Lawmakers’ retirements risk leaving doctor pay fix unfinished

Jessie Hellmann | CQ-Roll Call (TNS)

Physician groups and other advocates for overhauling the Medicare payment system will lose three of their biggest Capitol Hill supporters to retirement next year, raising questions about next steps for long-term changes to the Medicare payment program.

Republican Reps. Larry Bucshon of Indiana, Michael C. Burgess of Texas and Brad Wenstrup of Ohio, all members of the GOP Doctors Caucus, have been vocal in pushing for changes to the way Medicare pays physicians.

The current system has been fraught with controversy, with doctors complaining their rates don’t keep up with inflation and with requirements that payments be budget-neutral, resulting in cuts to doctor pay. Meanwhile, a near decadelong push to embrace value-based care has not panned out.

Burgess, Bucshon and Wenstrup, who are all doctors, have become well-known on Capitol Hill for translating wonky Medicare policies and communicating the needs of fellow physicians to their colleagues, carving out a particular niche issue in Medicare physician payments. Burgess and Wenstrup co-chair the GOP Doctors Caucus with Rep. Greg Murphy, R-N.C.

“They’ll really be missed,” said Margaret C. Tracci, chair of the advocacy council at the Society for Vascular Surgery.

Burgess, who came to Congress in 2003, is a former chair of the House Energy and Commerce Health Subcommittee, and Bucshon currently is the vice chair. They, along with Wenstrup, who came to Congress in 2013, owned or worked in private practice and came to the job with experience of not just treating patients but running small businesses and working with Medicare.

Tracci said their experience helped them translate the “very complex issue” of Medicare payment, easing the burden for doctors pressed to explain the complications of the payment system to laymen. “It really creates a lot more work for physicians and for physician advocacy groups to climb that hill again of trying to translate what the needs are,” Tracci said.

But now, the lawmakers’ retirements might leave a long-term overhaul unfinished, with Congress instead pursuing other priorities and distracted by an election year.

“It’s going to be hard, but I think we’re just going to try and lay some of the groundwork,” Bucshon said, referring to hoped-for changes to the Medicare Access and CHIP Reauthorization Act of 2015, commonly called MACRA, which aimed to stabilize physician payments and reward quality instead of volume.

The road to MACRA

Bucshon came to Congress in 2011, when doctors were fighting a similar Medicare payment problem: the sustainable growth rate, which also resulted in cuts to physician pay year after year, with Congress stepping in on an ad hoc basis to avert those cuts.

Viewing those short-term fixes as ultimately unworkable, Burgess led the effort to get Congress to pass MACRA, which repealed the sustainable growth rate formula while providing new frameworks to shift payments toward value instead of volume.

At the time, the lawmakers hoped that the new law would shift Medicare away from paying physicians for the volume of services provided and toward delivering good care that keeps patients healthy.

But it hasn’t quite worked out that way, doctors say.

The new law’s budget neutrality requirement has typically meant that pay increases for one specialty, like primary care doctors, have resulted in cuts to others.

Since 2020, Congress has stepped in to avert cuts triggered by the law’s budget neutrality requirements. But lawmakers haven’t acted on the issue this year, and cuts took effect Jan. 1.

“MACRA, in many respects, has outlived its usefulness,” said Susan Dentzer, president and CEO of America’s Physician Groups. “It was very important at the time and got us out of a rut that the system was in around a prior formula for setting payments. But it [MACRA] was enacted in 2015 and it’s been 10 years.”

While Bucshon, Burgess and Wenstrup are pushing for short-term fixes to the most recent cuts in the next spending package, the prospects for long-term change are murky.

Other options

One bill, sponsored by Rep. Mariannette Miller-Meeks, R-Iowa, and co-sponsored by Burgess, Wenstrup and Bucshon, would lift the budget neutrality threshold from $20 million to $53 million per year.

Currently, if the fee schedule increases spending by more than $20 million, cuts are triggered. Raising the threshold would provide more breathing room in the fee schedule, but the American Medical Association has pushed for a $100 million at least, paired with other changes.

“These are significant steps and the urgency cannot be overstated,” Burgess said on the House floor last month, referring to the legislation.

But floor action is unclear at this point. Negotiators are working on including some kind of “doc fix” in the spending package due in March. Broader, long-term changes will take time.

“It’s clear that we need to do some reforms to MACRA, and we clearly need to change the physician fee schedule, but it’ll be hard,” Bucshon said.

Bucshon also co-sponsors a bill, sponsored by Rep. Raul Ruiz, D-Calif., that would require that physician payment updates be tied to inflation, a concept also supported by AMA and other physician groups. That bill hasn’t received committee consideration.

“There used to be a greater opportunity for them [retiring members] to get something on their way out the door,” said Rodney Whitlock, vice president at McDermott+Consulting and a former GOP aide. “I’m not too certain that I’m as big of a believer in that as I used to be, but once you decide you won’t be here, you fight like hell to get something done on the way out, and I wouldn’t expect any less of these guys.”

Other problems

Also among disappointing aspects of the 2015 law, doctors say, are the pathways it set up for doctors to be graded and paid for delivering value-based care.

Nearly 10 years after the bill’s passage, the committee that advises Congress on Medicare policy has recommended that one of those pathways, the Merit-based Incentive Payment System, should be eliminated because it imposes a significant reporting burden on providers, exempts more physicians than will participate and results in small bonuses for those who do.

Meanwhile, participation in the other pathway, alternative payment models, and the savings it was intended to generate haven’t been as high as was originally hoped.

Physician practices had complained that the models available were not applicable to them. One of the main types of models, accountable care organizations, worked best for integrated health systems and not small independent practices, doctors say.

Those problems are harder to fix. And the loss of institutional knowledge from lawmakers like Burgess, who helped draft the law and knows in depth how it works and what was intended, is not a small thing, said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association.

“The comprehensive fix to what we’re dealing with — the aftermath of MACRA reform — would be helped by many of the physicians in Congress that unfortunately are retiring this year,” he said.

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