In a rare display of bipartisanship, Congress quickly passed its sixth temporary fix of the Medicare physician payment formula in 12 months, even as both sides acknowledged the legislation they just worked on together really did nothing to solve the problem.
Bipartisan bandage for doc payments
The Medicare and Medicaid Extenders Act of 2010, which would delay scheduled cuts in physician reimbursement totaling around 25%, passed the Senate unanimously Dec. 8 and by a 490-2 vote in the House of Representatives on Dec. 9. President Barack Obama signed the bill Dec. 15.
The cost of delaying the cuts and extending the current payment rates for 12 months is estimated at $14.9 billion. The legislation intends to pay for this over a 10-year period by raising caps on how much individuals and families must return if they receive overpayments from healthcare affordability tax credits.
Members of Congress have pledged to work together next year to find a better way to pay doctors for treating Medicare patients and to develop a formula that more accurately reflects the cost of that treatment.
Healthcare organizations and associations said Congress was well aware of the problem—the Medical Group Management Association said its members called, wrote or e-mailed their legislators 60,000 times with complaints about the sustainable growth-rate formula used to calculate Medicare payment rates. But it was unclear where the issue ranked on the list of priorities.
“It's just always there,” said Cindy Morrison, vice president of health policy for Sioux Falls, S.D.-based Sanford Health. “It's become a ‘core ask' and it's become part of almost every conversation you have with members of Congress.”
Although no one knows how the new Republican majority in the House will work with the Democrat-led Senate, House discussion—led by Frank Pallone Jr. (D-N.J.) and Joe Barton (R-Texas)—had a bipartisan air of collegiality. Both, however, had few kind words for the bill they were urging their colleagues to quickly approve. “This is just another short-term fix,” Pallone said. But he added that the current measure “is completely paid for” and “really not controversial at all.”
After a two-month freeze passed Dec. 19, 2009, Congress this year has passed payment-cut delays in March, April, June, November and last week. Barton committed to “sit down with stakeholders and our friends on the soon-to-be-minority side of the aisle” on a permanent solution.
“I know that it's going to be expensive, I know that it's going to be difficult,” Barton said. “But it will be possible.”
Bipartisan negative remarks came from California as Republican Wally Herger called the measure the first step toward “dismantling Obamacare.” At a cost of an additional $4.6 billion, the bill also extends several other Medicare programs. One of these, known as the “Medicare work geographic adjustment floor,” drew the ire of Sam Farr (D-Calif.), who called that section of the bill “an abomination” and “special pork” from “certain Midwest senators” that allows some physicians to be paid more than others.
“It is plain unfair to doctors in other states,” Farr said, though both he and Herger voted to approve the bill. The opposing votes came from Reps. Brian Baird (D-Wash.) and Tom McClintock (R-Calif.). A licensed clinical psychologist who has worked in state and Veterans Affairs psychiatric hospitals, Baird noted on his website that Florida receives 28% more funding per Medicare patient than Washington state because his state's healthcare system "is efficient and cost-effective.”
The official summary of the bill explained that the geographic adjustment floor is intended to reflect regional differences in costs of physician work, practice expense and malpractice insurance. Kent Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians, said Medicare divides the country into 89 localities whose boundaries haven't changed since 1997, which is the source of some complaints. But Moore said the AAFP is opposed to all geographic adjustments except those driven by policies seeking to promote physicians practicing in underserved areas. “If we had our druthers, we would do away with the whole geographic adjustment business,” he said.
He noted, however, that Farr's criticism may be misdirected. Quoting Medicare payments for a “midlevel, established-patient office visit,” Moore said Iowa physicians receive $63.80; nonurban California doctors get $67.85; while physicians in San Francisco, which is just north of Farr's Santa Cruz-area district, are paid $80.62.
When asked for comment, Iowa Republican Sen. Chuck Grassley 's office responded with an e-mail but did not supply a name to whom the comment was attributed.
"All of California's reimbursement is above average (and some parts of California get some of the highest reimbursement in the country), so that may be the basis for Rep. Farr saying it doesn't help California but it certainly doesn't hurt them," the e-mail stated. "Sen. Grassley's provision requires HHS to analyze and evaluate the use of actual data instead of the current, inaccurate proxies during the two-year transition in 2010 and 2011 and then use accurate data for all areas beginning in 2012. So if California gets hurt because CMS will be using more accurate data beginning in 2012, it's hard to be sympathetic to the California position. On the other hand, maybe those changes will benefit rural doctors in California, too."
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