Physicians' push for Medicare pay relief goes down to the wire

Washington -- With Congress out of time to implement a long-term solution to the Medicare physician reimbursement problem before adjourning, the American Medical Association has begun pressing for two years of temporary help while lawmakers continue to tackle the issue.

A Senate-passed deficit reduction bill proposes that doctors receive a one-year, 1% Medicare pay increase to take the place of the 4.4% cut that otherwise would kick in Jan. 1, 2006. When lawmakers return from their Thanksgiving break this month, they will try to resolve the myriad of differences between this measure and the House version of the bill, which contains no such Medicare provision.

But Congress needs additional time to develop a new reimbursement system, one that accounts for physicians' costs of providing care, AMA Board Chair Duane M. Cady, MD, told a recent House Energy and Commerce health subcommittee hearing. The Association believes that putting Medicare payments slightly into the black for only one year will not be enough.

"Working together, Congress, the administration and the physician community can strengthen this program and correct problems that undermine its goals," he said. "In the meantime, what's needed now -- this year -- is at least two years of positive updates to reflect increases in medical practice costs."

The new AMA strategy on Capitol Hill comes as lawmakers struggle to put their outstanding fiscal issues to bed before starting a new legislative session and budget-writing cycle next year. Whether the physician lobby can even secure a one-year reprieve from Medicare cuts -- let alone the two-year boost that it hopes to gain -- will depend on whether lawmakers agree to commit scarce funding toward reversing payment reductions.

Lawmakers did not say whether they would support a two-year temporary rate fix for doctors. But the AMA's warning that a reduction next year would harm seniors' access to care appeared to resonate with some subcommittee members on both sides of the aisle.

"We all know we need to do something before the beginning of the next calendar year," said Energy and Commerce Committee Chair Joe Barton (R, Texas).

The clock is ticking

Congress does not have much time to act. The House will return from its recess Dec. 6 and the Senate will reconvene Dec. 12, leaving few days before the year ends and physicians run out of time.

With the decision on doctors' 2006 rates coming down to the wire, representatives from physician groups, including the AMA, the American College of Physicians, the American College of Surgeons and the Alliance of Specialty Medicine, rushed to Capitol Hill late last month to make the case for themselves and their patients. The AMA flew in several trustees and a number of physician section leaders to lobby Congress personally in the days leading up to the subcommittee's emergency hearing.

Letting the clock run out without boosting Medicare rates would hit the medical profession the hardest in places where physicians are already struggling and where more doctors are needed right now, said Vineet Arora, MD, an internist and medical instructor in Chicago who testified on behalf of the ACP.

"It is so bad that many of the excellent role models in primary care that we meet every day in our training programs go so far as to counsel us not to go into primary care, and you may wonder why," she said. "It's because they tell us that there is no economic future in primary care."

But Congress continues to struggle with the policy details behind permanently overhauling such a massive system and with finding the tens of billions of dollars that would be required to fix it. The Senate estimates that a one-year, 1% boost alone -- which wouldn't even cover the estimated increase in physicians' practice expenses -- would cost nearly $11 billion over five years. Dr. Cady noted that subcommittee members agreed on the final goal of reforms but clashed over exactly how to achieve them.

Two years of breathing room "should prevent Congress from having to struggle with this problem -- as I've witnessed today -- again early next year," he said.

Pay-for-performance next year?

After months of mostly staying out of the debate over proposals to reverse next year's 4.4% cut, the Bush administration last month offered a slightly clearer picture of what it supports for 2006 and beyond.

Centers for Medicare & Medicaid Services Administrator Mark McClellan, MD, PhD, announced at the hearing that the White House would support legislation to reverse the reductions slated for 2006 and 2007 -- as long as doctors play ball when it comes to the agency's new voluntary quality reporting initiative. Only doctors who report quality measures should receive the full increases those two years, Dr. McClellan said.

Such a plan is opposed by the AMA, which voted at its Interim Meeting last month to reject the CMS Physician Voluntary Reporting Program that Dr. McClellan referenced. Dr. Cady said the Association had requested another meeting with the agency to reiterate physicians' grave concerns with the perceived shortcomings in the reporting system.

Conditioning payment increases in 2006 and 2007 on participation in the program effectively would change the voluntary initiative into a pay-for-performance program, something that physicians have said they will reject without broader payment system reforms. The AMA also opposes a long-term pay-for-performance plan that the Senate approved along with the one-time 1% rate increase.

At least one lawmaker questioned Dr. McClellan as to why the concepts of fixing the reimbursement formula and implementing pay-for-performance need to go hand-in-hand.

"I know folks ... believe that the only way the doctors should see any increase in their payments is by selling their souls to this so-called quality reporting," said Rep. Charles Norwood, DDS (R, Ga.). "The devil's in the details, and I'm ready to wait and learn, but I fear there's a lot of devil in the details we're going to learn."