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Waiting for Congress to act: Is it déjà vu all over again?

From the November ACP Observer, copyright © 2006 by the American College of Physicians.

As I started writing this column about Congress' failure—so far—to enact legislation to block pending Medicare cuts, it occurred to me I could have re-run a column I wrote on the same topic this time last year, similar columns I've written for the past six years.

Regrettably, Congress has fallen into an annual pattern of ignoring the pending SGR cuts until the last few days of the legislative session, and then rushing to pass a stop-gap measure to halt the cuts, while doing nothing to fix the underlying flawed SGR formula. To quote Yogi Berra, "It's déjà vu—all over again."

Different Circumstances

But for all of the similarities, there are some important differences this time.

In 2005, Congress waited until a few days before Christmas to try to get something passed, but couldn't get it done and allowed the 4.4% cut to go into effect on Jan. 1, 2006. Legislation to restore payments to the prior year's level was not enacted until the first few weeks of the 2006 session.

This year, Congress waited until a few days prior to recessing for the mid-term elections to float several "ideas" for addressing the SGR cuts. But it left it to a post-election "lame duck" session of Congress to decide what, if anything, will actually be done to halt a 5.1% cut that otherwise will go into effect on Jan. 1.

In the weeks leading up to the mid-term elections, the College along with the American Medical Association and other national and state medical societies engaged in a massive lobbying and grass roots membership effort to urge Congress to act before recessing for the elections. When Congress failed to do so, we urged that it take immediate action in the November lame duck session.

If Congress doesn't act in the lame-duck session, it will fall to the new 110th Congress, which takes over in January, to deal with the problem after the 5.1% SGR cut has already gone into effect. At press time, many political analysts speculated that the Democrats were in a good position to regain majority control of the House of Representatives, and possibly the Senate, in the 110th Congress.

If the Democrats are in control, it likely will take several weeks for the new leadership to organize the new Congress, make changes in committee appointments, and decide if, when or what it wants to do about the Medicare cuts. Even if the Republicans remain in control, there are no guarantees that they will act immediately to address the cuts. In the meantime, physicians and their Medicare patients would be forced to deal with the fallout of the 5.1% cut, with no assurance of future relief.

Impact of other payment policy changes

Other changes in Medicare payment policies also make this year different from others. For example, Medicare may reduce the impact of the SGR cuts for some specialties while increasing the cuts for others. The agency is expected to publish a final rule in early November to implement changes in the work relative value units (RVUs) that will result in substantial increases in relative payments for office visits and other evaluation and management services—improvements due in large part to the College's advocacy efforts. (see "How ACP pushed the envelope on payment reform" in the September 2006 ACP Observer.)

Internists were expected to gain approximately 5% in total Medicare payments, on average, from the RVU increases. Other specialties were expected to lose as much 7% from the "budget neutrality" offsets required to pay for the RVU increases and from proposed reductions in their practice expense RVUs.

As a result, while some other physicians could see cuts of 10% to 12% from the SGR cut and the RVU adjustments combined, most internists will not experience any net reduction in Medicare payments on Jan. 1, even if the 5.1% SGR cut goes into effect. This is not to say that the SGR cuts are acceptable for internal medicine. After working for over two years to persuade the CMS to increase the work RVUs for evaluation and management services, the College would be disheartened if much of the initial benefit to internists was cancelled out by the SGR cut.

Pathway to payment reform

Perhaps the biggest difference this year is that some congressional leaders are committed to addressing the broader problems with Medicare's dysfunctional payment system rather than just repeating the battle over the SGR cuts year after legislative year.

In September, William E. Golden, FACP, the chair of the College's Board of Regents, testified before a hearing of the Subcommittee on Health of the House Energy and Commerce Committee, which has principal jurisdiction over Medicare physician payment policy. Dr. Golden discussed the importance of Congress taking action to halt the SGR cuts and stabilizing payments for more than one year as a first step toward longer-term reforms.

He presented the College's recommendations to create positive incentives for patients to establish and maintain a long term relationship with a physician in a "patient centered medical home" He advocated for comprehensive reforms in Medicare payment policies to reimburse physicians for the work and office systems involved in coordinating and managing the care of such patients, especially patients with multiple chronic diseases.

Rep. Nathan Deal (R-GA), chair of the subcommittee, responded to Dr. Golden's testimony by expressing support for the patient-centered medical home. He and several other members of Congress also expressed concern about the impending "collapse of primary care medicine" in the U.S., as Dr. Golden described it in his testimony.

Rep. Joe Barton (R-TX), the chair of the full Energy and Commerce Committee, has incorporated ACP's proposal for a Medicare pilot test of the patient-centered medical home in a draft bill that would also halt the SGR cut and guarantee positive updates for the next three years. He promised to do everything possible to get his proposal enacted during the lame duck session. Similarly, Rep. Nancy Johnson (R-CT), chair of the health subcommittee of the House Ways and Means Committee, has stated that she intends to include a patient-centered medical home pilot program in a bill to halt the 2007 SGR cut.

So it isn't quite déjà vu all over again, even though the prospects for legislation to halt the SGR cuts are as uncertain as ever. Unlike past years, the RVU increases should provide internists with a level of insurance against losses in Medicare revenue if Congress allows the 5.1% cut to go into effect.

Most importantly, Congress' interest in the patient-centered medical home, and its particular focus on the problems facing primary care physicians, may yet lead to fundamental reform aimed at rewarding and supporting care that is managed by a patient's personal physician. Of course, it will take more than just words to demonstrate that Congress is ready to take on fundamental reform of a dysfunctional payment system, instead of just replaying the tired SGR song for another year.

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