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?


Jay Larson MD said...

We have danced this dance before. This is not the first time that the congress has recessed before an SGR fix was passed to stop an SGR cut. Once the legislation is passed, typically the payment increases (about 0.5% in the past) are retrospective to when the SGR cut was to go into effect. It just means that Medicare has to reprocess claims, which only increases the cost of running the Medicare program.

Eileen K. Carpenter said...

We need a permanent fix. The annual band-aids are a convenient way to pass legislation that doctors might otherwise oppose, like the Medicare part D legislation that precluded any cost controls.

Anonymous said...

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

It seems to me that the Party of Fiscal Repsonsibility never has a problem finding a few extra billion lying around to fund the latest anti-(Fill in the Blank) insurgents or to Bomb, bomb, bomb the latest boogey man country. These are also the same guys who have no problem cutting Medicare funding. If you really want to hold them accountable STOP VOTING FOR THEM...

Eileen K. Carpenter said...

Unfortunately, my district votes about 90% democratic, but due to a pretty obscene degree of gerrymandering, we are underrepresented in the US House and in the state legislature.

And did you know that the populations in rural districts are artificially inflated because they count the inmates in prisons as residents of the district where the prison is located, not at the inmate's home address -- even though they don't let them vote and have no intention of allowing them to settle in the local community after release.

And the saddest thing is that the percentage of US citizens in prison is so high that it makes a significant difference in the outcome of legislation.

When the government has the power to declare a person a felon, and felons become unable to vote for or against the people in that very government, it starts looking a lot like the Soviet system of declaring dissidents mentally ill to silence them politically.

marcsf said...

The real question is "Who defines value?" I am very afraid that self-styled elite policy makers, totally out of touch with reality very much like ABIM, will find plenty of excuses to cut internists pay. Non-practicing physician policy makers never understand the costs and expenses of running a practice

ryanjo said...

Did the cheerleaders in the medical societies lending support to this "doc fix" consider our bureaucratic burden? This complex "merit" system will likely take dozens of practicing physician hours to collect and report. But maybe this is the point, few will actually qualify for the bonuses, and opponents will be labeled "quality" laggards. As marcsf posted above, academics and lobbyists just pass this stuff down to some staffer.

eileen said...

Bob, what is the new, federally funded program to help smaller practices that's mentioned in your previous post?

Harrison said...

I will be willing to call the offices of Sen Feinstein and Sen Boxer. But how to hold them accountable? I'm not sure. Congress has become such a dysfunctional body.

I think it is worthwhile to point out that by holding the SGR over our heads for so long, we have pushed doctors into procedure oriented specialties. If the game of reimbursements is focused on volume, then it is important to do things that are rewarded reimbursement but that don't take much time. Procedures. Another EGD can be squeezed in. And the reimbursement per EGD won't go down.
But if you try to see more patients with E and M codes, then the likelihood is that one must switch to lower reimbursed codes.
It is tough to see 5 99214's per hour. If you see 4 or 5 patients in an hour, they are probably being billed 99213's.
If you are seeing 3, then you are probably able to bill 99214's and maybe the occasional 99215.

But really, for primary care, the reimbursement is around $200 to $300 per hour. That covers staff, and rent, and EHR's and paper, and insurance, and well, then we get whatever's left.
If Medicare cuts our real money income by 21%, then it will fall down to $160 to $240 per hour.
I'm not sure how we make that work.

Students can do this math. They are gonna choose procedures, and have done so for a long time.
Even those in primary care choose salaried positions. Hospitalist work.
And then there is the out for the office based practices.
I've had 3 offers in the last month to get $500 just to listen to a sales pitch about concierge practices.
This will make a dent in the primary care work force too.

I hope they pass this bill.
But....if Medicare wants to use PCP's to help make our system more efficient and get into value based practices based on evidence, then they may want to find a way to make the current PCP's a bit happier so that medical students and residents see us smile once in a while.

I'll call Sen's Boxer and Feinstein. I will.
And I'll express my disappointment.
And I'll ask them to vote for HR 2 without amendments.
And I'll remind them that the Senate chose to not deliberate on this.

But the Senate has also chosen not to comment on the war we are fighting again in Iraq.
And they have chosen not to confirm an unassailable attorney general candidate.
And 47 of them chose to write a letter to Iran suggesting that they might not back our President.

They are so inadequate in so many ways Bob.

Tell me how this changes.