For decades, there's been talk that the RVU system favors specialists and technologies.
In the lab industry, we've focused on legsilatioin PAMA 216 (2014) which affects lab pricing. But other and even adjacent sections of PAMA 2014 allow CMS much freeer hand to set physiciian prices (built on RVUs and supply costs), too.
NYT argues that's just what's happening now in this year's annual rulemaking, where proposals appear in summer, take public comment, and are finalized by fall.
NYT writes, "If approved, a new rule could end the entrenched pay advantages for specialists like surgeons over other doctors."
For the go-to book on the topic, see Fixing Medical Prices by Prof. Laugesen at Columbia.
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AI CORNER
I asked Chat GPT to read the PFS rule and compare it to the NYT predictions.
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The New York Times headline arguing that the 2025 PFS rulemaking could lead to real change in achieving greater payment parity between cognitive/primary care physicians and procedure-focused specialists is partially justified, but only within specific limits and contexts. Here's a detailed explanation based on the 2025 CMS Proposed Rule (CMS-1832-P) you provided:
What CMS Proposed and Why It Matters:
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Conversion Factor Changes (CF):
CMS proposes two separate conversion factors starting in 2026: one for qualifying APM participants (+1.2%) and another for non-qualifying participants (+0.7%). These modest increases alone would not drive significant shifts in payment parity. -
Practice Expense (PE) RVUs and Indirect PE:
CMS continues to rely on the outdated 2010 AMA PPIS survey data for PE/HR, which heavily influences PE allocations. Although CMS acknowledges the AMA has completed new data collection (PPI/CPI surveys), CMS explicitly states it is not adopting that data now due to concerns about accuracy. This postpones any material rebalancing in favor of cognitive services until at least 2027. -
Evaluation & Management (E/M) Services:
CMS maintains enhancements to E/M office visits from prior years, which already modestly improved payments for cognitive care. No major new valuation shifts for E/M are proposed this year. There is no sweeping reform or repricing of procedural codes that would reduce their dominance over time-based care. -
Advanced Primary Care Management Codes:
CMS is proposing new codes to support longitudinal care management and behavioral health integration. These codes aim to increase revenue opportunities for cognitive specialties. However, adoption rates and financial impact are uncertain and likely marginal in total dollars. -
Global Surgery & Valuation Revisions:
CMS hints at improving the accuracy of global surgery payments, which might address long-standing concerns about overvaluation of procedural services. However, no finalized cuts or redistributions are in this proposed rule.
Is the Headline Justified?
Partly, but overstated.
CMS's proposed rule reflects incremental, not transformational, progress toward payment parity. While there are efforts to:
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Sustain higher payments for E/M and behavioral health,
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Create new payment pathways for longitudinal management,
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Review practice expense allocations,
No major redistributive shift is occurring in 2026 to decisively close the gap between proceduralists and cognitive specialists. The real engine of change—new PE data from the AMA—has been deferred, and CMS is postponing systemic adjustments tied to it.
Why The NYT Headline Feels Misleading:
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CMS explicitly says it is maintaining the status quo for PE data.
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CMS continues to prioritize stability over redistribution in 2026.
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New codes for cognitive care are positive but not revolutionary in scale.
Conclusion:
The headline captures CMS’s direction but exaggerates the immediacy of the impact. The rule signals future movement toward parity, not parity itself. The 2026 rule continues evolutionary tweaks rather than enacting the kind of sweeping changes the NYT might imply.
If you'd like, I can prepare a summary table or a brief suitable for presentation comparing NYT’s claim vs. the actual rule content. Let me know.
