Who cleans up after the 'fix' is in?

James M. Berklan
James M. Berklan

It will be interesting to see what happens when the guitars are put away and the strains of "Kumbaya" die down after last week's ballyhooed passage of a new Medicare doctor payment rule.

Yes, Democrats and Republicans in both chambers of Congress came together to pass the bill. And provider representatives from nursing homes to hospitals and physicians and beyond stepped up with politically correct praise. None of them got exactly what they wanted, but they all fell in line and let the administration know that they were saluting the flag on this one — and expecting consideration in the future.

That's because Washington politics is always about “the next one.”

A few cracks in the united front of praise appeared even before the bill's passage. Take, for example, a report from the Office of the Actuary of the Centers for Medicare & Medicaid Services that came out after the House passed H.R. 2 on March 26. The report concluded that the new payment system would actually result in lower Medicare payments to doctors over the coming decade.

As we noted in a McKnight's Daily Update story, the report said that the risks to physician Medicare rates are “ultimately greater” than the “near term” impacts of the much-hated “sustainable growth rate” formula, or “doc fixes,” it applied 17 times before last week's “historic” bill passage.

If anybody thinks the doctors and their burly lobbyists are going to forget that golden nugget, they're crazy.

Then there are those who think the “fix” is headed for trouble for other reasons. Physician-blogger Westby G. Fisher, MD, FACC, is one.

 “When the federal government is ‘going to find a way to pay doctors based on quality and value,' ask yourself one question: ‘Value” to whom?' Patients will lose doctors and doctors will lose parts of their careers as this ‘fix' is enacted,” he recently posted.

Westby will surely have more company in the future, as details of the newly passed legislation sink in.

The new legislation is intent on forcing physicians away from a fee-for-service model, something they have been holdouts on. Then, even if they do go that route, within a decade they'll be subjected to pay increases that many observers predict won't keep up with the rate of inflation.

"The idea that this is a permanent fix is false. I just think that's total folly," James Capretta, a visiting scholar at the American Enterprise Institute, told Modern Healthcare."

The head of the American Medical Association, President Robert Wah, M.D., bluntly acknowledged on a recent C-SPAN broadcast that when doctors don't get the pay rates they like, it hurts the overall healthcare system.

 “Like any business,” he told show hosts, pay cuts compel physicians to consider pack their black bags and go home. When that happens, it would “be more challenging for them to continue to see their Medicare patients. And if that happens, the Medicare patients will have a harder time finding doctors that can take care of them, so they may have to drive further or call more doctors' offices."

Granted, he was talking about pending pay cuts of more than 21%, which would devastate almost any business endeavor. But the not so veiled threat is a billy club that has been used effectively and often in the past by physicians, and when much less was at stake.

Make no mistake, the Sustainable Growth Rate process had to go, and most sectors are the better for it, long-term care included. Back when the SGR was enacted, it was part of a smoke-and-mirrors routine that enabled other political goals for the then-administration. Eventually, though, it was exposed as the winds of time cleared the air.

That led to the universal realization that physicians, who affect every vein and nerve of healthcare, would need whopping pay relief. Everyone knew the docs would have to be paid more.

I can recall visiting lawmakers' offices on Capitol Hill with top long-term care lobbyists a handful of years ago. Their opening line wasn't, “How are you doing, Senator?” or anything similarly cordial. Rather, it was literally, “Don't be too hard on us.” Meaning don't take too much funding away from us when you look for ways to give the doctors what they want.

That's what led to everybody's rah-rah attitude about last week's bill passage. It turns out it was the best deal they could get, long-term care operators in particular. Taking “only” a 1% market basket increase in 2018 is a big part of the deal. Anybody else notice that next year's market basket increase, announced last week, will be a net 1.4%?

I won't attempt to get into the weeds with the expert number crunchers on that, but it seems clear that long-term care could have done much worse in the doc fix bill that passed.

Rest assured, however, the lobbying isn't over. It never is, especially when one of the competitors for dollars is the doctor profession.

James M. Berklan is McKnight's Editor.

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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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