Lawmakers Mull SGR Options

Bipartisan consensus for repeal of Medicare's sustainable growth rate appears solid, but there is no clear way forward. The latest meeting between lawmakers and stakeholders gives voice to the wide-ranging concerns of physicians.

The House Ways and Means subcommittee on Health spent two hours Tuesday exchanging ideas about reforming Medicare's sustainable growth rate with a group of influential healthcare stakeholders.

That the SGR needs the boot was a foregone conclusion among both the assembled panelists and the House members. In his opening comments, Rep. Kevin Brady (R-TX), committee chair, noted that participants in two previous SGR hearings held recently supported the repeal of SGR. "I couldn't agree more," he said. "The SGR is the major contributor to an unhealthy system and it needs to change this year."

While there was general agreement that a value-based system is preferable to the current volume-based system of physician reimbursement, the wide-ranging discussion among the committee members and the panelists, who included physicians as well as a health plan medical director and a representative of the National Quality Forum (NQF), demonstrated that the devil is indeed in the details.

The discussion was framed around two proposals: HR 574 (Medicare Physician Payment Innovation Act of 2013), a bipartisan effort from Rep. Allyson Schwartz (D-PA) and Rep. Joe Heck (R-NV), and a draft proposal from House Ways and Means chair, Rep. Dave Camp (R-MI) and Fred Upton (R-MI), chair of the House Energy and Commerce Committee.

The panelists and House committee members reviewed these broad concerns:

Stability
David Hoyt, MD, FACS, executive director of the American College of Surgeons, recommended that as the system transitions to value, physician payment stability be maintained for five years and tied to inflation.

The effort would allow stakeholders to ensure that "payment measures and quality measures, which will serve as the backbone of the new system, are properly aligned. That will take some time."

Transition
Charles Cutler, MD, chair of the board of regents of the American College of Physicians, also supports a phased-in approach that would allow physicians reasonable time to "get on a transitional value-based purchasing pathway that works for their specialty, practice setting, and patient population."

Small practices
"Can small physician practices do well in the new value system?" Rep. Sam Johnson (R-TX) asked the panel. Patrick Courneya, MD, the medical director for Minneapolis-based Health Partners, remarked that because he is from a small community in Minnesota, he is personally interested in making sure that any SGR replacement works for both small and individual practices.

"I think those one- and two-physician practices are the ones most burdened by the current FFS payment model. The only way their business can get payment for the work they do is [to] be on the treadmill running as fast as they can."

Health Partners participates in an alternative payment model and in its market. Courneya noted that solo practitioners are among the top performers in clinical quality.

Physician burden
"I don't want to heap another round of quality indicators, paperwork, and bureaucracy on physicians," stated Rep. Brady. He asked Courneya if Health Partners focuses on key indicators or a laundry list.

"We try to [focus on key indicators]," Courneya replied. He credits providers with holding Health Partners and other payers in the market accountable to agreed upon measures and not creating "the confusion that can occur when Health Partners and the other health plans in our market each have little variations" on the same quality measures.

"We have agreed as a market on things like comprehensive diabetes measures and we're actually achieving the goals and clinical targets," Courneya added.

Quality measures
Panelist voiced their support for basing Medicare payments on quality measures.

Of course, "getting those measurements right is very important," noted Rep. Brady. The NQF made a pitch to centralize the process with one central hub of measure and review—similar to what's already in place at the NQF.

Frank G. Opelka, MD, FACS, vice chair of NQF's consensus standards approval committee, notes that NQF stakeholders, including businesses, consumers, health professionals, and health plans "are concerned that establishing a separate process will simply result in more cost and redundancy."

Physician shortage
Rep. Jim Gerlach (R-PA) noted that a physician shortage is looming. "We need to figure out how to bring the joy of medicine back into medicine… that sense of buoyancy and… instead of just check[ing] the box and feeling defensive about the whole environment." He quoted recent figures from the Association of American Medical Colleges which projects a physician shortage in 2020 of "at least 91,000 physicians and by 2025 a shortage of at least 135,000 physicians.

Despite a robust enrollment forecast, 40% of medical school deans recently surveyed by the Association of American Medical Schools have expressed "major concern" that the number of available residency training positions will fall short.

Timing
How much time will be necessary to make the transition from volume to value? Panelists seem to agree on three to five years. Can the pace be accelerated? Dr. Hoyt said investment in information systems, including data registries as well as EMR, will be necessary to move more quickly. Incentivizing physician behavior and physician collaboration will be critical.

Rep. Brady expects to schedule additional hearings to explore alternatives to the SGR. In a prepared statement he said, "while the timing is ripe for action, we need to be sure we get the policy right. My hope is that we can put the days of kicking the SGR can down the road behind us."