The ACP Advocate Blog

by Bob Doherty

Wednesday, April 15, 2015

Goodbye and Good Riddance to the SGR

Yesterday’s 92-8 vote in the United States Senate to join the House in passing the Medicare Access and CHIP Reauthorization Act (MACRA), H.R. 2, represents a remarkable milestone for the Medicare program, and for ACP advocacy on behalf of internists and patients:

It is remarkable not only because it eliminates the failed Medicare SGR—how often does Congress admit it made a mistake, and then correct it?—but because it also fundamentally revamps how Medicare pays physicians.

It is remarkable that Congress did not take the easy way out and do what is had always done before, pass another short-term “patch” to stop the currently scheduled 21% cut—which would have been the 18th patch over the past 12 years.

It is remarkable because the bill passed both chambers with overwhelming majorities of Republicans and Democrats alike—an extreme rarity in today’s hyper-polarized world. (When was the last time a major and expensive bill had the support of Speaker of the House John Boehner, Minority Leader Nancy Pelosi, Senate Majority Leader Mitch McConnell, Senate Minority Leader Harry Reid, the chairs and ranking members of all three Medicare authorizing committees, the House Republican “doc caucus” and Democratic physician members of Congress—and President Obama?  I can’t think of any other).

It is remarkable because Congress passed the bill despite strong objections by self-described fiscal conservatives—fueled by powerful groups like the Heritage foundation--to its costs not being entirely paid for with cuts to someone else.

It is remarkable because the legislation includes entitlement reforms—including higher Medicare Part B and D premiums for wealthier beneficiaries, and a $250 Medigap deductible—that many liberals (and AARP) dislike.

Yet liberals and conservatives, in the end, came together to embrace the bill, recognizing that compromise was the only way to get a bill passed that would end the SGR.
It is remarkable in that organized medicine was more united than I have ever seen it, not just on repealing the SGR (that part was pretty easy!), but on the harder challenge of reaching agreement across the specialties and states in support of policies to further align Medicare payments with value, with over 750 physician membership organizations, national and state, endorsing it.

It is remarkable because ACP and other physician membership organizations were at the table all through the process, shaping the underlying bill last year, but also tweaking it this year and then working hand-in-glove with congressional leadership to get it enacted.  ACP, for example, helped get strong incentives included for Patient-Centered Medical Homes, a concept we have been championing for many years but that, until now, had limited opportunities for enhanced reimbursement under Medicare.  AMA deserves special credit for organizing and leading the broad physician coalition in support of the bill.

It is remarkable that our combined memberships again answered the call to pressure their own representatives and Senators to vote for the bill, even though so many times before their efforts led to disappointment.  The lopsided vote totals in favor of the bill demonstrate the power of grass roots physician advocacy.

Yes, enactment of MACRA was a remarkable advocacy achievement for organized medicine, not only for the successful result, but for the way it was achieved: through bipartisanship, compromise, pragmatic engagement with the process of crafting legislation rather than staying on the sidelines criticizing it, determined and persistent grass roots advocacy, and through remarkable unity across medicine, enabling us to achieve yesterday’s historic win for physicians and their patients.

I will have much more to say in future posts about the legislation itself—how it offers physicians numerous opportunities to achieve higher updates, how it encourages alternative payment models like Patient-Centered Medical Homes, how it offers the potential of harmonizing and streamlining quality reporting, and much more.  For now, you can read ACP’s statement congratulating Congress on the bill’s enactment, and my previous blog posts (like my entries from March 20th, March 24th, and March 27th) about the legislation.

Our advocacy is far from over, of course.  Like any law, H.R. 2 is imperfect—there are parts of it that we know will be quite challenging for our members.  We will have to influence its implementation by CMS, especially the selection of measures and the criteria for alternative payment models. We will have to work to ensure that it doesn't just add more complexity and more administrative burdens on physicians.   And if CMS doesn't do what’s needed, we may have to seek legislative changes later on. And we have a whole host of other issues that need attention from Congress—and getting rid of the SGR give us the opportunity to do so, instead of spending almost all of our political capital on one issue, the SGR, year after year after year.  

Yesterday’s vote shows what can happen when physicians are unified and engaged in the political process in pursuit of a shared goal. Wouldn't it be nice if we could replicate it on other issues of concern to physicians and their patients?

Today’s question: what is your reaction to Congress’s remarkable bipartisan vote for SGR repeal and H.R. 2?

Tuesday, April 14, 2015

Will the SGR still be with us tomorrow morning?

As I write this at 4:30 pm EST, the Senate had yet to take up the Medicare Access and CHIP Reauthorization Act of 2015, H.R. 2, which will repeal the SGR formula, reverse the 21% SGR cut that applies to claims for services provided on or after April 1, provide stable and positive updates for four and a half years starting in July, consolidate and streamline existing Medicare reporting programs into a new Merit-based Incentive Payment System, and create incentives for Patient-Centered Medical Home and other alternative payment models.  It needs to pass the bill, without making changes to what the House already passed, by midnight, or Medicare will begin applying the 21% cut tomorrow, April 15, for claims for services provided on April 1.  This will continue on a rolling basis until both the House and Senate approve identical legislation.

Senator Majority Leader Mitch McConnell and Minority Leader Harry Reid have expressed optimism that H.R. 2 will pass the Senate before midnight.  Reportedly, they are seeking unanimous agreement for up to six amendments to first be voted on, three from Republicans and three from Democrats.  All but one of the amendments would require 60 votes, making it very unlikely that the Senate will approve them.  One amendment, requiring that Congress find savings by the end of the fiscal year to offset the entire cost of the full cost of the legislation (instead of it only being partially offset as is currently the case), would require a simple majority vote.  If this amendment (or any of the other amendments) were to pass the Senate, then the 21% SGR cut will begin to be processed starting tomorrow morning, because there is no prospect that the House would be able, or inclined, to consider amendments that would upend the overwhelming bipartisan majority for the bill it passed last month.  Requiring that the entire bill be paid for would also certainly invite opposition from Democrats (who would be concerned that it would lead to entitlement cuts) and provider groups, like hospitals, who would be concerned that their Medicare payments would be at risk.

Keep checking ACP’s website,, and my twitter feed, @bobdohertyACP, for developments this evening.  

Friday, March 27, 2015

When it comes to SGR repeal, is the glass half empty? Or half full?

Actually, it’s both.  On the “it’s half full” side, the House of Representatives yesterday overwhelmingly voted for legislation to repeal the SGR and make other improvements in Medicare physician payments.  On the it’s “half empty” side, the Senate recessed for two weeks without taking action on the House bill, the Medicare Access and CHIP Reauthorization Act of 2015, H.R. 2, meaning that a 21% SGR Medicare physician payment cut will go into effect as scheduled on April 1, even though physicians won’t begin seeing the cut until April 15 (more on that later).

More on the half full side:

What the House did defied expectations—passing expensive, complicated, and one might have expected, controversial legislation making huge changes in the popular Medicare program, by a lopsided and bipartisan majority of 392-37.  The Washington Post reports that such a “Kumbaya” moment, when the two political parties vote together to get legislation passed, is exceedingly rare in “our modern, polarized era.”  Why did the SGR bill get so much bipartisan support?  For one thing, it was directly based on a bipartisan and bicameral bill that both parties and both chambers had agreed to last year, only to falter on the question of how to pay for it.  But because there already was agreement on the underlying policies, the House did not have to start from scratch this year on crafting a bill that both parties could support.

What really put it over the top, though, was the decision by Speaker John Boehner and ranking Democrat Nancy Pelosi to hash out an agreement on how to partially pay for it—partially being the operative word.  Had either insisted that it be fully paid for, it would have been near impossible to agree on enough budget savings that both parties could agree on.  

Like all compromises, the agreement had some things that both Speaker Boehner and Minority Leader Pelosi could take back as “wins” to their respective caucuses.  Boehner was able to talk up “entitlement reforms” in the bill that over time will require higher income beneficiaries to pay more for Medicare Parts B and D and apply a $250 deductible to Medigap plans.  Pelosi was able to talk up provisions in the bill that provide permanent funding for a program that lowers Medicare premiums for poorer beneficiaries, and  two years of funding for the Children’s Health Insurance Program, Community Health Centers, the National Health Service Corps, and GME Teaching Health Centers.  

The bill also had unprecedented support from stakeholders of all varieties, from more than 750 physician membership organizations (including ACP), from hospitals, from nurses, from consumer groups, from nursing homes, and many more.

Following the House vote, ACP issued a statement congratulating Speaker Boehner and Minority Leader Pelosi, along with the 392 representatives who voted for it, and urging the Senate to pass it before recessing today.

Now, for the glass half empty side.  Just like it takes two to tango, it takes both chambers of Congress to pass a law.  The House did its part, the Senate did not.  Instead, the Senate recessed at 3:30 this morning without taking any action on the House bill.  Both Majority Leader McConnell and Minority Leader Reid promised that the bill would be taken up “quickly” after the Senate’s return on April 13, but there is reason for physicians to be concerned that they will not act in time to avert a 21% SGR cut for services provided on or after April 1.  Because Medicare holds claims for 10 business days before paying them, the 21% SGR cut will begin to be applied on April 15 for physician services provided to Medicare enrollees on and after April 1. But because the Senate will not return from the recess until April 13, it will have fewer than 48 hours to enact H.R. 2 before the 21% cut will begin to directly affect payments to physicians for services provided to Medicare enrollees.

The cut would then continue until the House and Senate both pass identical bills to stop the cut and repeal the SGR, which could take days, maybe longer.   If, on the other hand, the Senate joins the House and enacts H.R. 2 immediately upon its return, and without making changes in the bill from the House-passed version that would delay enactment, Congress can still repeal the SGR in time to stop the 21% cut from actually affecting payments to physicians.

The Senate could have prevented all of this uncertainty if it had just passed the House bill before taking two weeks off, but it didn't.  ACP, in a release issued a few hours ago, expressed great disappointment with the Senate’s failure to take up the House bill and advised them that physicians and patients would hold their Senators accountable.

For that, we will need every physician to help us, by calling your Senators.  Insist that they commit to voting for H.R. 2 immediately upon return on April 13 from the recess, and before the cut begins to show up in your payments fewer than two days later.  They will be heavily lobbied from the right and the left by groups that don’t like some of the policies in the bill, and their efforts need to be countered by the physician community.

Otherwise, we will end up with an empty glass, drained by empty SGR repeal promises made by a Congress that, once again, will have failed to deliver the votes that were needed.

Today’s question: What will you do to hold your Senators accountable?

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

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