Physicians may have blown their chance to win some relief from Medicare payment reductions by supporting a managed-care reform bill against the wishes of the House Republican leadership.
Like every other provider in the healthcare spectrum, physicians are urging Congress to change some provisions of the Balanced Budget Act of 1997. In particular, doctors want HCFA to change the way it calculates the so-called sustainable growth rate, the target rate of increase in Medicare spending.
The rate is determined using a formula in the 1997 budget law. The formula is largely based on projected growth in the gross domestic product but is also affected by Medicare's expected fee-for-service enrollment.
If physicians get their way, HCFA would pay them from the pot of money set by that estimated growth rate and would readjust that pot after determining that year's actual growth rate.
Physician groups say HCFA's growth-rate estimates have been way off the actual figures. Physicians want HCFA to recalculate the rate yearly based on the prior year's evidence.
In testimony before the House Commerce Committee Sept. 15, the American Medical Association claimed that last year's projection errors caused Medicare to underpay physicians by $3 billion.
Those efforts to "fix" the sustainable growth rate continued quietly while the AMA lobbied loudly for aggressive managed-care legislation, including allowing enrollees to sue their HMOs.
"Organized medicine has been pretty active on the balanced-budget act issues," says Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians-American Society of Internal Medicine. "The managed-care debate took up a lot of attention and resources that might have been spent elsewhere, but we've hardly been on the sidelines of the (budget-law) issues."
On Oct. 7 the House voted 275-151 in favor of a controversial bipartisan managed-care bill sponsored by Reps. Charlie Norwood (R-Ga.) and John Dingell (D-Mich.). The AMA, the ACP-ASIM, and the American Academy of Family Physicians, among other physician groups, supported the measure.
With that battle behind them, the physician groups are turning their full attention to Medicare reimbursement issues.
Some lobbyists say House Republicans, still simmering after the doctors rejected their managed-care reform bills, are exacting a measure of revenge by disregarding doctors' requests to fix the reimbursement formula.
"As a general rule, members of Congress don't distinguish between different specialties or groups. They're all just 'the doctors,' " says Randy Fenninger, a lobbyist who represents a number of physician specialty groups. "The AMA went way out on a limb, and there's a price to pay for that in the near term. Had physicians worked with Republicans (on managed-care reform), they would have seen a more generous package (of Medicare adjustments)."
Doherty says he is not aware of any GOP backlash against doctors.
"There may be some negative reaction to us on other issues, like the (budget act) changes, but we wouldn't have traded anything away for reimbursement fixes," Doherty says. "We held out until the end, when we got behind the Norwood-Dingell bill, because we were waiting to see what the Republican leadership would do. We were committed to getting the best (managed-care) bill possible."
Some provider groups that kept a low profile during the managed-care debate-such as the American Hospital Association-are reaping the benefits of their silence.
Richard Wade, the AHA's senior adviser for communications, says his group didn't stay out of the managed-care circus entirely but didn't take center ring because none of the offered bills fit its members' needs.
From the beginning of the year, the AHA has focused most of its efforts on improving Medicare payments to hospitals and health systems. Those efforts have paid off to some extent, he says.
"We got an acknowledgment of the problem, and we got some relief," Wade says, referring to Medicare packages in both the House and Senate that committees voted on last week. "It's worked out that that's been a good strategy for us, but that was because of the complexity of the issue."
Congress and HCFA haven't ignored physicians' pleas. Earlier this year, HCFA sent a legislative blueprint to Capitol Hill that aimed to stabilize the sustainable growth rate and update it using actual data instead of projections (May 17, p. 6).
The House Ways and Means health subcommittee last week approved a proposal that would require HHS to correct growth rates for 1998, 1999 and future years by using actual data. Under that plan, physicians could regain nearly $1 billion in retroactive Medicare payments for the past two years of underpayment.
But Sen. William Roth Jr. (R-Del.), chairman of the Senate Finance Committee, is recommending that HCFA make the adjustments on its own and not make any retroactive changes.
Meanwhile, Sen. Don Nickles (R-Okla.), assistant majority leader and a member of Roth's committee, has publicly stated that he did not like the AMA's tactics on managed care.
It's unclear which plan, if either, will win congressional approval.
"I certainly sense some angst (among Republicans) about the way things turned out, but how long (the resentment against doctors) lasts, that's something else," Fenninger says. "It may not carry over to the next election in 2000."