If anyone were to ask members of Congress if doctors should be contending with Medicare pay cuts after a pandemic and a period of extraordinary inflation, and amid a chronic physician shortage, nearly all would say no.
Yet, that is what happened on Jan. 1,. And even powerful lawmakers who would like to ease or reverse that cut can't promise it will happen, even after recent actions to forestall hospital cuts and to extend expiring healthcare programs such as federally qualified health centers.
Related: Doctors facing Medicare cut seek new payment system
The most members of Congress were willing to say is that the cuts should be addressed, and to express a bit of optimism.
"I'm just not going to characterize what's going on with the talks, but I'm talking to my colleagues about it," said Senate Finance Committee Chair Sen. Ron Wyden (D-Ore.). "It's a very important issue. You've got to have healthcare providers."
Similarly, Sen. Dr. Bill Cassidy (La.), a member of the Finance Committee—which has jurisdiction over Medicare policy—and the top Republican on the Health, Education, Labor and Pensions Committee, proclaimed hope for a solution.
"I do think there'll be a fix for these doc cuts. Let me just say that," Cassidy said. "For the doctors, there's great sympathy."
The Centers for Medicare and Medicaid Services determined in the physician fee schedule final rule for 2024 that Medicare reimbursements would decline 1.5%. The cut is a product the statutory payment formula, and the net average rate change derives mainly from a 3.4% reduction in the conversion factor that CMS uses to establish a reimbursement baseline.
Often when important constituencies face cuts because of laws passed by a previous Congress, the current Congress will head them off.
For more than a decade, lawmakers routinely made doctors whole in "doc fix" bills that addressed cuts under the sustainable growth rate payment formula created in 1997. Congress repealed the so-called SGR in 2015 and replaced it with the Merit-Based Incentive Payment System, known as MIPS, and alternative payment options designed to encourage quality, lower-cost care.
As under the previous system, MIPS requires CMS to cap spending and to calculate the conversion factor as written in statute. Congress has blocked cuts under this reimbursement formula, as well. When providers faced steep cuts last year, Congress voted to restore 2.5% in 2023 and 1.25% in 2024.
This year's cut would have been about 4.6% without that boost. That step to help doctors, however, created complications that are part of the reason Congress hasn't acted this year, even as it attends to Medicaid disproportionate share hospital cuts, funding for community health centers and other health policy agenda items.
Those temporarily rescued initiatives fit neatly into what are known in Capitol Hill jargon as "extender" packages. All Congress really has to do is change a date to extend or delay programs such as those.
CMS incorporated the physician pay relief Congress enacted into this year's reimbursement rates. The agency can't go further unless Congress makes a new law, which would require legislating and negotiating far beyond what extenders entail.
Those talks are happening as lawmakers seek an agreement before March 8, when the current stopgap funding bill covering most federal healthcare spending runs out.
For doctors waiting a minimum of two months under current policy, it's a frustrating time—including for those who are lawmakers, such as Sen. Dr. Roger Marshall (R-Kan.).
"We're always on the table. Doctors are always the first ones on the chopping block up here, it seems like," Marshall said, citing data from the American Medical Association that estimates Medicare pays physicians 26% less than it did in 2001, when adjusted for inflation.
Marshall sought to include a doctor pay fix in the most recent short-term spending bill, in part because it would have been easier to make it retroactive before Medicare started paying claims at the lower rates, he said. "It'll be hard to make it retroactive. It's an uphill battle," he said.
Also up in the air is how much of the cut legislators may restore, and whether the issue could get entirely lost in the dysfunction that has marked the 118th Congress.
The Senate Finance Committee and the House Energy and Commerce Committee each passed bills that erase 1.25% of the cuts. Bipartisan groups in both chambers have offered legislation to undo the cut as well as proposals to peg reimbursements to inflation and end the annual pay cut dance.
"It's pretty much a mess," said Joseph Antos, a longtime Congress observer and American Enterprise Institute health policy expert who remembers the old "doc fix" rescues under the SGR. "I really think the issue is: Can they make a deal that is comprehensive enough?"
The short-term prospects of a comprehensive solution to physician reimbursements are poor, and the chances of a one-year deal are hard to predict, Antos said. A major underlying reason is the chaotic nature of the House, he said, where battles between hard-right conservatives and the rest of the Republican conference have stymied efforts to legislate on numerous matters.
This GOP infighting accounts for the odd structure of government funding this year. The latest temporary spending bill split the 12 annual appropriations measures into two tranches: Four expire March 1 and eight expire March 8, and most of the healthcare money is in the latter.
That could make raising healthcare spending tougher, Antos said, since that bill would come second. "When we finally get there, will there be room? Will they have left room from the first tranche?" he said. "Or will they have spent it all, in which case it will be a very, very difficult time on the health side, because that's where all the money is."
Such a fate was nearly unthinkable during the SGR era, but Antos reflected that most lawmakers don't really understand how the current system works, and are more focused on the hospital industry's woes in the aftermath of COVID-19's toll in 2020 and 2021, and amid the pandemic's ongoing effects on the healthcare system.
"There is this residual view that we've got to deal more with hospitals, because they really did have a legitimately hard time keeping everything open and dealing with this flood of patients," Antos said. "The hospitals are in a little better position to get some relief. But doctors need relief, too."
Marshall agrees, but conceded a comprehensive Medicare physician reimbursement bill is unlikely. "We were hoping to get a long-term fix for it, and this, it appears, is gonna be a short-term fix," he said.
The AMA and other medical societies favor scrapping MIPS and developing a novel reimbursement system.
Marshall insisted that he and others are not giving up and, like Cassidy, suggested the doctor pay issue hadn't been resolved because Democrats were interested in getting additional policy wins. Neither he nor Cassidy specified what the additional Democratic priorities might be.
Wyden declined to get into any specifics, and Senate HELP Committee Chair Sen. Bernie Sanders (I-Vt.) did not respond to requests for comment. Sanders favors higher community health center funding and Democrats generally support increased federal support for Medicaid.
Marshall said there is something physicians can do to help their cause: "I need doctors from across America to reach out to their senators, especially Democrat senators, and ask them to be a leader on this."
