Jarrod Shapiro, DPM
Goodbye Global Period:
Is This a Good Thing?

Recently I was reading the ACFAS Update mailer and was surprised to find a concerning article about global periods. According to the article:

"In the final 2015 Medicare Physician Fee Schedule rule, CMS announced its intention to eliminate all 10- and 90-day global payment periods for surgical services. The change will be implemented beginning January 1, 2017, when 10-day global payments will be eliminated. The 90-day payments will then be phased out on January 1, 2018".¹

For those of you who may not know what a global period is (most likely any students reading this), it is a block of time after a procedure is done, in which the surgeon does not get paid for evaluating and treating a post-surgical patient (with the exception of certain services). For example, if I do a bunionectomy, then I am not allowed to bill the insurance company for the evaluation and management parts of the patient care for 90 days of their postoperative course.

Sounds like it might be a good idea on the surface? Think again.

Arguments For the Change

According to the Federal Register, section 2.B.4, the Centers for Medicare and Medicaid (CMS) argues several issues that cause healthcare disparities (read this as "paying surgeons too much money").²

They are:

	1.	Payment rates are not updated regularly (the way hospital bundled payments are).
	2.	The relationship between RVUs (relative value units) and the number of postoperative visits is not always clear.
	3.	The prior system assumes an older model in which the surgeon always followed up on the patient rather than having someone else do it. Apparently, CMS thinks this has changed.
	4.	Surgeons perform a smaller number of evaluation and management services than the current global period assumes. If a procedure is calculated to have a physician see the patient 10 times during the global period, but he actually sees the patient 6 times, then the initial payment was overvalued, essentially overpricing the RVUs for that procedure. According to a couple of studies performed by the Office of the

Arguments Against The Change

Some argue that eliminating global periods will discourage care coordination¹ with subsequent decreased quality of patient care. This will happen in many unforeseen ways.

	1.	If patients begin paying for the postoperative office visits, they may be discouraged from having surgery in the first place.
	2.	Larger numbers of surgeons will begin having their postoperative patients follow-up with the primary care physician. This will be beneficial for the primary care physicians but for no one else. This would be bad for patients and would have significant downstream impact.
	3.	We may potentially see an increase in the number of lawsuits due to a decreased surgeon-patient relationship and a sense of abandonment by patients.
	4.	We may also see a larger number of significant postoperative complications when nonsurgical physicians perform the follow-up, waiting too long to seek expert care in the postsurgical period when a problem arises. How many physicians really know how to debride a wound dehiscence after a transmetatarsal amputation? How about applying a negative pressure wound therapy device? I can't see my primary care physicians doing that while their other 60 patients wait to be seen.

Other disparities will also occur. Currently, for Medicaid patients in California, podiatric care is not covered unless the patient is seen emergently in the hospital. I don't like this rule, but at least I'm able to provide care to these people acutely and still receive some, albeit small, reimbursement. In the acute situation, when I do surgery on this patient population, the global period makes it easy for me to follow-up after the surgery, heal the patient, and then later coordinate their care to see another provider on a chronic basis.

As it stands with this rule, I will do the high risk acute surgery on a Medicaid diabetic patient with an abscess and will receive less payment for the procedure. Afterward, the patient will have to pay out of pocket for their continued care – often a highly complex series of events – and thiswill be very expensive for them.

Of course, we all know this won't actually happen. What will occur is the patient will undergo the initial surgery and will follow up with their primary care physician, who is unlikely to be qualified to handle complex diabetic foot wounds and post amputation care. The patient will then end up in the hospital again with a much higher risk of limb amputation.

At first glance, eliminating the global period sounds like a good idea for doctors. Instead of not getting paid for 90 days, doctors will be able to bill more for their services with an increased number of postoperative visits and extra services (at least for the ones able to pay). And this may be true for some surgeons. I'm sure there will be some who will very quickly take advantage and make some extra money.

But for most of us, and especially our patients, the disparities that CMS is concerned about will only increase, likely hitting the lower socioeconomic classes harder than the wealthy. Surgeons will be paid less for our skills (which are already undervalued), and the unscrupulous will look for the inevitable loophole. Who suffers as a result? All of us. Bye bye global period. Nice knowing you.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]