SGR is Dead. What Happens Next?

Virtually every member of Congress who voted for H.R.2 can tell his or her constituents, in all honesty, that the bill keeps the doors open for critical healthcare programs in their districts.

After more than a decade of teeth gnashing, hand wringing, and ululating, the nation's physicians and other frontline providers can take comfort in knowing that Medicare's hated Sustainable Growth Rate funding formula has been euthanized, with a DNR attached for good measured. The President's signature is assured.

In the morning afterglow it's time to sweep up the various flotsam and commentary surrounding H.R.2, which does a lot more than simply kill the SGR. In fact, this bill is the most sweeping and costly piece of healthcare legislation since the Patient Protection and Affordable Care Act of 2010.

Here are a few morning-after tidbits I've collected.

AMA Priorities Shift
American Medical Association CEO James L. Madara, MD, held a telephone press conference with reporters this morning and said the AMA's efforts now shift from lobbying for the permanent repeal of the SGR, toward ensuring that the payment reforms replacing it are properly implemented.

"We will have our finger on the pulse of the implementation and [will be] working with the federal government to make sure that this tracks in a correct way," Madara says.

Senate Passes Permanent SGR Repeal

H.R.2 has been called a "permanent fix" for the SGR, even though the chief actuary for the Centers for Medicare & Medicaid Services says Congress will have to revisit the issue in 10 years. Madara says that even if that is the case, H.R.2 better than the status quo it replaces.

"We will be working with federal government not 10 years from now, but tomorrow, the day after that, and every day from now until the end of the next 10 years," he says.

Besides, he says, the actuary's concerns cannot take into considerations the potential for tremendous change in the healthcare landscape over the next decade.

"Projections are useful when one gets into an area that is so complex and starts thinking of nothing changing for a period of 10 years and in the second instance longer than that, about a quarter century," he says.

"That's interesting to know. It's input. But one does not make linear trajectories over periods of a decade or more and assume that is where we are going to end up. That assumption is that nothing happens in the interim, and as we all know that is simply not the way life works."

"It's also true that we have to compare this bill with the trajectory that we were on under what was previously law and this bill in our view is a tremendous improvement over the disconnected environment with competing and non-harmonized measures that we were facing in what until yesterday was current law," he says.

The 8 'No' Votes

H.R.2 passed the Senate 92-8 on Tuesday night, less than three hours before a 21% cut in Medicare reimbursements would have kicked in.

Eight Republicans voted against the bill. They are: Sens. Ted Cruz, Mike Lee, David Perdue, Marco Rubio, Ben Sasse, Tim Scott, Jeff Sessions, and Richard Shelby.

The primary objection raised by these senators was that there were no offsetting "pay-for" provisions in the bill, which adds about $141 billion to the deficit.

Supporters of the bill, which included the Republican leadership, didn't argue, but said doing nothing would cost $900 million more over the next decade, according to the nonpartisan Congressional Budget Office.

Also, Sens. Rubio and Cruz are running for president in 2016 and they couldn't vote for anything that could be perceived as supporting Obamacare.

"I cannot support the Boehner-Pelosi bill, which institutionalizes and expands Obamacare policies that harm patients and their doctors while adding roughly half a trillion dollars to our long-term debt within two decades," Cruz said in prepared remarks.

"The so-called 'SGR' is a flawed approach that needs to be eliminated, but doing so should be a catalyst for real entitlement reform. Any deal should be fully paid for and include significant and structural reforms to Medicare that provide seniors more power and control over their healthcare."

NP Join the Celebration
Physicians aren't the only ones cheering. Nurse practitioners also scored a major victory in H.R.2. The American Association of Nurse Practitioners points out that the bill:

• Authorizes NPs to document evaluations for durable medical equipment
• Includes NP in the first year of the Merit-based Incentive Payment System
• Ensures that NP-led Patient Centered Medical Homes are eligible for incentive payments for chronic disease management
• Reauthorizes the Children's Health Insurance Program, which will ensure access to for millions of children, including those who receive needed services from NPs

"The national nurse practitioner community is grateful to the U.S. Senate and House of Representatives for preserving the health services our seniors need, and further recognizing that seniors increasingly rely on the expert care of nurse practitioners who have become the providers of choice for diverse patient populations," AANP CEO David Hebert said in prepared remarks.

Health Centers Re-funded
The best news for people living in underserved communities is that H.R.2 also includes a two-year funding extension for Community Health Centers, the National Health Service Corps, and the Teaching Health Centers Graduate Medical Education Program.

"America's Health Centers and the more than 23 million patients they serve are extremely grateful that this bipartisan legislation recognizes and invests in the health center system of care," Tom Van Coverden, president/CEO of the National Association of Community Health Centers, said in prepared remarks.

"Health centers have been living under the uncertainty of the Primary Care Cliff, and, now that this legislation has passed, our dedicated clinicians and staff can get back to the daily work of providing high quality primary and preventive care to underserved patients and communities."

HLM Journalist in Shock!
I'm still trying to get used to the liberating notion that I will no longer write about the SGR in the present tense.

I wasn't covering healthcare back in 1997 when Congress passed the SGR, so I wasn't really sure what they were trying to accomplish beyond applying a sledge hammer to stem the growth in Medicare spending. Clearly, it did not work.

Every spring for the past several years, I've camped out in front of CSPAN and watched the endless bloviating around a dumb policy that was never enforced, and which should have been repealed years ago.

It was particularly frustrating because everyone agreed that SGR was dumb policy, but year after year nobody acted to repeal it. And with every Band-Aid patch—there were 17 "Doc fixes" since 2003— and the debt kept growing, making the eventual day of reckoning costlier.

I am not a Congress watcher, so I can only guess as to why lawmakers decided to act this year. I think Congress was as sick of the SGR as everyone else. They just wanted it done with, and the CBO gave fiscal hawks just enough cover to vote for it.

Attaching funding for popular and critical healthcare programs, such as community health centers, was smart. Virtually every member of Congress who voted for H.R.2 can tell his or her constituents, in all honesty, that the bill kept the doors open for critical healthcare programs in their districts.

Maybe the CMS actuary is correct. Maybe Congress will have to revisit the "permanent fix" at the end of the decade and throw more money at it. After reporting on temporary fixes for the better part of a decade myself, however, I'm OK with a 10-year reprieve.