AMA meeting: Physicians feeling Medicare pay pinch before 6-month fix stalled in Congress

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Note:This article appeared in the July 5 print issue, which was readied for the press before the developments reported in a story posted June 24, link.

Lawmakers officially ran out of time to prevent physicians from feeling the effects of a 21% cut in Medicare payments. A last-minute attempt in the Senate to reverse the reduction and raise pay by 2.2% through November ran into some initial trouble in the House.

After a jobs bill containing a 19-month pay patch passed in the House, but failed in the upper chamber, Senate Democratic leaders reduced the length of the physician piece to six months and stripped it out of the package, passing it separately by unanimous consent on June 18. But with the expiration the same day of a Medicare claims hold designed to give lawmakers more time to act, it already was too late to stop Medicare contractors from starting to process the first June claims with the 21% cut applied.

That meant the roughly 50 million claims backlogged since the beginning of the month would start being paid at the reduced rates, on a first-in, first-out basis. The Centers for Medicare & Medicaid Services said it would automatically reprocess those claims as soon as a patch retroactive to June 1 was enacted, at an expected additional cost to the government of 30 cents per claim.That enactment had not come by this article's deadline. House Speaker Nancy Pelosi (D, Calif.) criticized the Senate for passing a scaled-down physician payment bill separate from the rest of the jobs bill, which contains other provisions that are a high priority for Democrats. "I see no reason to pass this inadequate bill until we see jobs legislation coming out of the Senate," Pelosi said in a June 18 statement, though congressional aides expressed confidence that an agreement could be reached soon.

The American Medical Association slammed Congress for allowing such an unprecedented cut to take place, even temporarily.

"Congress is playing Russian roulette with seniors' health care," said AMA President Cecil B. Wilson, MD. "Congress has finally taken its game of brinkmanship too far, as the steep 21% cut is now in effect and physicians will be forced to make difficult practice changes to keep their practice doors open."

Looking for another way

Frustrations over the near-constant threat of huge Medicare pay cuts helped motivate the AMA House of Delegates to adopt policies supporting more Medicare participation and payment flexibility during the Association's Annual Meeting in Chicago.

As the Senate was still attempting to move its physician pay bill, delegates on June 14 adopted a resolution calling on the AMA to write its own bill to allow additional Medicare fee-for-service payment options. The bill would permit patients and physicians to contract freely for payments that differ from the Medicare fee schedule, while still allowing patients to use Medicare benefits. About two-thirds of delegates supported the resolution.

Under current Medicare rules, physicians can contract privately with Medicare patients only if the doctors opt out of the program completely for two years, during which time neither they nor their patients can claim any money from Medicare for care those physicians provided. Balance-billing, asking a patient to pay the difference between Medicare fees and the cost of providing the care, is also strictly limited to doctors who don't accept Medicare assignment.

"A new patient-centered category of Medicare payment will allow seniors to use their Medicare benefit fully for the health care they need," said AMA Board of Trustees member David O. Barbe, MD, a family physician from Missouri. The policy set a Sept. 30 deadline to finish the bill.

The resolution was offered by members of a coalition of 15 state medical societies and four specialty societies that formed last year during the national debate on health reform.

"We see this as a giant step in the right direction toward restoring patients' access to physicians by guaranteeing they can see the doctors they need to see," said M. Todd Williamson, MD, immediate past president of the Medical Assn. of Georgia and spokesman for the Coalition of State Medical and National Specialty Societies. The coalition felt that the AMA hadn't lobbied hard enough for Medicare private contracting and balance billing despite extensive AMA policy supporting it.

Most delegates speaking about the resolution supported it. But others raised concerns.

"There's language in here that I believe very strongly is unachievable and will get us laughed out of the room," said Richard F. Corlin, MD, a former AMA president. A day before the AMA house approved the resolution, outgoing President J. James Rohack, MD, also cautioned that Congress may not be receptive to such alternative Medicare pay options.

But Dr. Williamson said that until Congress is willing to pay the actual costs of treating patients, private contracting with fewer limits is the only way to ensure that physicians will be able to cover their costs and care for patients. "The fact that Congress isn't receptive to this doesn't mean much to my patients. The need is there."

Delegates also sought additional flexibility in Medicare participation. The house adopted policy calling for elimination of "any restrictions, including timing, on physicians' ability to determine their Medicare participation status." Currently, doctors choose whether to enroll on an annual basis, sometimes without knowing the new fee schedule.

"It's not good business practice to sign a contract unless you know what's included," said Paul A. Wertsch, MD, a family physician from Madison, Wis., and a Wisconsin Medical Society delegate.

Coated messages

Delegates urged lawmakers to prevent Medicare pay cuts and overhaul the sustainable growth rate formula by writing messages to lawmakers on white coats, an event the AMA dubbed the Write Coat Rally. The coats were delivered to congressional offices.

Some delegates said good working relationships with elected officials have not always translated into votes.

Stephen Tharp, MD, an internist from Frankfort, Ind., and delegate for the Indiana State Medical Assn., wrote "Retire the SGR or we retire" on three white coats headed for his congressional representative and senators. "I believe all three have not voted to repeal the SGR," Dr. Tharp said, adding that they've told him the cost of repeal is a barrier. Dr. Tharp interprets this as meaning there's not enough money to support government-driven health care.

"Please follow the advice of the president and kill the SGR," wrote Michael M. Miller, MD, a Wisconsin delegate and addiction medicine specialist from Madison. He said the U.S. House has adopted a permanent reform plan, but more pressure is needed in the Senate.

Tom Garcia, MD, a cardiologist from Houston and a delegate for the Texas Medical Assn., wrote "Please repeal the SGR" on his white coats.

Dr. Garcia said repeal is necessary because he is already seeing an influx of new patients from other physicians who have stopped taking Medicare. "It's about patients," he said. "It's always been about patients."

--Kevin B. O'Reilly contributed to this article.