MGMA’s Senior Advocacy Leader Offers His Insights on This Moment in Congress
As Healthcare Innovation noted in in a Nov. 12 report, “The leaders of the Englewood, Colo.-based MGMA (Medical Group Management Association) are appealing to the senior leaders of both parties in Congress to consider—and act on—the reimbursement challenges that medical groups are facing in the current moment. On Nov. 12, MGMA sent a letter under the signature of Anders Gilberg, the association’s senior vice president, government affairs, to the four senior leaders in Congress: Rep. Mike Johnson (R.-La), Speaker of the House of Representatives; Sen. Charles (Chuck) Schumer (D.-N.Y.), Senator Majority Leader; Rep. Hakeem Jeffries (D.-N.Y.), House Minority Leader; and Sen. Mitch McConnell (R-Ky.), Senate Minority Leader.”
The letter asked the four senior party leaders in Congress to address “three key issues important to medical groups: averting the finalized cut to Medicare payment and providing an inflationary update for 2025, passing prior authorization reform, and extending telehealth flexibilities.”
The letter noted that “The Centers for Medicare & Medicaid Services (CMS) recently finalized its 2025 Medicare Physician Fee Schedule (PFS) that will cut the Medicare conversion factor by 2.83 percent beginning Jan. 1, 2025. MGMA asks that Congress quickly pass the Medicare Patient Access and Practice Stabilization Act of 2024 (H.R. 10073) that would stop the full cut to Medicare conversion factor, in addition to providing a positive update equal to half of the Medicare Economic Index (MEI) to Medicare reimbursement for 2025. Without stopping the cut and providing this modest update, medical groups will endure an untenable further reduction to physician reimbursement that will compound other financial pressures such as staffing shortages and rising operational costs.”
And a press release that MGMA posted to its website on the same date put forward the following recommendations:
Ø The Centers for Medicare & Medicaid Services (CMS) recently finalized its 2025 Medicare Physician Fee Schedule (PFS) that will cut the Medicare conversion factor by 2.83 percent beginning Jan. 1, 2025. MGMA asks that Congress quickly pass the Medicare Patient Access and Practice Stabilization Act of 2024 (H.R. 10073) that would stop the full cut to Medicare conversion factor and provide a positive update equal to half of the Medicare Economic Index (MEI) to Medicare reimbursement for 2025.
Ø While avoiding this impending cut and providing a positive update to account for inflation in 2025 is of foremost importance, permanent reform to the Medicare payment system is needed to sustainably support medical groups and avoid these yearly threats to their financial viability. MGMA asks that Congress pass the Strengthening Medicare for Patients and Providers Act (H.R. 2474), which would provide an annual Medicare physician payment update tied to inflation, as measured by the MEI.
Ø Modernizing changes are needed to the antiquated budget neutrality policies in the Medicare PFS to avoid this continual dance of physician practices staring down yearly cuts to reimbursement. MGMA asks that Congress pass the Provider Reimbursement Stability Act (H.R. 6371) that would make updates such as increasing the triggering threshold from $20 million to $53 million (while adding an update to keep pace with inflation) and instituting new utilization review requirements to better reflect the reality of providers using certain services compared to CMS’ estimates.
Ø Onerous prior authorization requirements continuously rank as the number one regulatory burden facing medical groups. The Improving Seniors’ Timely Access to Care Act (S. 4532) has the support of a bipartisan majority of the House and Senate, nearly 500 endorsing stakeholder organizations, a minimal expected CBO score, and little to no opposition. MGMA urges Congress to ensure this bill is included in any year-end budget package.
Ø MS finalized its extension of certain telehealth policies in its 2025 Medicare PFS, but many of the central policies that have allowed telehealth to flourish will expire soon without congressional action. MGMA urges Congress to act before the end of the year to extend the removal of geographic and originating site restrictions, the expanded list of providers, and more to ensure Medicare beneficiaries can access care no matter where they are located. Not doing so would significantly hinder medical groups’ ability to offer telehealth services nationwide.
Following the publication of the letter and the press release, MGMA senior vice president-government affairs Anders Gilberg spoke with Healthcare Innovation Editor-in-Chief Mark Hagland, regarding these pressing policy, regulatory, and reimbursement issues. Below are excerpts from that interview.
Looking at all the elements in the current policy and reimbursement landscape in Congress, what should our readers know about this moment?
Congress came back from recess yesterday, which is partly the impetus for the timing of the letter. And as you know, healthcare policy is no longer really dealt with in any organized manner during the calendar year in Congress; it’s typically handled in a crisis environment at the end of the year, when policies will change at the end of the year, such as with the fee schedule and the telehealth flexibilities. And this year, we’re seeing a presidential change and a change in the control of the Senate, and the Republicans will control the House. So we have dynamics driving the political agenda of what will really get done in the lame-duck session. So it’s very much sort of an unknown, but that’s the environment we’re working in.
Is there any chance that Congress would try to repeal the Affordable Care Act?
I don’t think they can. And as you know, there’s a difference between campaigning and governing, and also a big difference between being in the majority and the minority. And you think about all the Republican-dominant states that expanded Medicaid with Republican governors; and frankly, those states are more reliant on Medicaid than others. So I really don’t think that the ACA is going to be fully repealed. Consider, for example, under the first Trump presidency, the one real change made to the ACA was that the ACA’s provision for fining individuals who were eligible to purchase insurance through the exchanges but did not do so, was eliminated.
Meanwhile, from our perspective, the Medicaid expansions were really the game-changer in the ACA. Because of all the Medicaid expansions, more of our practices were able to see many more patients; and there’s no way you can take that away. The difficulty is, and we saw this in the first Trump administration, that you need to both repeal and replace, and there hasn’t been any clear indication of what the replacement might be. And because the Republicans will control the White House and both houses of Congress, and in effect the Supreme Court—I imagine they might implement some broadly symbolic policies. But they can’t take away healthcare without providing some replacement; otherwise, it will be a very short majority. And nothing major changed during Trump’s first term, except that the penalties for not buying insurance were taken away. And there just wasn’t a significant alternative put on the table in the first term. And I will say that they will not roll back Medicaid expansion; that would be political disaster.
Is there a possibility that Congress could reverse a part of the Medicare physician fee schedule cuts?
I think there is a possibility, yes. And a lot of what we advocate for isn’t controversial. The bills that we’re referring to in our letter as critical, they’re bipartisan. The prior-authorization legislation has a majority in both houses, and was scored at zero dollars by the Congressional Budget Office—it costs nothing. And 500 organizations, including the Medicare Advantage plans it would impact, support it. The question is whether the political winds are blowing in the direction that any policy change would pass. And per the cuts, we don’t expect the bipartisan legislation to be dealt with in the lame-duck, but per the 2.83-percent cut, does the new Republican majority, do they want the very first thing that happens in January, to be their having to preside over a cut to the nation’s physicians of that magnitude, or do they at least want to level the playing field before next year? The Democrats might also say, we’ll let you deal with it as a majority.
As you know, the Democrats have been helping the Republicans in the House to pass the budget resolutions. And that might be the impetus to pass a continuing resolution that expires on December 20. And are factions once again going to hold the leadership hostage in such a way that would shut down the government? The majorities are still going to be razor-thin. So in many ways, the Republican majority in the House needs to get its alignment together; and that’s a lot of what will impact the lame-duck session.
How will the dynamic tension play out over the ongoing exploding costs in U.S. healthcare—the total annual expenditures for healthcare rising from the current $4.8 trillion to an anticipated $7.7 trillion in 2032, according to the Medicare actuaries—alongside, at the same time, the need to adequately pay physicians and hospitals?
I think of it like this: there’s been no effort in Medicare to address the aging of the population. People are living longer. And theoretically, society benefits when the elderly population is healthier. But once you’re on Medicare, you’re on Medicare. So I guess you could debate whether people are sicker; but they’re living longer, and the population on Medicare is getting bigger. And you can tinker around the edges, and there’s always an initial impulse to cut provider reimbursement. But there’s no amount of reimbursement-cutting that will address the longer-term issue [of the aging of the population and the explosion in chronic disease]. So will there ever be a wherewithal in Congress to raise the Medicare eligibility age? You can only cut so much.
In addition, it’s worth noting that, at this point, 80 percent of physicians are employed, either by larger medical groups or hospitals and health systems, which are incredibly important for the districts of members of Congress; so simply cutting physician reimbursement will not in and of itself accomplish what one might think it would accomplish. And obviously, it's a political problem if a hospital in your district fails. And so the irony of healthcare spending is that spending in physician offices isn’t the problem; the larger problem is hospital-based care. And so what’s happening now is that there’s been so much consolidation in the industry, and consolidation generally speaking creates more cost. So the irony is that the red tape and other issues, impact solo and small-practice doctors more than they impact hospital systems, which have the ability to cross-subsidize physician salaries in the larger systems.
Are value-based contracting and/or mandatory programs, in danger, beginning in January?
It’s interesting: there are a lot of critics of CMMI [the Center for Medicare & Medicaid Innovation] on the Republican side. There have been questions over how much CMMI has been showing savings, for $1 billion of support from Congress. But one of the interesting things is something I was not expecting. I was a lobbyist for the American Medical Association years ago when a lot of this was starting, and I worked on the quality issues for them, and the approach was very bipartisan. And Mark McClellan was the CMS Administrator under the Bush administration, and there was a lot of support. And more recently, value-based contracting was not necessarily under threat from Republicans, but more under criticism from Democrats, especially in the House, who were advocates for a single-payer system. And certain liberal Democrats have been criticizing value-based care because it doesn’t move us towards a single-payer insurance system.
Also, we’ve been on this trajectory for a while. Medicare Plus Choice was the first iteration of Medicare Advantage. And as of last year, a majority of Medicare recipients are in MA plans. And more and more will be in those plans by 2025, and you have a completely different dynamic there, where you have private insurers accountable to their shareholders. Indeed, now, instead of Medicare patients seeing any doctor they want under Medicare Part B, they’re in narrow networks and they face prior authorization and utilization review under MA. So the question is, how will value-based care survive in the context of the growth of the MA program, and will it be less under the purview of CMMI and the government and more under the peer review of these contractual relationships?
And, per all that, you don’t believe that the federal government will pull away from its commitment to Medicare Advantage, do you?
No, I don’t believe it will. And philosophically, this trend towards further expansion of MA will continue.
