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.