Clinical Data Challenges CMS's Proposed 'Efficiency Adjustment' in Medicare Payments

The Centers for Medicare & Medicaid Services (CMS) has proposed a 2.5% reduction in physician payments for 2026, citing presumed improvements in surgical efficiency as the basis for an 'efficiency adjustment.' However, emerging research indicates that this assumption may be unfounded. A recent study published in the Journal of the American College of Surgeons analyzed data from over 1.7 million surgeries across multiple specialties between 2019 and 2023. The findings reveal that, contrary to CMS expectations, operative times have generally remained the same or increased, with a 3.1% overall rise in procedure durations.

Researchers examined CPT-coded surgeries from the American College of Surgeons National Surgical Quality Improvement Program and discovered that 90% of these procedures took as long or longer in 2023 compared to 2019. This suggests that surgical complexity and operative duration have not lessened over time, even as patient case complexity has grown. Metrics such as patient age, comorbidity burden, and complication rates all indicate increased patient complexity, yet 30-day mortality rates did not change significantly.

This evidence questions the validity of CMS's assumption that surgical efficiency has improved sufficiently to warrant a payment reduction. Dr. Christopher Childers, lead author of the study, emphasized that their findings demonstrate most surgeries take the same or longer, implying that the proposed 2.5% cut does not accurately reflect current clinical realities.

The study underscores that patient complexity has increased, making the proposed payment adjustment both inappropriate and potentially detrimental to quality care. Patricia L. Turner, MD, MBA, FACS, Executive Director of the American College of Surgeons, expressed concern that such a policy could adversely affect patient outcomes by misrepresenting the actual work involved in surgical care.

As CMS considers implementing this policy, experts advocate for a more thorough examination of clinical data to ensure payment reforms align with evolving surgical practices and patient needs. The study highlights the importance of basing policy decisions on concrete evidence rather than assumptions of efficiency gains.

Source: MedicalXpress