Our intrepid members of Congress return from their year-end holiday and district work sessions breaks in a couple of weeks. While a heaping plate of healthcare concerns will demand their attention, here I focus on four items I'd put at the top of the pile.
1.Fix the SGR
In the current political climate it is laughable to imagine that Congress will look long-term (meaning beyond the next election cycle) and either repeal or replace the sustainable growth rate, but that is exactly what needs to happen.
When the SGR was developed back in 1997, its formula was designed to control Medicare spending on physician services. Everything worked pretty well when the formula was followed, but about 10 years ago Congress began tinkering with the SGR and overriding the formula.
Now doctors are looking at a cumulative 27.4% reduction in reimbursement rates in 2012. Just before its holiday break, Congress did step in and delay the reduction for 60 days with an eye to extending it for a full year, but just about everyone agrees that it's time to bite the bullet and do something permanent with the SGR.
What's particularly egregious is the across-the-board application of the reduction. Cost-conscious physicians get slapped with the same reduction as spendthrifts, which mean there's no incentive to practice the triple aim of better care, better health, and lower costs.
The Centers for Medicaid & Medicare is awash in demonstration projects that reward efficient and effective care. How about developing a system wide approach to reimbursement that employs lessons learned from the demonstration projects?
What Congress might really do
It's an election year so don't expect to see any new trails blazed on this issue. Looks like we're in for another one-year extension, which means a lame-duck Congress will take up the issue (again) at the end of 2012.
2.Don't mess with the new MLR rules
Health insurance agents and brokers are angry about the medical loss ratio and worried that new requirements in the federal Patient Protection and Affordable Care Act will hit them where it hurts—their bank accounts.
The National Association of Health Underwriters lobbied hard to get the Department of Health and Human Services to exclude broker and agent fees from MLR administrative cost calculations, but HHS declined to make the change in the final rule.
Now there's talk that Congress may step in and try to reverse that decision. But consider this General Accounting Office report, which concludes that 64% of all healthcare insurers in 2010 would have met or exceeded the 2011 MLR requirements contained in PPACA. And the PPACA itself expands the MLR definition to include programs like case management for chronic diseases, care coordination, quality initiatives, and the IT needed to support the programs.
Those extras will help insurers increase their MLRs. Yes, some insurers are paying lower sales commissions but that's one step among many that they are taking to boost their MLRs. Congress needs to give the system some time to work.
What Congress might really do
The House Energy & Commerce Committee's Subcommittee on Health held a number of hearings in 2011 on the issue of broker commissions and is itching to do something. Still, HR 1206, a bill to "preserve consumer and employer access to licensed independent insurance producers" has languished in the committee since March 2011. There doesn't seem to be a big legislative appetite beyond the subcommittee for this particular fight.
3.Give the IPAB a chance
The controversy that surrounds the Independent Payment Advisory Board has the makings of a great novel—with power, politics and money at center stage. IPAB is empowered to analyze the drivers of Medicare cost growth and then to recommend to Congress policies to control those costs, if spending exceeds a targeted growth rate.
The 15-member board, which will be named by the president and confirmed by the Senate, will be comprised of doctors, nurses, medical experts, and consumers. Supporters see IPAB as similar to Medicare Payment Advisory Commission (MedPac), but with the power to implement what it decides needs to be done. IPAB recommendations will be put in place unless Congress votes to block them and comes up with equivalent cost-cutting measures.
Congressional objections to IPAB seem to focus on the potential power of the un-elected IPAB board. If IPAB is implemented, Congress may not control the purse strings when it comes to Medicare. Stakeholders such as the powerful American Medical Association aren't too thrilled with IPAB's potential to cut provider payments.
Meanwhile America's Health Insurance Plans objects to the exemption of hospital costs from IPAB consideration until 2019. On the other hand, the American Academy of Actuaries has crunched some numbers and thinks IPAB needs more authority to help move Medicare toward a more sustainable financial model.
What Congress might really do
Congress is focused on repeal when tweaking is probably what's needed. Both the Senate and the House have bills in place to repeal IPAB. More than half of the House members, including some Democrats, have signed on as co-sponsors of HR 452. The House bill may gain some traction, but that won't make any difference unless the Senate can get something bipartisan going.
S 668 was introduced in March and sits in the Senate Finance Committee. The bill has 32 Republican co-sponsors and zero co-sponsors from the other side of the aisle, which means it will probably go nowhere.
4. Stop leaving everything to the last minute
As crazy as it may seem, people in the real world (outside of Capital Hill) are actually affected by many of the decisions Congress makes. So when members talk about how important is it to develop long-term plans to tackle Medicare reimbursements or payroll taxes it's annoying to watch Congress run the clock down to minutes before a calamitous deadline and then settle on short-term, patchwork action that simply postpones real resolution. Until the cycle starts up again. It's time to stop this.
What Congress might really do
With Congressional approval ratings hovering in the single digits expect members of Congress to return from the holidays with a spring in their step and a determination to boost their ratings by rolling up their sleeves and making the hard decisions. Gotcha! After much hand wringing and finger pointing it will be business as usual on Capital Hill. Oh wait. It's an election year. So things will move even slower.
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
