Wednesday, October 21, 2009

Congress again fails to end the SGR lunacy

Just a few days ago, it looked like Congress might actually do the right thing and end the annual cycle of enacting short-term measures to stop Medicare payment cuts caused by the Sustainable Growth Rate (SGR) formula, only making the problem harder and more expensive to fix the next time around.

But today by a 47-53 vote, the Senate - including 13 Democrats - voted against a motion to end a filibuster against S. 1776, the Physician Payment Fairness Act of 2009, even though the bill had the support of the White House, Senator Finance Committee Chair Max Baucus (D-MT), and Senator Chris Dodd (D-CT), acting chair of the Senate HELP committee during the (late) Senator Ted Kennedy's illness. S. 1776 would have repealed the SGR and eliminated all of the accumulated cuts caused by the formula.

S. 1776 failed despite a huge grass roots push by the ACP, American Medical Association, and other physician organizations, and despite the fact that AARP, the voice of America's seniors, supported the bill.

The bill was victim to the dysfunctional political environment today that makes consensus so difficult. Many Republicans viewed the bill largely as a Democratic effort to "buy" physicians support for health care reform (a cynical and unsupported allegation - more on this later) and they wanted to deny the Democrats a victory on anything having to do with health care reform. They also wanted the cost of the SGR repeal to be counted against the cost of the health reform bill, so that the bill would be seen as blowing a hole in the deficit. (Never mind that the SGR, which has led to all of the accumulated cuts and costs we are now facing today, was created by the Congress in 1997, when the GOP was in control, and that past Congresses, Republican and Democratic alike, have failed to take the steps needed to fix it. The SGR problem and its cost would be with us today, even if there was no health reform bill.)

It also seems many Democrats have had the equivalent of a death-bed conversion to fiscal responsibility, or at least a make-believe version of fiscal responsibility that says that pretending to save taxpayer's money is the same as saving them money. The Senators know that the $245 billion price tag for SGR repeal is itself a budget fiction, because it requires that we suspend disbelief and assume that Congress will actually allow double-digit cuts in physician payments to go into effect. They won't and they know it. Medicare will end up spending the $245 billion anyway, but that doesn't matter, as long as the Senators can tell voters that they didn't vote for a bill that would add to the deficit.

ACP has released a statement that is harshly critical of the Senate vote and vowing to continue to push for SGR repeal. The statement takes on the charge that S. 1776 was offered in exchange for physician support of health reform:

"The American College of Physicians rejects the cynical charge made by some that physicians' support for health care reform is conditioned on repeal of the SGR. Instead, ACP supports health care reform because we believe that all Americans should have access to affordable care. Our positions on the pending health reform proposals will continue to be based on how they align with ACP's long-standing policies on ensuring coverage, reversing a catastrophic shortage of primary care physicians, and testing and implementing new models of payment and delivery to align positive incentives with the value of care provided. At the same time, we believe that repeal of the SGR is necessary to provide the stability needed to achieve real and lasting physician payment reform, to implement payment reforms to support the value of care provided by primary care physicians, and to assure seniors' access to care."

Where does this leave us on the SGR? Right where we were in . . . 2008, 2007, 2006, 2005, 2004, 2003, 2002, and 2001 . . . with Congress saying that they know the SGR has to go, that they won't allow the cuts to go into effect, that they know that have to find a permanent solution, but not now, some other time. Like the Chicago Cubs and a World Series appearance, it seems it is always "wait til next year" when it comes to repeal of the SGR.

Today's question: What is your opinion on the Senate's rejection of SGR repeal?


Jay Larson MD said...

Such is life. At some point this will be addressed, possibly when the next cut enactment comes up in 2011. At least at the end of this year I won't have to take Xanax.

Arvind said...

I am not surprised about this vote. It would have passed if they had just voted along party lines. The whole idea that this 250 billion was somehow not part of the overall health care bill is the problem. What you failed to mention is that SGR was signed into law by Bill Clinton (better to be honest with the whole truth) even though passed by a Republican Congress.

In a strange way I feel that this is a good development (as I mentioned in a previous post) because it will finally convince physicians that they simply cannot rely of govt-controlled health care - whether Medicare or Medicaid or the so-called Public Option. The only way government will learn is when there is actual loss of access to care for patients. It is unfortunate but a bitter pill is a must in such circumstances.

PCP said...

It is an indication of where their priorities are on Healthcare reform. Their priorities are with politics, grandstanding, "looking fiscally responsible even if not" and disregarding the genuine concerns of arguably the most vital stakeholder in Healthcare reform, Physicians. First went Tort reform, and now goes the SGR repeal. What exactly are we left with? We will be left with all stick and no carrot. That is not my idea of compromise.
In the end the Drugmakers, the PBMs the DME suppliers, the Home health, Hospitals etc etc, and I suspect in the end even the Insurers will all come out doing OK. NO SGR for the past decade, Medicare D with no offsets and no negotiations, Medicare Advantage with federal subsidies, unrestricted growth in every other industry, all while suffocating out of existence Physician delivered primary care. Hmm.

The final result will be that Doctors and PCPs especially will end up with the shaft. Not only will we be subject to the indignity of going cup in hand to the Gov't each year just to get a sub inflationary adjustment in fees, basically instead of setting our fees each year, we will each year be reduced to beggars, we will continue to have senators derisively compare the AMA to the worlds oldest profession and we will continue to stay fragmented and fearful instead of exercising our collective power and trust on this issue to a positive effect. We will continue to see Primary care medicine be reduced to NP and other mid-level delivered care for the masses, and MD delivered concierge care for the few, and we will continue to have the developed worlds weakest Primary care system.

Our politicians on this issue and on many others over the last year have demonstrated that slavery is alive and well. They are the slaves of corporate elites. They see it as their duty to "sell an issue to the public". Doing the right thing has become a relic of the past for the politicians of today. Partisanship has become so entrenched that I am convinced many politicans now vote to harm their political opponent rather than on the fundamentals of the issue.
The outcome of this will not be good for physicians. It is time to start valuing ourselves and not be abused in this way. This is not just a political defeat, this is frankly a slap in the face to every dedicated physician in the country.
On the basis of this, who in their right mind belives that health care reform will do anything but screw us further? Is there any doubt now? What is the credibility of the legislators on this issue now for us?

Robert J. Sobel, M.D. said...

Bob, did you really have to bring up the Cubs? As a lifelong northsider, I'm giving them a reprieve through 2015 (that would be 100 years with Wrigley as their home); after that?

Regarding Congress, is this not the body that overrode Bush's 2008 veto of the temporary fix by a near unanimous margin? The argument about budget neutrality is understandable, so why don't we explore further what growth in other sectors determined the need to adjust downward the physician fee schedule? Is there an equivalent control on drug costs or new technology utiization? If our share of Medicare costs is only 20-30%, why should we bear the brunt of unevenly applied cost control? Could you please clarify what reform would both allow stable and predictable reimbursement and not involve new bureaucratic imperatives?

Physicians have been paying for the growth in all these other sectors. If we leave that process at it's current dys-regulated status quo, it would be hard to fathom how independent physicians can remain solvent?

Joseph said...

Ironic that Republicans did not seem to mind adding to the deficit when they enacted Medicare part D but now say their hands are tied in terms of eliminating SGR because they need offsets.

Jay Larson MD said...

What a second. With all the focus on the Chairman's Mark postponing SGR cuts for another year, it slipped my mind that NO legislation has been passed yet to postpone the 21% SGR cut starting 1/1/2010. Bugger. Now where is that bottle of Xanax.

Jim Webster MD, MACP said...

If all we do is ask for more money of course we won't get much sympathy. "We" must do a bottoms up total reform of care delivery and payment. Start with PCMH's and ACO's and we have a great case. ACP should lead the efforts.
Jim Webster

Unknown said...

Once again this demonstrates the folly of getting in bed with politicians to determine our livelihood If the ACP and the AMA think that they will receive any better treatment for signing on to Obamacare, they will be sadly mistaken. Organized medicine should fight this with every fiber of their being. You should be our advocates not sell us down the river.
Kenneth R Bergman MD FACP

Rich Neubauer MD said...

I left the world of internet, health care reform and the SGR for a few days by traveling into the Shenandoah National Park surrounded by fall colors, great weather and the blissful thought in mind that (whatever else transpires) this part of life for physicians would be transformed. I exited with the news that we are back to square one.

It seems that Congress is burdened with lack of courage, vision, and conviction. Dr. Larson, may have to pass the Xanax!