An elderly doctor passes away, and he find himself standing before the Pearly Gates. The Almighty greets him and says, “In recognition of your stellar life of service to your patients, family and community, I welcome you to paradise. And because I know that doctors have a great sense of curiosity about all things, you can now ask me any question—any—and I will answer it.” The doctor ponders for a moment or two, thinking about all of the mysteries of the world, and comes up with the one question that has troubled him the most. “Can you tell me, your greatness, whether Congress will ever get around to repealing the Medicare SGR?” God hesitates for a moment, and responds, “Yes … but not in my lifetime.”
(A version of this joke has been around for years, only the question asked was whether Congress would ever enact universal health insurance coverage. With the ACA getting us close to universal coverage, I thought that substituting the SGR would make for a more timely question for the good doctor to ask the Almighty!)
And after more than a decade of botched efforts, who can blame doctors if they begin to think that it will take an eternity—or longer, if that is possible!—for Congress to finally get around to repealing the SGR. Year after year, they have seen the same tired script replayed. CMS announces that the SGR will cut physician payments (by an escalating amount each year). Members of Congress pledge that it won’t happen and that this will be the year when the SGR will be repealed. You can believe us for sure, this time will be different, we promise you, wink, nod. They then ask physicians not only for ideas on replacing the SGR but also commitments (like agreeing to be measured on their performance). Physicians dutifully offer serious proposals and commitments, Congress thanks them, then dithers for months, gets itself into a partisan spat about how to pay for SGR repeal, waits to the very last minute before the cut is supposed to go into effect ( and in some instances past the last minute, requiring a retroactive fix) and then finally—hallelujah!—passes something that averts the cut for a few months, or maybe a year or two (at best).
And then we start the whole darn thing all over again. If that isn’t the earthly equivalent of eternity, it is pretty darn close.
But maybe, just maybe, there is now cause for hope that this year could be different.
First, the Congressional Budget Office cut in half its estimate of the cost of repealing the SGR, down from $244 billion to $138 billion (over ten years). Glenn Hackburth, chair of the Medicare Payment Advisory Commission, told the House Energy and Commerce Committee that “In effect, SGR repeal is now on sale. But the sale may not last forever.” (Still a lot of money, but with the new CBO numbers, it makes it easier for Congress to find a way to pay for SGR repeal.)
Second, for the first time in a very long time, there actually is a draft plan on paper to eliminate the SGR that has the support of congressional leadership. The plan, offered by the Republican leadership of the two House committees with jurisdiction over Medicare, would eliminate the SGR in three phases and begin to link future updates to physicians’ participation in quality improvement efforts or new payment models.
Third, Congress actually is talking about putting partisanship aside—imagine that, what an idea!—to come up with an SGR repeal plan. Rep. Fred Upton (R-MI), chair of the House Energy and Commerce Committee, said his hope is to get a bill on the floor of the House by August, and that he would seek support from Democrats on a bill that could pass the Senate. Related, a bipartisan bill, the Medicare Physician Payment Innovation Act, to repeal the SGR, stabilize payments, provide higher updates for undervalued evaluation and management services, and transition to new models was re-introduced by Reps. Allyson Schwartz (D-PA) and Joe Heck (R-NV). The bill, which is strongly supported by ACP, is in many respects similar to the one proposed by the House committee leadership.
Finally, Congress is actually listening to the doctors! The plans being floated directly reflect ideas offered by ACP, AMA, and more than 100 physician organizations—demonstrating an unprecedented degree of unity.
It still may require divine intervention for Congress to enact legislation to repeal the SGR, and I wouldn’t bet on it. But at least for the first time in a decade there is at least a prayer of making some progress.
Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.