Hopes run high for pass­ing doc fix when Se­nate re­turns in April

Modern Healthcare - - NEWS - By Paul Demko

WASH­ING­TON—The fix isn’t in yet, but it’s close.

The Se­nate ad­journed for its spring break Fri­day with­out tak­ing ac­tion on leg­is­la­tion per­ma­nently re­peal­ing and re­plac­ing Medi­care’s sus­tain­able growth-rate physi­cian-pay­ment for­mula. That fail­ure to act was greeted with wide­spread dis­ap­point­ment from health­care groups, which had hoped that the decade­long headache of short-term fixes would fi­nally end.

But doc­tors won’t face an im­me­di­ate pay cut of 21.2% when the cur­rent patch ex­pires March 31. That’s be­cause the CMS has in­di­cated that it can de­lay pro­cess­ing claims to stave off the cut.

Op­ti­mism re­mains high that the Se­nate will re­solve the is­sue and join the House in pass­ing the bi­par­ti­san mea­sure when it re­con­venes April 13. “We’ll re­turn to it very quickly when we get back,” Se­nate Ma­jor­ity Leader Mitch McConnell said Fri­day af­ter a marathon ses­sion dur­ing which Repub­li­cans passed their bud­get blue­print. “I think there’s ev­ery rea­son to be­lieve (the doc fix) is go­ing to pass the Se­nate by a very large ma­jor­ity.”

On Thurs­day, the House voted 39237 to pass the leg­is­la­tion, which in­cludes a two-year ex­ten­sion of the Chil­dren’s Health In­sur­ance Pro­gram. It was a rare act of re­cent bi­par­ti­san ac­cord on a ma­jor piece of leg­is­la­tion. House Repub­li­cans largely ig­nored the protests of some con­ser­va­tive ad­vo­cacy groups that the deal was fi­nan­cially reck­less. It’s ex­pected to add $140 bil­lion to the fed­eral deficit over the next decade, ac­cord­ing to the Con­gres­sional Bud­get Of­fice.

Democrats set aside queasi­ness over in­creased costs for higher-in­come Medi­care ben­e­fi­cia­ries that will raise nearly $35 bil­lion through 2025 and po­ten­tially set a prece­dent for fu­ture pro­gram re­struc­tur­ing and ben­e­fit re­duc­tions backed by Repub­li­cans. They also were ner­vous about bar­ring Medi­gap poli­cies with­out de­ductibles. Those con­cerns were partly mit­i­gated by a pro­vi­sion in the bill mak­ing per­ma­nent a pro­gram that pro­vides pre­mium as­sis­tance to low-in­come Medi­care ben­e­fi­cia­ries.

Hos­pi­tals sup­port the leg­is­la­tion de­spite fac­ing nearly $20 bil­lion in cuts to an­tic­i­pated spend­ing over a decade. “It was in­evitable that some of this pack­age was go­ing to have to be paid for, and I think this was prob­a­bly the best pos­si­ble agree­ment out there that we could get,” said Tom Nick­els, the Amer­i­can Hos­pi­tal As­so­ci­a­tion’s se­nior vice pres­i­dent for fed­eral re­la­tions.

The leg­is­la­tion in­creases pay­ments to physi­cians by 0.5% an­nu­ally for the next four years. Af­ter that rates will re­main flat for six years. Then pay­ments for most physi­cians will in­crease by 0.25% an­nu­ally.

Joe An­tos, a health­care pol­icy ex­pert at the con­ser­va­tive Amer­i­can En­ter­prise In­sti­tute, scoffed at the idea that this will end the de­bate over Medi­care pay­ments to doc­tors. “If you re­ally think docs are go­ing to be thrilled with a 0.5% in­crease, you are in­sane,” he said. “This is the beach­head.”

But the SGR re­peal-and-re­place bill also es­tab­lishes a two-track pay­ment sys­tem in hopes of prod­ding doc­tors to move to­ward value-based pay­ment mod­els such as accountable care or­ga­ni­za­tions and bun­dled pay­ments. Physi­cians who have at least 25% of their Medi­care rev­enue tied to such pay­ment mod­els in 2019 will be el­i­gi­ble for 5% bonuses.

“That’s noth­ing to sneeze about,” said James Reschovsky, a se­nior fel­low at Math­e­mat­ica Pol­icy Re­search. “I can’t pre­dict how big an im­pact it’s go­ing to have. There’s a lot that is push­ing physi­cians in that di­rec­tion al­ready.”

In Jan­uary, HHS Sec­re­tary Sylvia Mathews Bur­well set a goal of ty­ing half of all spend­ing in tra­di­tional Medi­care to con­tracts with in­cen­tives to man­age qual­ity and cost. But ex­perts warn that designing mea­sure­ments for meet­ing those tar­gets across dif­fer­ent types of providers will be chal­leng­ing. “There are big ques­tions about how it’s go­ing to work and what kind of pres­sures it’s go­ing to cre­ate for physi­cians,” said Paul Van de Wa­ter, a se­nior fel­low at the Cen­ter on Bud­get and Pol­icy Pri­or­i­ties.

Back­ers of the physi­cian-pay­ment changes re­ceived a boost when the Con­gres­sional Bud­get Of­fice determined that they would save $900 mil­lion over a decade com­pared with keep­ing doc­tor pay­ments flat. That com­par­i­son made log­i­cal sense be­cause an­nual physi­cian fee changes have ranged from flat to a 2.2% in­crease since Congress in 2003 started pass­ing tem­po­rary doc fixes to over­ride SGR-based cuts.

But the Se­nate’s fail­ure to act last week raises the prospect of more lob­by­ing and more med­dling with the pack­age when the up­per cham­ber re­con­venes. For ex­am­ple, ad­vo­cates of ex­tend­ing CHIP for four years rather than two still plan to pro­mote their cause.

“Sen­a­tors aren’t used to be­ing pre­sented with a take-it-or-leave-it propo­si­tion from the House,” said John Rother, pres­i­dent of the non­par­ti­san Na­tional Coali­tion on Health Care, which sup­ports the pack­age. “But I do think that it will pass be­cause of the House vote.”

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