Elections over, organized medicine begins Medicare payment campaign

The American Medical Association and others in organized medicine say they are pushing for a Medicare pay solution that would prevent any threatened cuts through 2011.

Once that is attained, the AMA and others said they would work with the new Congress -- which will have a narrow Democratic majority in the Senate and flip to a solid Republican majority in the House -- to find a permanent solution for the sustainable growth rate formula, part of a mechanism that determines physicians' Medicare payments. The prospect of ever-rising mandated Medicare pay cuts has been a major concern for physicians in recent years, particularly in 2010. Congress has had to intervene on four separate occasions in 2010 to avoid a large reduction in Medicare physician payments.

The AMA and other leading organized medical organizations said they realize that the upcoming lame-duck session, which begins Nov. 15, will not pass the permanent solution to the SGR that is desired. They are seeking a 13-month patch to at least get them through 2011 while they negotiate with lawmakers.

"That will at least give us time over the next year to work with the new Congress and get rid of this horribly flawed [SGR] formula, and put in place a method of physician payment that works," said AMA President Cecil B. Wilson, MD. "The AMA is urging Congress to take swift action when it returns in November."

That view was echoed by Roland Goertz, MD, president of the American Academy of Family Physicians. "Is this completely acceptable? No, it's not. But it should help us move toward a more permanent solution. And hopefully now that the elections are over, there will be a settling effect that focuses on what we need in the future."

Physicians are slated to get hit with a 25% reduction in Medicare payments over two months, according to the final 2011 physician fee schedule released Nov. 2 by the Centers for Medicare & Medicaid Services. CMS revised that downward from its original estimate of a 29.5% cut. Pay is still slated to go down 23% on Dec. 1 but would go down 2% -- rather than 6.5% -- on Jan. 1, 2011, assuming Congress takes no action.

As of Nov. 5, three days after the election, Republicans won enough seats to get a 239-187 edge in the House, with 9 races undecided. Democrats held a 51-46 lead in the Senate, though it is 53-46 counting two independents who caucus with the Democrats. One race -- Alaska -- was still undecided.

Unfinished business

But before that new Congress is seated on Jan. 3, 2011, there will be a lame-duck session of the current Congress, which is 256-178 for Democrats in the House, and 58-42 for Democrats in the Senate (including the two caucusing independents). The Democratic edge in the lame-duck Senate fell by one when Illinois voters elected Republican Mark Kirk to fill the unexpired term of Obama, replacing an appointed Democrat. The number of Republicans in the lame-duck House fell by one because Kirk will leave his seat there to go to the Senate.

The lame-duck Congress is expected to have a full plate of big issues that were shelved before the elections -- most notably whether to make permanent the tax cuts, passed during the administration of former President George W. Bush, that are set to expire at year's end. Other expected issues include whether to extend unemployment benefits, votes on funding of government operations and the possible repeal of the "Don't ask, don't tell" law that allows gays to serve in the military only if they do not disclose their sexual orientation.

Another complicating factor, this one specific to Medicare pay, has a Tea Party connection. Observers say that debt-cutting goals of the Tea Party organizations probably will affect the debate. The estimated $17 billion cost of a 13-month patch might have to be cut from somewhere else, creating a logjam in Congress.

"One of the key issues that appears to be leading the Republicans is that federal spending is out of control, so at this point, SGR fixes need to be paid for," said Paul Ginsburg, PhD, president of the Center for Studying Health System Change. Nevertheless, "both the Republicans and the Democrats want to fix the SGR and avoid a sharp decline in payment rates."

Lawmakers have been unable to reach agreement on a permanent solution because of the price tag -- the most recent estimate by the Congressional Budget Office places the cost at $276 billion over 10 years.

"For physicians, the SGR challenge does not get any easier. It's a bipartisan problem. The cost is enormous, and the money is very hard to find so it doesn't matter who is in charge," said Kristen Hedstrom, assistant director of legislative affairs at the American College of Surgeons.

Many experts feel the most likely scenario is that the lame-duck Congress will pass a one- or two-month SGR reprieve, and that the new Congress will pass a longer patch to get through 2011. "I think we're likely to see a short-term patch that's going to punt it down the road, as usual," said Jack Lewin, MD, CEO of the American College of Cardiology. "[But] we would like to see a 13-month patch, at a minimum, to get us through 2011 and at least start us with conversations with the new Congress."

Stability desired

Observers say Congress is aware that a cut in physician pay probably would restrict access for Medicare patients. Dr. Wilson said a recent AMA poll shows that the ongoing threat of cuts is having an impact, with about one in five physicians already limiting the number of Medicare patients they treat.

Research released Oct. 25 by the Medical Group Management Assn., which represents physician practices of 10 or fewer doctors, concluded that 67% of medical practices are likely to limit the number of new Medicare patients they accept unless Congress halts the upcoming Medicare payment cuts.

In the past, when pay cuts became effective before Congress could pass a short-term patch, lawmakers instructed the Centers for Medicare & Medicaid Services to hold claims to ensure that physicians did not receive checks reflecting the cuts. In each case, Congress passed a short-term patch that reversed them. Nonetheless, the process has proved exasperating to those in the system.

Moving back to dealing with an annual cut at least would restore some stability to the system, others agree.

"We want to at least see this get back to an annual basis and put some predictability back in the program," said Shawn Martin, director of government relations at the American Osteopathic Assn. "This 30-day or three-month mentality has wreaked havoc on our membership."

Ultimately, the AMA is hopeful that lawmakers will find common ground and ensure that patients have access to health services.

"As the nation's largest physician organization, the AMA remains committed to working with lawmakers on both sides of the aisle in the 112th Congress to make improvements on issues important to patients and physicians, including fixing our broken Medicare physician payment system, enacting medical liability reforms, and addressing the Independent Payment Advisory Board and other refinements to the health system reform law," Dr. Wilson said.