Friday, April 16, 2010

The SGR Farce

Once again, Congress is playing with fire by not enacting a permanent solution to the Medicare SGR physician payment cut problem.

Congress got itself tied up in knots trying to figure out a way to reverse a 21% cut in Medicare payments to doctors that went into effect yesterday. It ended up agreeing to legislation, which was signed into law late Thursday evening by President Obama, to restore payments to the pre-cut (2009) levels through the end of May. The action, though, may have come a dollar short and day late: CMS has indicated that it had no choice but to tell carriers to begin processing claims with the 21% cut, starting yesterday.

Even though those payments will now be retroactively restored, it is ridiculous that physicians have had to deal with what ACP President Joseph W. Stubbs, MD, a private practice general internist himself, called the "chaos" created by Congress' dithering on the SGR.

Now, I know that some people are going to somehow try to pin the blame for this on "ObamaCare." But the truth is that even if health care reform had never seen the light of day, physicians would have been dealing with the 21% cut. And it is also a fact that the House of Representatives passed legislation this past fall, with the support of President Obama, to permanently eliminate the SGR and replace it with a system that would provide higher updates to all physician services.

The problem now is the U.S. Senate, where not one darn thing can get done if a single member objects - that is, without going through a series of procedural votes that require at least 60 votes.

ACP refuses to play the game of helping Congress get the votes it needs for a short-term reprieve. Instead, we are asking our members to tell Congress that the only effective outcome is throw out the SGR and replace it with a system that provides fair, stable and positive updates.

Yes, getting rid of the SGR will result in higher Medicare spending than if Congress allows the doctor fee cuts to go into effect. Some fiscal conservatives therefore object to a doctor pay fix because it will increase the deficit. But they should know that it is ridiculous to pretend that Medicare will save money from scheduled cuts that everyone knows will never take place.

It is the failure of both political parties, over many years, to honestly deal with the SGR, including the cost of getting rid of it, which has resulted in the current ongoing SGR farce. And yet members of Congress wonder why the public holds them in such low regard.

Today's questions: How will the SGR cut affect you? What are you telling your members of Congress?


Unknown said...

In my opinion, ACP should not have supported the "health care reform" bill without the SGR fix. Shame on the ACP.

PCP said...

The great folly of Organisations like
the ACP and the AMA, to support the single largest reform of healtcare in generations, and support it like giddy cheerleaders, sans any of the items supportive of Physicians is quite laughable.
We are now the laughing stock of the country, thanks to your strategy. We have been reduced to begging every month or so for a pay freeze to be maintained.
This is one doctor who refuses to do so. How did our professional organisations allow us to go from usual and customary to this sorry state for the profession?
With all this our organisations have been hijacked by the universal health coverage (aka gateway to universal healthcare aka gateway to national health care).
For those of you excited by the universal coverage and prospects of your newly minted primary care provider status, did any of you enjoy reading the associated press article about Dr Nurses. Welcome to the future your organisations have embraced.

In the single biggest reform, we saw no SGR repeal and no nationwide Tort reform, no definition of professional responsibility, yet we offered arguably the most vehement support incredulously to a country that was highly skeptical.
Now our professional representatives are angered at the approach of Congress! We are somehow surprised that politicians are not treating us fairlY?
I thought Bob, you gave us a tutorial in one of your blogs recently about the art of crafting legislation and the give and take in dealmaking? Must not be going that well eh.

Yet you extend the folly in believing we have any negotiating leverage left at all after the legislation. How exactly did you think Mr Obama and Co. planned to make this work? Did you realistically think that they could do it by just cutting the fraud and abuse and a paltry 100 billion a year of sadly inflating dollars?
This is a frankly incredulous topic for me.
This will lead to two tiered care that much is obvious.

Unknown said...

It's ridiculous that ACP, and you, continue to repeat that the ACP is "doing everything possible", or words to that effect, to alter Medicare physician payment policy. You're doing anything but that.

By continuing to perpetuate the notion that more phone calls and letters to Congress is going to change anything-- after a dozen years of these pathetic attempts-- ACP is actually suppressing meaningful actions by doctors by implying that all this talk is the only action available, and by also stating that physician refusal to continue to provide care to Medicare patients under the current system is unethical.

ACP can and should recommend that its members withhold routine medical care to Medicare patients until there is real reform. It's ridiculous to assert that this is unethical when the fact is that none of us will be in business in the future to deliver any care at all if payment doesn't improve. And who are you to decide what is ethical, anyway?

In my general IM, all Medicare practice, I did exactly this for two weeks since March 1st... and my patients were overwhelmingly supportive. Even if ACP remains too timid to recommend anything more than continuing to blather to our so-called representatives, it should at least make better publicized the real grass-roots efforts of doctors that are willing to do more than talk.

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

The treatment of primary care and other private practice physicians has indeed been counterproductive. The inability to have the counter-arguments of the Republicans fall into a coherent construct leaves a sour taste that leaves little reason for us stubborn optimists to remain so. The relegation of professional services to this SGR formula, while marketing and infrastructure growth profit on the hope of the new and the unregulated cost of new drugs and technologies, is a sad reality that seems to bypass most experts. From Health Care Economists to Hospital Administrators to Insurance executives to the IT industry, the sheer audacity of the hype is shameful and dangerous.

Day after day, I collect the stream of administrative creations that reflect the wasted repetitions of the "managed care" dogma. Erroneous interjections of non-adherence accusations toward my patients, accusations that I may have overlooked considering a statin or checking an A1c in my diabetic patients, and outright coercion to change medications based on the current success or failure of price negotiations that involve neither patient nor physician, continue to flow unabated. Worse, the IT mandates from the Stimulus package threaten to worsen the overhead devoted to these tasks.

There is an absolute urgency that CMS advocate for its program in a way that directly addresses primary care in the here and now. The SGR must be overturned. The Republicans and Democrats can correctly identify the outright waste and probable fraud that is the product of their loophole laden legislative product. Pay as you go is a fine philosophy; a bottom-line blind mentality that refuses to see how Medicare has gotten to this point and punishes indiscriminately is not.

I promise you I could provide immediate savings to our system without limiting patient choice or access, forcing more physicians out of providing primary care and participating in insurance plans, stymiing innovation, or wasting more on bureaucratic oversight that would fail to efficiently deliver on its promises.

The CMS, Legislature, and the Judicial branch must rectify the failed financing that has fueled the medical-industrial complex. Cuts on non-core services, private overlay in public programs (Part D, Medigap), and for-profit insurance investor diversions, would unequivocally provide substantial savings without either promoting fraud or making the government's regulatory role more difficult.

Saving us from our ongoing, dys-regulated pharmaceutical financing, is the other urgency that remains under-appreciated, as everyone worries about their particular well-being within the health care system. It remains a deep frustration that rhetorical flourishes are repackaged and perpetuated, while true discussion of the concrete changes that we need (not the imagined reforms of pay for performance, that sound more like packaged Wall Street Investment tools)is glaringly absent.

Arvind said...

I cannot add anything more to what Ken, PCP and Rob have already said. It seems that you have come a full circle now; hopefully you are beginning to realize the wisdom in the advice of those of us that were opposed to the ACP's wholehearted support of this new Law without a completer SGR repeal and meaningful reform of the medical liability law.

Every time I receive an email from ACP asking me to call my Rep, i simply file it away under my "ACP" category. As I have said before, I am wishing that that the 21% cut goes through, and physicians simply are forced out of government slavery, i.e. Medicare. This government will only respond to a crisis, and it will take a crisis to shake them out of their slumber.