The Quiet Cut

How a Line Buried in a Medicare Rule Will Punish the Sickest Patients — and Why Your Silence Helps It Pass

By Eric J. Lullove, DPM, CWSP, MAPWCA, FFPM RCPS(Glasg)

There is a particular kind of policy violence that never makes the evening news. It doesn’t arrive as a headline or a hearing. It arrives as a payment formula, published in the middle of July, in a document thousands of pages long, written in language specifically designed so that no ordinary person — and almost no busy physician — will ever read it. And then, if we say nothing, it becomes law by default.

That is exactly what is happening right now with the CY 2027 Medicare Physician Fee Schedule.

I’ve written before about what this proposed rule does to physicians. Today I want to write about what it does to patients — because that is the part CMS is counting on you to overlook, and it is the part that should make every one of us pick up a pen.

What the rule actually does

On July 14, 2026, CMS released its proposed rule for how it will pay physicians in 2027.¹ Buried inside is a change to something called Modifier -25. In plain English: when a doctor addresses a separately identifiable problem and performs a procedure on the same day, the current system pays for both. Under the proposal, the most expensive service that day gets paid at 100 percent — and every other service gets paid at 50 percent.² Half. CMS is specifically proposing to cut payment when a physician handles a same-day office visit alongside a procedure that carries a global surgical period.³

CMS calls this eliminating “duplicative” payment. I call it what it is: a financial penalty for taking care of complicated patients in a single visit.

And here is the quiet part said out loud. This penalty does not fall evenly. CMS’s own analysis expects a large negative impact on dermatology, otolaryngology, and podiatry, while most other specialties actually see a small increase as those dollars get redistributed to them.⁴ The money doesn’t disappear. It gets moved — away from the specialties that manage skin, wounds, feet, and chronic complexity, and toward specialties that don’t.

Now think about whose care this is

This is the part I need you to sit with, because the abstraction hides the cruelty.

Who are the patients who show up with two problems on the same day? They are not the healthy. They are the diabetic on dialysis whose foot ulcer needs débridement and whose new pressure wound needs evaluation. They are the elderly, the neuropathic, the vascularly compromised, the medically fragile — the people for whom a single appointment already takes real effort to reach, and for whom being told “come back another day for the second problem” isn’t a scheduling note. It’s a barrier that ends in an infection, a hospitalization, an amputation.

When you cut the second same-day service to half payment, you don’t cut a line item. You create an incentive to send that patient home with one problem unaddressed. The system will quietly reward doing less for the people who need the most. The patients with the hardest, most complex, most expensive-to-manage conditions are precisely the ones this rule makes least worth treating in full.

Let me say that as plainly as I can: this proposal will hurt the sickest Medicare beneficiaries in America, and it will hurt them most where their problems are most complex. That is not a side effect. It is the mathematical center of the policy.

Before you read further: The comment period on this rule closes September 14, 2026. Anyone can file one at regulations.gov, file code CMS-1848-P.

It takes five minutes and you do not need to be an expert. The Capitol switchboard is (202) 224-3121.

Dr. Eric Lullove treats the patients this rule is about—the diabetic on dialysis, the neuropathic foot, the wound that turns into an amputation if it waits two weeks for a second appointment. He read the CY 2027 fee schedule so you don’t have to, and he found the line where CMS quietly decided that the second problem you bring to a doctor is worth half as much as the first.

The deadline and the link are free, above, and they’ll stay free. Please use them whether or not you ever pay us a dime. What’s behind the wall is the harder half: why a payment formula that punishes complexity fits a pattern this administration keeps repeating, and how a system that gives hospitals an inflation raise every year while cutting physician pay for two decades isn’t broken so much as built.

That reporting takes a working physician’s time and a publication willing to print what he actually thinks. Subscribers are the only reason both exist. If you’ve been meaning to, this is a good week for it.