Updated 3/18/2014 to reflect Sen. Max Baucus’ new role.
In a rare show of bipartisan cooperation, Democrat and Republican members of Congress are united in backing legislation that would to keep physician pay high under the federal Medicare program. Combined, the lead sponsors of the House bill and the Senate bill have reaped nearly $3 million in campaign contributions from health professionals.
The American Medical Association (AMA) and a long list of physician specialty groups have heavily lobbied both Congress and the federal agencies, according to Sunlight’s Influence Explorer and Docket Wrench tools — on an issue that otherwise attracts little public attention. The AMA is a political powerhouse; this election cycle alone, the group’s PAC has raised $1.3 million. The group and its state subsidiaries have also reported spending $18.2 million on lobbying.
Critics of the legislation say it is skewed toward the interests of physicians over those of the public at large, and specialist physicians in particular. “This really is pretty much an inside baseball bill,” Robert Berenson, a fellow at the Urban Institute who has testified before Congress on the issue told Sunlight. “A lot of policy people think there’s too much giveaway to the specialty groups.”
The physician groups are standing behind H.R. 4015 and S. 2000, which would permanently repeal a 1997 formula for determining Medicare physician fees. In theory, this formula has required a reduction in physician fees every year since 2001. However, Congress has jumped in every year to rescue doctors with a “temporary” fix. The Congressional Budget Office puts cost of repealing the formula at $116.5 billion over ten years; advocates for the legislation argue that this is much less expensive than the temporary fixes Congress has favored.
The current patch is scheduled to expire by March 31, when fees would decrease by 24 percent. The AMA and other groups are lined up behind legislation originally sponsored by former Sen. Max Baucus, D-Mont., and Rep. Michael Burgess, R-Texas, both of whom have enjoyed generous support from physician groups for their campaigns. Health professionals were top donors to Baucus’ campaigns, contributing more than $1.3 million over the years, according to Influence Explorer. (Baucus left the Senate in February to become President Barack Obama’s ambassador to China.) Burgess, himself a doctor, has a top donor list that looks like a who’s who of medical specialties, including the American Association of Orthopaedic Surgeons, $55,500; the AMA, $54,500; the American Academy of Ophthalmology, $50,500; and the American Academy of Radiology, $49,500. Overall, health professionals have contributed more than $1.5 million to his campaigns.
The political bedfellows supporting the bill are quite odd indeed: Burgess, an avowed conservative who also counts Koch Industries among his top donors, is joining hands with the decidedly liberal Reps. Harry Waxman, D- Calif., and Jim McDermott, D-Wash., both of whom have also gotten ample campaign contributions from health professionals, according to their Influence Explorer profiles. McDermott is also an M.D. who served as a psychiatrist for the U.S. Foreign Service before entering Congress.
The proposed bills, agreed on after several years of debate and congressional hearings, would repeal the 1997 formula — known as SGR, or Sustainable Growth Rate — and in its place guarantee physician fee raises of .5 percent over the next five years. It also converts the current clunky fee-per-service schedule into a different system, which is meant to reward physicians for quality care over volume of procedures. However, as set out in the legislation, it’s the physicians groups themselves that will be given the opportunity to develop the quality measures in question.
To critics like Berenson, the approach is clumsy and will likely backfire. “Although we agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services (CMS), despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future,” he and Deborah R. Kaye write in an editorial for the New England Journal of Medicine last November. “[T]his policy overreach could undermine the quest for higher-value health care.”
Another critic, Jeff Goldsmith, president of Health Futures Inc. and self described “health care futurist,” was even more blunt: “[T]he proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, that the disease we have now,” he wrote in a blog post for Health Affairs.
The AMA is rounding up its grassroots force with an advocacy kit complete with sample language for physicians to use when writing members of Congress, copies of letters to Congress sent by the AMA and other specialty groups, and even a flyer for doctors to distribute to their patients. A sign-on letter supporting the legislation includes the names of more than 65 specialty groups, ranging from the American Pediatric Association to the American Society of Interventional Pain Physicians to the National Association of Medical Examiners.
To give a feel for the magnitude of activism by the vast grassroots of physicians, consider that more than 13,000 comments were filed with the CMS on proposed revisions of physician fees for 2014. Indeed, this particular rulemaking has ranked among those getting the most comments government-wide for several weeks running, according to analysis by Sunlight based on its Docket Wrench tool.
One cluster of more than 1,800 comments appears to come from patients being treated for pain urged to write by their doctors. “I am very worried that these policies will reduce access to my local pain doctor and may force them to close offices,” reads typical language in these letters. Another cluster of 500 comments comes from radiologists. Still another of more than 350 appear inspired by this alert by the College of American Pathologists. This same alert discusses how members are meeting with members of Congress and urging them to contact CMS on revisions to physician fees: “We need to continue engaging Congress and have them weigh in with CMS.”
Because of its hefty price tag, the path toward passage for the Medicare physician fee legislation is far from certain. Congress’ most recent actions on the issue was the three-month patch as part of the budget deal earlier in the year, which delayed the cuts until March 31.