The fate of the loathsome sustainable growth rate formula is one of two big unknowns that will have a large impact on how doctors are reimbursed in the New Year.
It is an easy exercise to begin 2014 by reviewing what happened the previous 12 months and then try to plan for a more appropriate path going forward.
That task, however, is nearly impossible for the tumultuous healthcare industry, especially for physicians. They won't get a true indication of what 2014 and their longer-term future will be like until the end of March, when we hit two key deadlines:
- The three-month Sustainable Growth Rate (SGR) patch expires
- HIX enrollment ends nationwide
The final number attached to both of these will largely determine how physicians practice in the remaining months of 2014 and beyond.
Last of the SGR Patches?
The bipartisanship on repealing the SGR in 2013 was not surprising. The threat to cut provider reimbursement has long been dogged by both Republicans and Democrats. But there is real hope that the band-aid box used to avert the cuts in years past will finally be put away with a draft proposal that is, in the words of American Medical Association President Ardis Dee Hoven, MD, "bipartisan, bicameral, and … enthusiastically supported".
Unfortunately, there is no agreement on how to pay for the SGR repeal, so the issue has, again, been kicked down the road for Congress to deal with in March. A three-month patch was included in the budget President Barack Obama signed in late December. Instead of a 20% payment reduction, physicians will receive a 0.5% bump for services provided through the end of March. The extension should give Congress enough time to reach an agreement on paying for permanent repeal.
The AMA and other groups are understandably unhappy with yet another so-called "doc fix." American Academy of Family Physicians President, Reid Blackwelder, MD, FAAFP, cites the SGR issue as a major challenge in developing physician-led teams, a trend that holds the promise of improving care, quality, and lowering cost in an era of diminishing primary care access.
An Issue for Medical Students
"One of the biggest barriers is the reality that our current system pays for volume," says Blackwelder. "And that has created some significant challenges all over the country in that we're not used to recognizing the value of primary care especially in the setting that physician led teams can bring to the table. So as we transition from paying for volume (fee-for-service) to paying for value, the system we're trying to get away from doesn't have a way for me to easily document and be paid appropriately for it."
He also says that SGR uncertainty contributes to decisions medical students have to make now that affect patients and care in the future.
"When [medical students] are looking at four years down the road or even eight years down the road, we're still at the crossroads of… the SGR. We haven't repealed it, we don't know what the pay-fors will be, and that is actually a very important variable in the next steps this country takes toward the changes that have to happen in healthcare delivery and healthcare payment. The payment reform, incentivizing primary care, these are huge issues for medical student interest into becoming the physician leaders of their team," says Blackwelder.
Will HIX Enrollment Numbers Meet Expectations?
January 1, 2014, marked the beginning of what will be Obamacare's fourth, and arguably, most tested year. The massive volume of regulations included in the Patient Protection and Affordable Care Act has already changed the environment for all of healthcare's key players, but now previously uninsured patients are expecting delivery on the promise of access and care through a health insurance exchange (HIX).
The consumer protections, drastic payer changes, and drug discounts implemented in previous years were the run up to exchanges, which began with a whimper in federally facilitated exchange states (the majority). Exchanges are the most visible component of PPACA, and will become either a beacon or a relic. Critics could point to the troubled start of the exchanges as an indicator of it being the latter. But the real test is the end of March, when HIX enrollment ends.
By March 31, 2014, the Centers for Medicare & Medicaid Services (CMS) has projected 7 million Americans enrolled in the health insurance exchanges. There are numerous reports of how far behind estimations are.
High Anxiety
According to a September letter to the House Ways and Means committee [PDF], by December 2013, the agency believed 3.3 million would have enrolled. The number is close to, 2 million. The technical glitches barring some from enrolling in the federal HIX surely is to blame for the shortfall; however, there are three more months to get to the 7 million mark.
Of that number, 2.7 million people aged 18−34 need to enroll to ensure an adequate risk pool. It's not clear if young people are signing up, as hoped, as expected, and most importantly, as needed.
The effect of the surge of newly insured patients seeking out care is expected to put a strain on physicians, who are already being squeezed out of some insurance networks or being asked to take reduced reimbursement for new patients.
And, if the SGR three-month patch is extended to yet another temporary fix to be dealt with after the 2014 mid-term elections, physician groups may not be able to back burner or recapture their optimism for a permanent repeal in 2015.
The impact of these wildcards on how physicians care for patients and are paid for their services can't be underestimated. During the next three months of intense healthcare transformation, expect some anxiety among physicians.
Jacqueline Fellows is a contributing writer at HealthLeaders Media.