Congressional leaders remain committed to finding a permanent solution to the SGR problem that has plagued the Medicare program and provider payments for over a decade. Although there has long been bi-partisan agreement that the SGR formula developed during the Clinton Administration was seriously flawed, a permanent fix has remained elusive.
Although an SGR fix is not imminent, due to a convergence of factors, a permanent fix appears achievable in 2013. All of the Congressional Committees (Senate Finance, House Ways and Means and House Energy and Commerce) that share jurisdiction over Medicare Physician Payment reforms have held hearings and solicited feedback from stakeholders on possible permanent solutions. Democratic and Republican leaders in both the House and Senate remain committed to finding a permanent solution whereas in years past, the level of commitment to finding a permanent fix has not been as strong.
Draft proposals have been circulated amongst the various physician and other healthcare organizations, and industry feedback and reaction have been sought.
If Congress should fail to come up with a permanent fix before the end of 2013, current estimates are that a cut of approximately 24% in provider payments will be necessary to comply with the SGR law.
Some of the common themes that are emerging as part of the SGR discussions center around the following concepts:
Repeal SGR and replace with statutory increases (possibly 1 – 2 % per year but still to be determined) for a period of time (possibly 3 – 5 years but still to be determined). This would eliminate the 24 % cut slated for January 1, 2014.
- Incorporate Specialty Specific Quality Measures as part of the payment formula (aka Update Incentive Program).
- Provider payments would be a combination of a “base rate” plus a variable rate tied to quality/performance (Specialty Specific Quality Measures).
- Score on Quality would be based upon a comparison against peers (risk adjusted) AND compared to the individual provider’s prior year scores AND provider participation in specialty specific clinical improvement initiatives.
- Each provider would “self-identify” with a peer cohort (i.e. providers of the same specialty); and provide information on each of the following:
* Identifies the peer group the provider wants to be compared to; and
* Provides information on each quality measure applicable to such peer group to which the provider shall be assessed.
The Secretary of HHS will be responsible for developing the methodology for assessing the performance of providers with respect to the measures and with developing the methods for collecting information needed for such assessments. The Secretary is directed to establish these processes in a way that minimizes the “… amount of administrative burden needed to ensure reliable results.”
In reviewing the proposals, several administrative/operational questions have arisen. These include:
- Auditing/data retention requirements
- Claims reporting requirements
- Administrative complexity of process
- How/when will payments be made
- What will be necessary to support provider participation in this type of payment model
- Predictability of payment
Clearly, much still needs to be done to address and hopefully to resolve this ever-pressing matter.
reprinted with permission, Healthcare Business & Management Association (HBMA)