Could 2013 finally be the year to eliminate the Sustainable Growth Rate formula?
Officials at the American Medical Association say there’s a chance that Congress could decide to permanently scrap the unpopular formula, which drives payment under the Medicare physician fee schedule, as part of a larger deal to cut the federal deficit.
"The fact that we’ve got this big potential deficit-reduction package would make us more optimistic that we can get [the SGR] taken care of this coming year," said Dr. Jeremy A. Lazarus, president of the American Medical Association.
William Zoghbi
SGR repeal has been included in bipartisan deficit-reduction plans created by outside groups several times, including the Simpson-Bowles Commission, the Senate Gang of Six, and others.
Although complete SGR repeal carries a 10-year price tag of nearly $300 billion, physicians argue that, since Congress always acts to avert the pay cuts triggered by the formula, the federal government does not save any money by keeping it on the books. The large cost of repeal, however, means that it may be easier to get the SGR fix inserted into a larger bill than to get lawmakers to approve it separately, Dr. Lazarus said.
The AMA is asking Congress to not only repeal the SGR but also to establish a period of stable Medicare payments so that physicians can begin to transition to a new payment system that focuses on quality of care, Dr. Lazarus said. In the meantime, the AMA and other groups have been working on developing new delivery and payment reform options that could offer an alternative to the current fee for service system.
"We do hope we can start changing the equation on reimbursement and going from fee for service to accounting for quality," said Dr. William A. Zoghbi, president of the American College of Cardiology.
ACC officials are eager to move away from the SGR but they are concerned about where the money to do so might come from. Dr. Zoghbi said that he doesn’t want to see lawmakers robbing other health care priorities to pay for the fix. For instance, in December, lawmakers considered a proposal to pay for a 1-year SGR fix using money that was slated for increasing Medicaid payments to physicians providing primary care services.
"These fixes cannot be on the backs of the professionals providing care," he said.
ACA milestones
This year also will see some practice-impacting milestones under the Affordable Care Act.
Federal money now helps pay for preventive services for Medicaid patients, and many primary care services provided under Medicaid now are paid at the higher Medicare rate. Under the ACA, Medicaid payment increases to 100% of Medicare rates for family physicians, internists, and pediatricians when they provide certain primary care services. Subspecialists in these areas are also eligible for increased payments. The pay hike is for 2013 and 2014.
The law also provides an additional 2 years of funding to the Children’s Health Insurance Program to continue coverage for those children for eligible under the Medicaid program.
The Independent Payment Advisory Board is slated to start work this year, even though its members have yet to be named by President Obama. The controversial 15-member panel is charged with making recommendations on how to reduce Medicare spending. Dr. Lazarus said the AMA will continue to work toward eliminating the IPAB.
Some of the biggest changes under the ACA – the expansion of Medicaid eligibility and the creation of state-based health insurance exchanges – are coming in 2014, but physician leaders said that doctors need to start preparing this year.
Robert Doherty
Exactly how to get ready will vary by state since both the Medicaid expansion and the exchanges will be largely state-run. The AMA is pushing to give physicians greater say by getting them seats on the boards of state exchanges. But even as physicians await more information on these changes, they can prepare by becoming more familiar with the Medicaid program since they are likely to see more of those patients, said Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians.
Penalties kick in
This year the Physician Quality Reporting System (PQRS) transitions from a pure incentive program to a mixed incentive/disincentive program. Previously, PQRS offered small bonus payments to physicians for successfully reporting on quality measures. Now, physicians who don’t participate in the program will be assessed a penalty. The 1.5% cut to Medicare fees won’t come until 2015, but it will be based on participation this year. Physicians will see a 2% penalty in 2016 if they don’t successfully report data during 2014.