Every day, I reflect on what an honor it is to help lead the ACR during this most critical time for medicine and its associated professions. This role is also challenging, as this is the most volatile time that any of us can remember. Right now, we face several important issues that will profoundly affect all of the members of the ACR. I am ready to face all of them with you during the next year, with the help of our board of directors, its committees, and our impressive staff.
Many unprecedented issues will confront our members, whether they are primarily clinical practitioners or those whose work is mainly scientifically oriented. We have long sought relief from the albatross known as the Sustainable Growth Rate (SGR). The set of expectations that is likely to replace the SGR will require great changes for all of us.
This month, I would like to address efforts to replace the SGR, discuss what this will mean for patient care and reimbursement for that care, examine how the ACR will be helping our members prepare for what will be a new world, and, finally, explain what we need you to do.
How We Got to the Edge of the Cliff
The SGR formula is a payment system whose effectiveness ended many years ago. Enacted in 1997 to update payments and rein in costs, the SGR ties Medicare physician payment updates in part to economic growth, as measured by changes in Gross Domestic Product. But the SGR has proven unworkable. Since 2003, Congress has had to step in to block the catastrophic cuts in payments the formula called for each year.
The next SGR cut will be on January 1, 2014, to the tune of almost 25%, unless Congress repeals the SGR or steps in again with yet another temporary fix. The result of this cycle of payment cuts suspended at the last minute has been not only perennial fear and uncertainty about whether practices or academic units will be able to serve Medicare patients or even operate, but also a growing cost for permanent SGR repeal each time a temporary fix is passed.
Rheumatologists and our colleagues in other specialties have petitioned Congress for years about the insanity of “cliff drop” cuts related to this unworkable formula and about repealing the SGR. In 2013, Congress began to really listen and to formulate a potential solution, especially in the context of healthcare reform. However, three questions remain: 1) What will the new system look like for rheumatologists? 2) Will we continue to lend support to Congress so they finally get us off this cliff? and 3) How can the ACR help our members in this new territory?
What Congress Might Do
Congress agrees with us in concept. On a bipartisan, bicameral, across-the-board basis, thanks to years of outreach, nearly all federal lawmakers support SGR reform. For many, it is a priority. Most are tired of temporary annual fixes. It helps that the “price tag” for repeal as calculated by the Congressional Budget Office has dropped from $316 billion just over a year ago to “only” $138 billion now. This bargain is due to slowing in the rate of Medicare spending.
The tangible result of the efforts of physicians and other health professionals is the SGR reform initiative in the U.S. House and Senate, which remarkably has both strong bipartisan support and support in both chambers. This year, the ACR was asked seven times by congressional committees to provide feedback on SGR reform legislation, and seven times we responded promptly and vigorously with our recommendations. This is a real product of strong ACR presence on the Hill and at the Centers for Medicare and Medicaid Services. We continue to weigh in with leaders to try to further hone and improve their initiatives, which was in discussion draft form at the time of my writing this column.
As currently drafted, the evolving SGR repeal plan would:
- Finally repeal the SGR;
- Prevent the 25% cut scheduled for January 1, 2014;
- Keep fee-for-service as a payment option for providers;
- Provide opportunities for updates if providers score well in the Value Based Payment program;
- Provide opportunities for updates if providers participate in an Alternative Payment Model;
- Provide no automatic payment updates for the first ten years due to budget constraints;
- Repeal PQRS, Value-Based Modifier, and Meaningful Use penalty programs, and streamline efforts into one Value Based Payment program;
- Provide support for small practices to help with implementation; and
- Provide support for quality measures development by societies.
The ACR is asking for automatic increases, in addition to several improvements to the Value Based Payment program, and several other modifications. We have asked to tie updates to the Medical Economic Index, and we have also argued for an update of at least 2% higher than the baseline for those providers who primarily provide evaluation and management services for patients. This would serve to benefit and buttress those specialties and subspecialties like rheumatology that are not procedurally focused but who instead evaluate, coordinate, and manage the conditions and care of patients with chronic illnesses.
What We Need To Do Together
There is a lot of optimism that the SGR, this perennial problem for predicting the solvency for our practices or units, probably will be solved. However, as I write this, the end result is not really known. It is not clear that Congress will pull us back from the SGR cliff. It is possible that SGR reform will be included in the broad package of reform Congress seems to be contemplating. It is also possible that the stalemate in Congress will continue, and SGR reform will again be neglected. Those of you who have been advocates for the ACR know well that getting anything done in Washington, D.C., takes patience and hard work. This is true not just for us, but for the lawmakers and staff who must create and pass legislation.
The heavy lifting to create and support a plan for replacing the SGR is done now, and there is strong bipartisan support to bring physician payment back to more solid footing. However, SGR reform carries a high price in cost and priority. The cost of around $140 to $180 billion is difficult for Congress to find unless it includes SGR in a larger budgetary package. With all of the pressure to negotiate the specific “grand bargain” package, it will take tremendous effort to keep SGR reform in the spotlight and on the table.
My call to you, and to all of our colleagues, is twofold. First, do not automatically let “perfect” be the enemy of “better” when considering how we can end the SGR. Second, do not become complacent and expect that SGR reform will definitely happen. It is true that leaders in Congress have committed to getting this done for us. We had all fantasized that Congress would pass a simple one-sentence law that repealed the SGR, but that will not happen. In return for this change, they are asking us to include more focus on quality measures in our daily practices, and their proposal also reflects the reality and constraints of the current federal budget. Whatever happens will require change on our part, too, but change is inevitable. We must work together and with Congress to solve this perennial problem for the sake of our patients and our practices. We don’t want to spend another ten years staring into the abyss.
Rheumatology Will Lead
Even after SGR reform is passed, work will remain. We must, as a subspecialty, accept the new demands regarding how we care for patients and how we report that care. How well we handle those demands will determine how well we will be paid for the care we provide. The ACR is building on its already robust quality initiatives and working with Congress and CMS from the outset to ensure appropriate measures exist for rheumatologists under any new program. We will also continue to inform and train our members on how they many need to modify their practices to fit the new framework.
I commit to you that the ACR will provide clear communication about what is changing, why it is changing, and how you can best prepare to deliver care—in ways that sustain not just the health of your patients, but also the health of your practices and your families. Let’s all pledge, together, to be vigilant in our outreach to members of Congress and their staffs about how important a permanent repeal of the SGR is, and that appropriate action needs to be undertaken this year. We cannot take the realization of SGR reform for granted.
Years from now, we will look back on this as a time of great change and perhaps difficult transition. For the sake of our patients and our profession, we must we embrace the future and work vigilantly to be included in planning that future, and work with leaders in Washington who are trying to get us and our patients to the practice of the future. We must lead, and I look forward to leading with you.
Dr. Flood is a rheumatologist at the Columbus Arthritis Center and adjunct associate professor at The Ohio State University College of Medicine and Public Health, both in Columbus. Contact him at [email protected].
