Medicare SGR Update

The Senate passed HR 4851, the Continuing Expansion Act of 2010, this evening preventing the scheduled Medicare cut until June 1, 2010. The bill was passed in the House before the Spring recess with an effective date through  May 1, 2010. The Senate bill is being sent back to the House for approval to reconcile of the dates. It is expected to pass this week.

Opportunity Forfeited by National Physician Groups

Today, the Senate is expected to vote on HR 4851, the Continuing Expansion Act of 2010. It will maintain Medicare payments on the level prior to the 21.3% cut which occurred April 1, 2010 because Congress has not yet permanently fixed the Medicare Sustainable Growth Rate (SGR) formula. Until now, CMS has been holding claims payments hoping for another Congressional fix; but the agency can only hold claims for 10 business days and must begin payments on April 15. If Congress approves this billl, it will kick the proverbial can down the road for another month, with another fix needed on May 1, 2010.

The question is why would our national physician organizations endorse a supposed comprehensive health reform plan that did not assure that physicians would be able to afford to continue to provide services to their patients? Did they not understand who their members are and that this is not a fiscally feasible business model for physicians? Why would such powerful organizations, with lawyers on staff, give up their leverage in bargaining for a permanent SGR fix for a politician's promise to take care of it at a later date? Did they all fail Negotiations 101?

At first, I too, believed that might have been the case, but that is perhaps too easy an answer. In hearing the coments of some of Democratic politicians (who eventually voted again the bill) regarding the arm twisting that went on behind the scenes, I heard one congressman say they were effectively told how lucky they were to even be invited to the table, otherwise they would have been the main course. Funny, I heard the same words from the leadership of one of our national physician organizations at the end of November. Coincidence?

Physicians representing national physician organizations may have been invited to the photo-ops, but at best, they were only give a crumb or two that fell on the floor with offers to study solutions to the malpractice problem. They were cleasrly not invited to the table to find solutions for healthcare delivery. Were they tricked into believing attendence was participation?

Given the Chicago-style politics in Washington today and the Chicago roots of our largest organizations, were they also strong armed? Did they willingly let the wool be pulled over their eyes? Was it Stockholm syndrome? Or perhaps the did fail Negotiations 101...

As Academia Slept...the Government Took Over

The dearth of media coverage regarding the federal takeover of the federally funded student loan program (i.e. Sallie Mae) and the elimination of private lending via the Federal Family Education Loan (FFEL) program, is astounding. Americans were caught off-guard, when the political debate seemed to be about healthcare. After the fact, most assumed it was Washington padding the bill to make the healthcare numbers look more favorable.

With the government now the only lender to students, do you believe tuition increases will be permitted to continue unabated? "The National Association of Independent Colleges and Universities (NAICU), says...the average annual increase in tuition and fees has been 6 percent over the last 10 years... Do the math and you'll see that an average annual increase of 6% leads to an 80% rise in tuition costs over just one decade!" [Money and Markets and Federal Reserve Bank of St. Louis]

Our government is already in hoc up to its proverbial eyeballs to foreign debtors and in danger of losing its triple AAA credit rating. Why would it choose to take on more long-term debt, especially with student loan default rates reaching a nine year high of 6.5%? Defaults typically increase in tough economic times; consider the last recession, in 1989, when default rates reached 22%. Given that less foreign creditors are showing up at Treasury Department auctions, and the Federal Reserve is now monetizing the debt (buying unsold Treasuries at auction) -  Why would the government choose to become the sole provider of funds for federal loans [Stafford and PLUS] at this time?

With money tight in the public sector and credit tight in the private sector, wouldn't it make better sense to reform the interest subsidy and loan guarantee process to guarantee more loans for less money ( paying only on the unrecoverable amount of the defaulted loans), Rather than tie up money directly laying out the entire sum of the loan? After all, we do not have a sovereign wealth fund with money lying around to invest, as some countries do.

Given that all federal student loans will be subject to and administered by the Department of Education, which is funded at Congress' discretion, and given this Congress' track record for deal making - do you believe that these will continue to be distributed without favoritism to all those in need? As money gets tighter, will some states receive preferential treatment? Will the alma maters of certain politicians receive favoritism? Will certain degree programs receive preference? Where will osteopathic medical schools fall in this mix? Will physicians receive less favorable terms going forward if they are training in specialties or geographic areas which are not deemed shortage areas? What happens when the government decides to apply a Sustainable Growth Rate (SGR) formula to tuitions because there is not enough money to go around?

Given the current trends in Washington to "never let a crisis go to waste" - was this good economics, concern for students or control?

I invite your comments -

Senator Reid makes the Doctors Pay for Medicare under Senate Bill 3590

The politicians are claiming that Senator Reid's bill will save the country money according to the latest CBO report. Physicians were scheduled to have a 21% pay cut caring for Medicare patients as of January 1, 2010. However, under Section 3101, this bill provides for .5% increase for physicians in 2010 but assumes no further increases or change to the Medicare Sustainable Growth Rate formula which is used to compute physician payment rates. It is known to be a flawed formula requiring an act of Congress to "fix" each year. Politicians have always provided some nominal increase in physician payments, even if it has not kept pace with inflation. According to the Alliance of Specialty Medicine, "If the SGR formula is not fixed, physicians will receive negative updates of approximately five percent each year from 2006 until 2013 and rates will not return to their 2002 level until well after 2013. In other words, physicians will receive less reimbursement in 2013 than they did in 2002 for the exact same procedure, regardless of inflation and increases in practice costs." This unrealistically assumes doctors will bear the cost burden for the Medicare population. More likely physicians will have to stop Medicare participation (stop caring for Medicare patients) under these conditions. It seems disingenuous to claim "savings," when not all the costs have been realistically accounted for in this bill. This bill will surely go over the CBO estimates if real world historical political behavior of annual "fixes" are assumed as opposed to the static assumptions of the CBO.

HR 3961, HR 3962, the Medicare SGR & the Debt

We are still awaiting the CBO's scoring of the bill which came out of the Senate majority leader's closed door discussions. Similar to the "bill" sent to the CBO by the Senate Finance Committee, it is still in the conceptual stage and has yet to be officially written.

On the other hand, the bills in the House were merged to form H.R. 3962, the Affordable Health Care for America Act, which was released October 29th. As mentioned in the analysis of the Baucus Bill, H.R. 3962 does not include fixing the physician reimbursement rate (Medicare SGR). While it claims to save the federal government $104 billion, it leaves in place the 21% SGR cut scheduled for 2010, and makes no further provisions to fix the formula. This is clearly unsustainable, as providers will have no choice but to opt out of the program, leaving seniors without care.

Interestingly a separate bill, H.R.3961, the Medicare Physician Payment Reform Act of 2009, was introduced the same day. It restructures the SGR formula, increasing physician payments for Medicare, Medicare Advantage and TRICARE. One quarter of that increase would come from premium increases paid by Medicare Part B enrollees. Ultimately, this bill is estimated to increase the direct spending of the Federal government by $210 billion over the 2010-2019 period.

According to the numbering system, it seems the Medicare Physician Payment Reform Bill was introduced first. It seems someone in the House was aware of the SGR problem. Since this wasn't an afterthought, wouldn't it have been logical to have “fixed” the problem in the comprehensive bill before introducing it? After all, for months politicians have been insisting that we must have ONE bill to reform healthcare. But without the "fix," House politicians could and did proceed to hold press conferences, claiming victory and “savings” for the American people all the while putting us $100+ billion further in debt. This behavior is disrespectful of the hardworking Americans who voted them into office and it does nothing to increase sustainability or affordability.

The Baucus Bill & Physician Reimbursement

The Baucas Bill [America's Healthy Future Act of 2009] does not eliminate the flawed physician reimbursement formula [Medicare SGR (sustainable growth rate)]. It allows for the .5% increase Congress appropriated for 2010; however, it does not eliminate the scheduled 25% cut in 2011. It is assumed that reimbursement rates will remain at current low levels (as specified by the SGR) for the subsequent years through 2019.

Historically, Congress has made adjustments annually to this "flawed" reimbursement formula which rises significantly slower than the rate of medical inflation. By cutting reimbursement rates in 2011 by 25% and keeping them there, there will be far fewer providers willing to provide services to Medicare patients. On the other hand, if Congress continues the annual adjustment process, the projected Congressional Budget Office "savings" in the bill begin to evaporate.

The bill does little to address the current high costs of providing actual care, which someone must pay. Physicians will not be able to sustain a 25% pay cut to provide care for Medicare patients. Those that do, will not be able to continue such services in subsequent years without any inflation adjustments. Apparently, a significant portion of the expense of providing care for the elderly in the future is expected to be born by physicians.

The projected "savings" of this bill are dubious at best; it is really cost-shifting. It seems a bit premature for the Senate Finance Committee to be patting itself on the back, given that this is not actually a viable solution.