practices in the next two years (Figures 3 ). Seventeen percent expected to become a hospital or group practice employee while 43% were likely or very likely to retiring earlier than planned (Figure 4 ).

Figure 2

A. How significantly has COVID impacted your practice?. B. How much of an impact will the Medicare payment changes have on your OBL?

Figure 3

A. What is the likelihood of closing your interventional practice in the next two years? B. What is the likelihood of selling your interventional practice in the next two years?

Figure 4

A. What is the likelihood of you becoming a hospital or group practice employee in the next two years?. B. What is the likelihood of you retiring earlier than planned?

Converting to an Ambulatory Surgery Center in the next two years was seen as likely by only 10% (16/154) and to a hybrid ASC/OBL model by 16% (23/143) (Online Supplemental Figure 1 and 2). More respondents were likely to add wound care (24%; 32/131) or other services (36%; 51/140) to their practices (Online Supplemental Figure 3 and 4). Other services included cosmetic/aesthetic procedures, interventional oncology, lymphedema care, and MedSpa services. The responses in the open Comments question primarily expressed deep concerns about the financial viability of their OBL and clinical practices in the context of recent CMS reimbursement changes and anticipated decreases in physician payments in the non-facility outpatient setting.

Multivariable Analysis

A multivariable analysis was made to ascertain potential relationships between clinical practice and physician characteristics and expected changes due to the COVID pandemic and CMS physician fee schedule implemented in January 2022. The most established physicians were least likely to have experienced staff shortages. For each category increase since completion of training (see Table 1), the odds ratio of a staffing shortage was 0.53, meaning a decrease of 47%. The odds ratios for those in private practice, multi-specialty groups or hospital employees increased when compared to practice owner but did not reach statistical significance. There was a significant association between practice type and the likelihood of adding additional physicians within the next two years (P=0.036). Office-based practices were less likely to add a physician associate while those with an OBL were more likely to do so (Table 2 ). Adding other clinical services is less likely by older physicians and surgeons when compared to cardiologists and radiologists. (Table 2). Expected practice change, a composite outcome of converting to an ASC or ASC/OBL, adding wound care or other services, was found to be less likely in an office-based practice (P=0.0088) as compared to those in an OBL and more likely by younger physicians (Table 2).

Table II

Multivariable Analysis of the Impact of COVID-19 and Medicare Reimbursement Changes

	Staff Shortage∗	AddPhysician ‡	Add Other Services #	Practice Change#
Specialty	NS			NS
Surgery (reference)
Cardiology			-0.886 (0.0153)
Medical			0.090 (0.7863)
Other			0.143 (0.5953)
Radiology			-0.578 (0.0468)
Society Membership	NS
AVLS (reference)
OEIS			-0.114 (0.6249)	1.535 (0.1823)
Practice Type	NS	P=0.036	NS
Office Based Practice (reference)		75
OBL		98		-2.618 (0.0088)
Hybrid OBL/ASC		81
Hospital Outpatient		83		-2.644 (0.1219)
Physicians in practice	1.16 (0.93, 1.44)		0.002 (0.9618)	NS
Clinical Practice	NS		NS	NS
Venous Superficial (Reference)
Venous - Deep
Peripheral Arterial
Cardiac
Employment Model			NS	NS
Practice Owner (Reference)
Hospital Employee	1.86 (0.32, 10.85)
Multi-specialty Group Employee	2.70 (0.49, 14.92)
Private Practice -Not owner	4.49 (0.91, 22.20)
Years since Training	0.53 (0.34, 0.85)		0.361 (0.0018)	0.677 (0.0170)
Years in Interventional	1.42 (0.97, 2.08)		-0.158 (0.1270)	NS

Odds ratios with 95% confidence intervals from logistic regression;

Estimated coefficients with p-value from multiple linear regression; NS = variables not significant

Kruskal–Wallis testing with mean rank score when p-value less than 0.05

Discussion

Over the past fifteen years, there has been a significant increase in the performance of interventional vascular procedures performed in the office, OBL and ASC locations. It is estimated that there are now more than 750 OBLs and 5,000 ASCs in the United States, far surpassing the number of hospitals and accounting for the majority of outpatient surgical procedures. , This reflects the safety and efficacy of these procedures in the non-facility setting, both in a private practice and academic situation, with clinical results equivalent to or better than when performed in the hospital. , , The American Vein and Lymphatic Society is the largest professional society focused on venous care while the Outpatient Endovascular and Interventional Society is a multi-disciplinary organization with members performing outpatient venous, arterial, and cardiac outpatient procedures primarily in the OBL setting. As such, a survey of the members of these two societies provides valuable insights on the effects of both COVID-19 and recent Medicare reimbursement physician payment policies on outpatient office-based vascular interventions.

The survey respondents represent a broad distribution of specialists (Figure 1) working in the office, OBL, and hybrid OBL/ASC environments (Table 1). Their clinical practice similarly reflects a focus on superficial and deep venous interventions along with peripheral arterial procedures. With a majority being single-physician independent private practices with more than 16 years since training and a similar length of experience performing interventional procedures, they have been directly involved in patient care during the COVID pandemic and have suffered the associated financial challenges. More importantly, as private independent physicians, they are also directly responsible for managing the practice, staff recruitment/retention and maintaining the financial viability of their practices. It is therefore relevant to note that 98% felt that COVID had impacted their practice. This is very similar to the MGMA survey reporting 97% of 724 medical practices being negatively affected and the reduction in income by 79% of plastic surgeons in private practice. A staff shortage was reported by two thirds of respondents with specific difficulties seen in hiring and retaining nursing staff, administrative office staff and vascular technologists mostly due to higher salary expectations. Such recruitment and retention difficulties may be the result of the increased stress encountered during COVID by health care workers and desire to decrease their work hours, possibly due to increased governmental unemployment benefits. These have resulted in both a professional and economically stressful effect on outpatient vascular proceduralists. The most established physicians were least likely to have experienced staff shortages, possibly due to longer physician-staff relationships and stronger financial status.

With the COVID pandemic not yet completely resolved, OBLs and office practices have faced a new and additional economic challenge due to the decreased payments under the new physician fee schedule from CMS implemented in January of 2022. Although ameliorated to some degree by Congressional action, by July 1 of 2022, physician payments under Medicare Part B will decrease by 0.75% due to the Conversion Factor required for evaluation/management code changes, a cut of 2% for sequestration required by the Budget Neutrality Act of 2011, and an additional cut of 1% for Clinical Labor Update costs (with additional 1% yearly cuts for the subsequent 3 years). This overall 3.75% decrease, however, is not evenly distributed and disproportionately affects interventional practices with high equipment and supply costs. For example, cuts to arterial revascularization and outpatient venous procedures reimbursement in the office and OBL setting are estimated to reach more than 20%. The Society for Vascular Surgery has estimated that there will be a $44 million decrease in payments for outpatient vascular interventions in 2022. While physicians are facing these cuts there is a planned a 3.2% increase in payment to hospitals and 8.5% to Medicare Advantage insurers, both of which are not bound by budget neutrality rules as are physicians. , In this context, it is not surprising that 94% of the respondents in the survey expect that the recent Medicare payment reductions to physicians will have a negative impact on their practice (Figure 2B). More than one quarter felt it likely that they will close or sell their interventional practices in the next two years (Figures 3) with 17% of them expecting to become a hospital or group practice employee (Figure 4). Such an expectation would be a continuation of present trends wherein by the January of 2022 fully 74% of all physicians in the United States were employed by hospitals or corporate entities, a 19% increase during the past three years. Unfortunately, such practice consolidation leads to greater cost and expenditures for health care and decreased access to care, especially for marginalized underserved populations who may not be able to afford the higher co-pays in the non-office setting. , Changes in Medicare reimbursement for dialysis access led to the closing of 20% of dialysis centers in 2017. Furthermore, the economic impact of Medicare re-imbursement decreases will not be limited to just the care of Medicare patients. Private commercial insurers follow the lead of Medicare in payment policies.

As a result of these decreases in re-imbursment, two-thirds of the survey respondents thought it unlikely that they would add other physicians to their practices. This is consistent with recent survey of 92 medical groups of which 42% expect to implement a delay or have a hiring freeze.76 Office-based practices were less likely to add a physician associate while those with an OBL were more likely to do so (Table 2), probably because of a stronger financial status of the latter group. Compensating for these financial changes, most physicians anticipate expanding their clinical practice by adding wound care or other services (Online Supplemental Figure 3 and 4). Older physicians and surgeons were less likely to do so, possibly because they may already be providing additional services or because they see less of a long-term need to do so. The need to expand scope of practice to account for decreased reimbursement has also been espoused by other specialties. , However, only a minority anticipate adding an ASC or hybrid ASC/OBL, likely due to the significant conversion costs and regulatory burdens.

Among the survey’s most concerning results were those indicating that 16% of physicians feel it very likely, and another 27% likely, that they will retire early. This is of great concern as prior studies have demonstrated that expressed intent to leave correlates well with actual departures. , In a national survey of more than 20,000 health care providers, 24% of physicians and 33% of mid-level providers indicated that they were likely to leave their current practices within 2 years due to COVID related stress, with those in practice for greater than 20 years being two and a half times at higher risk. This is not dissimilar to our survey’s finding that 27% of respondents are likely to close or sell their practice within two years (Figure 3) and an even higher percentage planning on early retirement (Figure 4). Similar results have been found in surveys of primary care physicians lending credence to an expected exacerbation of physician shortages in the next two years. The impact on vascular surgeons, and related specialties performing outpatient vascular procedures, can also be problematic if it discourages medical students from entering this field of practice.

As with many surveys, a limitation of this study is that the reported information is based on a response rate from a minority of subjects. There is therefore the possibility of response bias in that those who responded might have been more likely to be negatively affected by COVID or the changes in reimbursement policy. Similarly, respondents’ actions may be different than their stated expectations. However, in the presence of high inflation and additional proposed CMS cuts next year, the financial repercussions may be even worse than they expected when completing the survey.

Conclusions

The emotional and economic effects of the COVID-19 pandemic on physicians have been significant. For vascular proceduralists, the additive effects of the cuts in reimbursement instituted by Medicare in 2022 portend even greater challenges for the financial viability of office practices, OBLs and OBL/ASC. The requirement for budget neutrality in Medicare Part B payments for physicians, no adjustment for inflation in physician payments since 2001, and the annual inflation rate now at 9.1%, a forty year high, all indicate impending economic hardships for physicians providing outpatient vascular care in the non-facility setting. It appears that structural changes in CMS physician reimbursement calculations need to be made to prevent irreparable harm and continue viable independent private practice care of vascular patients.

Likelihood of converting to an ASC.

Likelihood of converting to an ASC/OBL model.

Likelihood of adding wound care to practice.

Likelihood of adding any other services to practice.

Online Supplement 1

Impact of Medicare Payment Changes Questionnaire

The changes in Medicare payment recently enacted and effective on January 1, 2022, have the potential to significantly impact office-based laboratories and procedural centers. As a member of OEIS/AVLS, we would like to invite you to participate in a survey through which we wish to evaluate the real-world effects of these changes.

Your confidentiality is assured and all answers will remain completely anonymous. Your participation is voluntary but we very much encourage your contribution.

1) Select your Specialty

Vascular Surgery

Radiology

Cardiology

General Surgery, Family Medicine, Internal Medicine

Dermatology

Other

2) Which of the following societies are you member of:

OEIS AVLS

3) Do you work in an (Check all that apply; Except for Office-based practice, all others require presence of X-ray fluoroscopy units):

Office-based Practice OBL ASC Hybrid OBL/ASC Hospital Outpatient

4) Are you a:

Practice Owner

Private Practice but not the Owner

Multi-specialty Group Employee

Hospital Employee

5) Select all of the procedures that you perform:

Venous – Superficial

Venous – Deep

Peripheral Arterial

Cardiac

6) How many years has it been since you finished your training?

1-5, 6-10, 11-15, 16-20, 20+ years

7) How many years have you worked in an interventional practice?

1-5, 6-10, 11-15, 16-20, 20+ years

8) How many physician associates are in your interventional practice?

1, 2, 3, 4, 5, 6+

9) Are you experiencing a staff shortage?

Yes No

If yes, please describe

10) How significantly has COVID impacted your practice?

Not at all

A little

A moderate amount

A lot

A great deal

11) How much of an impact will the Medicare payment changes have on your OBL?

Very negative

Negative

Neutral

Positive

Very positive

12) What is the likelihood of adding physician associates to your interventional practice in the next two years?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

13) What is the likelihood of closing your interventional practice in the next two years?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

Not applicable

14) What is the likelihood of selling your interventional practice in the next two years?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

Not applicable

15) What is the likelihood of you becoming a hospital or group practice employee in the next two years?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

16) What is the likelihood of you retiring earlier than planned?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

17) If not already, what is the likelihood of converting to an Ambulatory Surgery Center (ASC) in the next two years?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

Not Applicable (Already an ASC)

18) If not already, what is the likelihood of converting to an ASC/OBL model in the next two years?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

Not Applicable (Already an ASC/OBL)

19) If not already, are you likely to add wound care to your practice?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

Not Applicable (Already do Wound Care)

20) Are you likely to add any other services to your practice?

Very unlikely

Unlikely

Neither likely nor unlikely

Likely

Very likely

If likely, please specify the service

Additional Comments:

Uncited reference

27., 29..