Despite historic health care vote, no sustainable growth rate reform

"They are forcing us to consider access issues with Medicare beneficiaries," declared Jeffrey Frankel, MD, president of the American Association of Clinical Urologists (AACU). "We don't want to stop seeing Medicare patients, but they are forcing us to do that. Apparently, it's the only thing they understand."

Unwilling to include reform of the Medicare fee payment system in the new health care reform law because it would send its cost soaring over the magical 10-year, $1 trillion mark, Congress now must figure out a solution as uncertainty reigns for physicians and their patients.

The agency ordered that claims submitted on or after April 1 be held for an additional 10 days before being paid. Then, on April 15, yet another temporary fix came. This latest congressional action set June 1 as the first day the cut will be effective.

"What is in the works is a 7-month extension through October 1," said Karen Lencoski, JD, MBA, government relations and advocacy manager for AUA. "But nobody really has a plan. They will probably just keep doing this.

"How do you reform health care when one of your largest programs is flawed?" Lencoski asked. "They just completely separated it out. It's just playing games, and it's frustrating."

Extension anticipated

Dr. Frankel says his "gut feeling" is that Congress will pass an extension that would last until after the November mid-term elections so it can, once again, delay making the difficult decision of how to pay for the "doc fix."

Lawmakers have overruled similar reductions every year except one since Medicare's sustainable growth rate (SGR) formula was implemented as part of the Balanced Budget Act in 1997. In some years, the congressional action came even after the planned reductions took effect, requiring CMS to go back and reimburse physicians after the fact. Meanwhile, every year the scheduled cuts required by that law grew larger as one reduction was piled on top of the others.

In November 2009, the House passed legislation that would replace the schedule of cuts with annual increases costing $210 billion over the next decade. This year, the increase for physicians would be about 1.2%, reflecting the rise in the Medicare Economic Index, according to the Congressional Budget Office.

But the Senate never took up that legislation, and instead passed a bill delaying a decision until Oct. 1. At press time, the bill still needed House approval to become law. Congress, exhausted from its long debate over health care reform, left town without even passing another 30-day extension to provide time to consider the 7-month extension. Then, when it returned after its Easter break, it approved a temporary reprieve until June 1, so a longer extension is still possible.

During the debate in the Senate over the reconciliation bill, Sen. Judd Gregg (R-NH), ranking member of the Senate Budget Committee, offered an amendment to extend the current formula for 3 years, and said it would be paid for by savings Democrats claimed would occur under the new health care measure.

"We all know that these scheduled cuts will never take place," Gregg said. "If they did, doctors wouldn't be able to afford to see Medicare patients. Medicare patients deserve access to quality care, and doctors deserve to be paid fairly for their services."

As Senate Democrats sought to minimize any amendments to the reconciliation measure that could jeopardize its passage in the House, Gregg's amendment was not approved.

But the point about access to care for Medicare patients was emphasized in a survey of physicians conducted by the American College of Surgeons, which showed that 37% of respondents would change their Medicare status to nonparticipating, while only 31% said they would remain a Medicare participating physician. Twenty-nine percent said they would opt out of Medicare for 2 years and privately contract with Medicare patients, while 3% said they would remain a Medicare nonparticipating physician.

Among urologists, of whom 98% currently participate in Medicare, only 25% said they would remain in the program, while 39% said they would change to nonparticipating and 34% said they would opt out for 2 years.

The bottom line is that physicians are thoroughly frustrated with Congress for not resolving the SGR issue after all this time.

"It's just not right," Dr. Frankel said. "It's disconcerting that this government thinks we can be played with. Any normal business needs to know its source of revenue. You just can't operate a medical practice this way."

Bob Gatty, a former congressional aide, covers news from Washington for Urology Times.