Wednesday, December 14, 2011

The Medicare SGR and Charlie Brown’s Football

An iconic symbol of hopeful—or hopeless—futility is Charlie Brown lining up, year after year, to kick the football placed by his devious friend Lucy—only to have her pull it away at the last minute. Physicians know how Charlie Brown feels. Each year, Congress offers doctors a football called SGR repeal, only to pull it away from them in the end.

This year, it was the House Energy and Commerce Committee, Republicans and Democrats alike, who told medicine on March 28 that this year would be different, that Congress—really, really, promise, promise—was going to repeal the Medicare SGR formula and replace it with a better system. Here is what chairman Fred Upton (R-MI) and ranking member Henry Waxman (D-CA) wrote to the doctors:

“Unless we begin the process of developing a long-term solution, we will once again be faced with the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries. We cannot let either happen.”

Medicine answered the call by offering Congress concrete ideas for stabilizing payments for the next five years and transitioning to a better payment system for patients and their physicians.

Well, we now know how all that turned out. Here we are, just 17 days before Medicare payments to physicians will be cut by 27.4%, and Congress still hasn’t figured out how to stop the cut, never mind enact a long-term solution.

Last night, the House of Representatives passed a bill that would replace the SGR cuts with one percent annual increases in 2012 and 2013, but it does not repeal the SGR or result in a long-term solution. It is paid for by controversial Medicaid and Medicare payment cuts to hospitals for indigent care and outpatient facilities, increased Medicare premiums to higher income beneficiaries, reductions in funding for prevention and wellness programs, and money that is set aside to pay for health insurance subsidies created by the Affordable Care Act—cuts that are being fiercely contested by hospitals, AARP, and the American Cancer Society-Cancer Action Network, among others. The SGR provision is just one part of a broader package that would extend unemployment benefits and the expiring Social Security payroll tax cut, but it includes other policies that are so strongly opposed by the White House and Senate Democrats that it is considered to be “dead on arrival” in the Senate.

What happens when the GOP bill fails in the Senate, as expected? Negotiations likely will take place over the weekend between Senate Democrats and House Republicans on a compromise package, but no one knows if they will be able to reach a deal that can pass both chambers before the SGR cut goes into effect and the payroll tax cut and unemployment benefits expire on January 1. The odds still favor an agreement to stop the 27.4% SGR cut, although the issue may not be decided until after Christmas—just days before it is scheduled to go into effect.

It’s enough to make you want to shout “Good Grief!”

Of course, it isn’t fair to put all of the blame on the current Congress. Remember, the Democratically-controlled 111th Congress failed on multiple occasions to pass more than short term (sometimes just weeks or months) patches to prevent scheduled SGR cuts, and in June 2010, it actually allowed the cut to go into effect for several weeks, during which CMS held Medicare claims until Congress got around to passing another temporary reprieve.

Much of the same can be said about the 110th Congress, and the 109th, and the 108th, and the 107th . . . all of whom enacted short-term reprieves to prevent scheduled SGR cuts but could not come up with a permanent solution. As much as physicians wanted a permanent solution, their professional associations usually ended up helping Congress get the votes for a temporary patch because the consequences for patients of allowing the SGR cut were too dire.

Not this time, though: ACP (and most other physician organizations) are telling Congress that although it is imperative that they act, before recessing for the year, to reach agreement on a viable bipartisan approach to prevent the SGR cuts, we cannot endorse a bill that just results in another temporary reprieve from the SGR cuts resulting in even deeper cuts in future years. Instead, Congress must enact comprehensive and long-term payment reform that eliminates the SGR, provides stable payments for all physician services for at least five years, and establishes a transition to better payment models.

Sure, Congress isn’t likely to reach agreement on a long-term SGR solution before it recesses for the year—although a Christmas miracle to that effect would nice! Another short-term fix is much more likely. But if Congress once again chooses “. . . the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries” it is doing it without the help of organized medicine. Medicine is willing to line up (again) to kick a football called SGR repeal, but only if it really has a chance of getting over the goal post.

Today’s question: Do you agree that physicians should withhold support from any SGR bill that provides a temporary reprieve from the 27.4% cut if it results in deeper cuts in subsequent years, and doesn’t move toward a permanent solution?


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

At a time when we are being bonused and penalized at 1-3 % (we, being those who stay in traditional medicare or who see private insurance emulate its model), the SGR is even more perverse. Obviously, we have seen the primary care MD marginalized into a commodity of service levels and fixed payments, while new multimillion dollar hospital structures, billion dollar biologics, and procedure happy algorithms suck up our health care dollar. The administrative that has entered Medicare is inexcusable; the monoply doesn't need the games. Should it be a monopoly is the question and you can review Ryan-Wyden for us.

The drug "free for all" is in need of urgent reform. Eliminate the SGR on the backs of pharmaceuticals moving forward immediately. Soften the blow from the stick with indefinite exclusivity. End the absurd brand-generic games that drive pharmacy benefit harassment.

Steve Lucas said...

As a business person I see this as a loose, loose for doctors. Wait for a permanent fix and loose revenue Accept a temporary fix and return to this same situation again in a short time.

Dr. Sobel’s comment stuck a cord as we have seen in my local area doctors become simply the front end of a medical monster designed to “maximize your insurance and assets” as bluntly told to me many years ago by a doctor.

If we, as a society, truly value front line medical care we need a fair and stable financial structure for doctors to work in. My personal belief is that within this structure we can find cost savings.

Dr. Sobel is absolutely correct in:

“new multimillion dollar hospital structures, billion dollar biologics, and procedure happy algorithms suck up our health care dollar.”

We need to now tip that scale back in favor of the front line doctor and their patient.

Steve Lucas

Harrison said...

Your question is whether we should withhold support for any bill that only provides a temporary reprieve from a 27.4% cut in our fee schedule.
As opposed to?
We are caught in the middle of a political debate.
Just like the payroll tax cut.
Just like the Keystone Pipeline.
Just like the Unemployment benefits.
We should accept any reprieve we are given.
We have to continue to work tirelessly to introduce sanity into political discourse.
But we can't get there by holding our breaths and pouting.

We have great points to make.
We are not the only ones in this economy with great points to make.
All we can do is make ours, and express disappointment when our Congressional representatives choose ideology and solidarity with their political caucus over the right thing to do for their constituents.

The GOP vote in the House today was deeply disappointing.
The Republican party in this country is badly broken.
That is not to say that the Democrats are a model or that they don't succumb to corruption and bad judgment.
But the Republican party does all of that, and is broken to the point where their Presidential primary reads like a reality tv show, and their leaders in the tea party and in the media contradict themselves from one week to the next in the interest of political expediency.
Federal marshalls to arrest judges and justices because of disagreeable bench decisions?
That is from the current front runner.
The Speaker assured the Senate Republicans just days ago that his caucus would support the amendments in the Senate bill. Now the GOP vote nearly unanimously against those amendments, which the Senate Republicans favored, nearly unanimously.

And Donald Trump with his questions about where President Obama was born carries serious political clout among Republican primary voters, such that every candidate visits him in New York.