Tax law may threaten Medicare, provider pay

Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

Congress ended 2017 with its first big legislative win for the Trump administration: passing a sweeping tax bill that promises the biggest reform to the U.S. tax program in over 30 years. But despite Republican claims that the tax cuts will pay for themselves, numerous nonpartisan analyses estimate that the bill will add billions, if not trillions, to the national debt over the next 15 years, leaving many to worry that cuts to federal programs like Medicare and Social Security are inevitable.

Adding to these fears are recent statements by House Speaker Paul Ryan (R-WI), who specifically called out Medicare as being the "biggest entitlement that's got to have reform.” Unfortunately, Speaker Ryan and other GOP lawmakers have given virtually no details on what “Medicare reform” on the horizon might look like, leaving the health care community to speculate on the details, particularly with respect to potential payment cuts for physicians.

Medicare crisis averted, but battle not over

When President Trump signed the tax bill into law in December 2017, he effectively reduced the potential revenue to the federal government by almost $1.5 trillion, according to the nonpartisan Joint Committee on Taxation. GOP lawmakers have continually claimed that the tax bill will “pay for itself,” but the reality is unless it generates a substantial amount of economic growth to offset the decrease in revenue, the new law will likely add to the national debt.

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A fiscal impact that large would have normally triggered the Pay-As-You-Go Act of 2010, which requires cuts to Medicare and other programs if a new law increases the deficit. Fortunately, both the Senate and the House passed a continuing resolution on Dec. 21 to prevent the automatic cuts to Medicare as a result of the tax bill, which was estimated to be around $25 billion.

But the threat to Medicare still looms. Speaker Ryan has made it clear that he plans to push entitlement reform in 2018, especially in the health care space: “Frankly,” he said, “it's the health care entitlements that are the big drivers of our debt, so we spend more time on the health care entitlements-because that's really where the problem lies, fiscally speaking.”

Next: What reform could mean for urologists

What reform could mean for urologists

Despite being outspoken on his intentions to focus on entitlement reform in 2018, Speaker Ryan has yet to give any indication of what that might look like in the Medicare program. However, recent changes and existing efforts provide a glimpse into what reform could mean for providers in the coming year.

One example is the recent push by the Centers for Medicare & Medicaid Services to develop and examine new and “innovative” payment models to reduce costs and improve quality of care while also rolling back mandatory participation in certain programs. This effort was made clear with the agency’s decision to eliminate two mandatory bundled payment models-under which multiple providers are reimbursed with a single lump-sum payment for a complete episode of care-and reduce participation in a third. CMS plans to replace these models with new voluntary payment bundles soon, which will have a renewed focus on voluntary, not mandatory, participation and fewer regulations in an effort to decrease the regulatory burden on physicians.

In all, the ongoing efforts of CMS to discover and test new payment models that seek to reduce costs while maintaining quality care for patients indicates the agency’s desire to find ways to restructure how physicians are reimbursed for services under Medicare.

CMS also recently indicated that it will begin taking a more proactive, targeted approach to auditing and recovering fraudulent and erroneous Medicare payments to providers by expanding the Targeted Probe and Educate program it began 3 years ago. This likely means that physicians will see an increase in Medicare audits as their billing practices come under more scrutiny.

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CMS also announced in November the 2018 premiums, deductibles, and coinsurance amounts for Medicare Parts A and B, which indicated that some beneficiaries will see increases in their cost-sharing obligations under the program.

But perhaps the biggest Medicare reform concern for urologists is the potential for provider reimbursements cuts, a threat that has continued to loom over the health care community for some time. If recent events are any indication, this threat is moving closer to becoming reality, perhaps best evidenced by the massive cuts to the payment rate for certain Medicare Part B drugs purchased by many hospitals through the 340B Drug Pricing Program. These cuts reduced the amount hospitals participating in the program are reimbursed from a rate of the drug's average sales price plus 6% to 22.5% less than the average sales price, constituting a 28.5% reduction in reimbursement payments for drugs purchased under the 340B program.

Threat of IPAB still looms

What’s worse, despite widespread efforts to repeal by the AACU and numerous other advocates in the health care field, the threat of the Independent Payment Advisory Board (IPAB) still exists. If triggered, IPAB would likely make significant cuts to Medicare payments for physicians and ultimately have a devastating effect on patient access to care.

Congress has failed to pass a bill repealing IPAB, despite widespread bipartisan support in both the House and Senate, and while IPAB managed to avert being triggered this year, the July Medicare trustees' determination report predicted that its triggering is likely as early as 2021. The continued threat of IPAB combined with the new threat to additional payment cuts as part of Medicare reform in the coming year is quite ominous for the urology community.

The AACU is committed to advancing and advocating for the interests of urologists across the country, and will continue to actively engage with lawmakers in 2018 to ensure any attempt at Medicare reform will not harm the urology community.

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