AMA Advocacy Insights webinar series: The latest on Medicare payment legislation

Webinar (series)
The latest on Medicare payment legislation—and how to get involved
Jan 9, 2024

Physicians face a 3.37% reduction in Medicare payments at the start of 2024, absent congressional intervention. Lawmakers have until Jan. 19 to act and avoid this potentially devastating cut to physician practices—practices that have already weathered the pandemic, a 2% pay cut in 2023 and no adjustment for inflation. Without a sustainable Medicare payment system that physician practices can rely on, patient access to care will be in jeopardy.

Watch this Advocacy Insights webinar to hear about what’s happening with Medicare payment on Capitol Hill as the new year begins, what the AMA is doing to fight for legislative solutions and how you can get involved in the AMA’s Physicians Grassroots Network campaign.


  • Willie Underwood III, MD, MSc, MPH, chair, AMA Board of Trustees


  • Rob Jordan, vice president, Political Affairs, AMA
  • Jason Marino, director, Congressional Affairs, AMA

Dr. Underwood: Good afternoon and good morning for some. And thank you everyone for joining us today for the latest of our Advocacy Insight webinar series, and our first of 2024. Hi. I'm Dr. Willie Underwood, the chair of the Board of American Medical Association and a urologist in Buffalo, New York. Today, we'll be—

Today, we'll be diving into a topic that I know is at the top of everyone's mind, and many physicians as we begin the new year—the steady, the two decade long decline of Medicare reimbursement, and what it means for physicians, and our practices and our patients. There's a lot of attention being paid to this issue in Congress at the moment, and that's extremely, extremely good.

The AMA and our Federation partners across the country have done a wonderful job explaining the high stakes of this rather complicated issues in simple ways that lawmakers can understand. And there are some bipartisan bills pending right now in Congress that could reduce our outright—or outright eliminate the cuts planned for this year, although their prospects of reaching President Biden are uncertain. Until that happens, and until major Medicare payment reform advanced out of Congress, the AMA is going to keep the pressure on.

The simple fact is our AMA payment—that our medical payment system is broken and in need of immediate change. The very health of our nation, our health care system is at stake. Even before the COVID pandemic and rampant inflation, physicians were facing an unsustainable trend.

When adjusted for inflation, Medicare physician payment was effectively declined 26% since 2001. This includes 2% pay cut in 2023. And unless we are successful in reversing it, an additional 3.4% in 2024. Physicians are bearing the brunt of this broken system, and we are the only providers without an automatic annual increase to account for inflation. And that is unsuccessful—unacceptable and unsustainable.

I don't know many businesses in any industry that could withstand a 26% drop in revenue and still survive, much less an industry like ours, which is so essential to the health and well-being of our nation. We know what happens when doctors lack the resources they need to keep their practices open. They close.

They close their offices and they reduce their hours. Or they may do with inadequate technology and equipment, and fewer support staff. And they limit the number of new Medicare patients that they can take in, or stop seeing Medicare patients altogether. I'll worry about the ability of the patients on Medicare to get the kind of care they need over the long term, if payment rates fail to adapt to the increasingly high cost of providing care and maintaining a striving physician practice.

As we know, that delay in care, particularly among populations underserved, already limited access to care, are associated with worse health care outcomes, and acerbated an already huge health inequities across the communities. So today, we'll talk with two of the AMA's own experts on Medicare payment reform, about where things stand right now and what's ahead of 2024. Wow.

While the payment cuts has already gone into effect as January 1, there's an opportunity to get the fix in the near term as Congress wrestles with this must pass legislation this month. Since we held our last webinar on Medicare payments in November, just two months ago, we have made major strides in the fight to fix Medicare payments.

The AMA was successful—was successful at the end of last year to secure the introduction of the H.R. 6683, Preserving Seniors' Access to Physician Act, which would eliminate the full 3.37% Medicare physician payment cuts set to go into effect this year. This is bipartisan legislation championed by representative Dr. Greg Murphy, Republican from Northern North Carolina, and five bipartisan original sponsors.

Prior to the introduction of H.R. 6683, select AMA and Senate committee with jurisdiction over the Medicare program took interim steps to alleviate a portion of the planned payment cut. In November, the Senate finance committee passed the Better Mental Health Care, and the Low Cost Drugs, and extent—Extenders Act in 2023.

Sweeping legislation, that among other things, provided physicians with an additional 1.25% increase to the fee schedule conversion factor. This would, essentially, reduce the plan, 3.37% cut to just over 2%, which is still too much.

And in December, the House of Energy and Commerce committee passed a separate standalone legislation, H.R.6545, the Physician Fee Schedule Update and Improvement Act, that also would provide physicians with an additional 1.25%, as well as extend the alternative payment model, incentive payment and increase the $20 million statutory threshold that triggers the need for the budget neutrality adjustment to $53 million.

And we still need Congress to pass a bipartisan bill that was introduced in the House of Representatives earlier this year, strengthening the Medicare for Payments and Providers Act, H.R. 2474, which would do what the AMA has long advocated for, providing physicians with an annual payment update to account for practice cost inflation and reflect in the Medicare Economic Index.

This would—this would simply put physicians on equal footing as inpatient and outpatient hospitals, skilled nursing facilities and other who receive payment through Medicare. So there are a lot of potential legislation fixes that—to these issues that we would drive to—dive into the day, and with our experts. And want to make sure that we have plenty of time to answer your questions. So let's get started.

With me today is Rob Jordan, vice president of political affairs for the AMA. Rob is an accomplished campaign executive, with the experience in transforming and growing political and grassroots issues, advocacy programs, Rob's advocacy focus includes nonprofit, management and strategic planning. Welcome, Rob.

Also, with us today is Jason Marino, AMA director of congressional affairs. In this role, Jason helps to lead the AMA federal advocacy around the issues that impact the practice of medicine, the delivery of care, patient access, including Medicare payment reform. Welcome, Jason.

Marino: Thanks for having me.

Dr. Underwood: Jason.

Marino: Thanks for having me, Dr. Underwood.

Dr. Underwood: All right. What was good news? Go ahead. So I'm going to let you rock and roll. I'm going to let you guys get going.

Marino: I'll jump first here. Let me just frame up what I—what's at stake here. Around New Year's Eve, I was in New York City, Times Square, with the crowds looking up. Saw the ball. When that ball fell, ushering the joy of a new year, 2024. But I'll be honest, if I didn't tell you, I thought about what that means for physicians. When that ball fell, physicians are facing now another 3.4% cut in Medicare.

And at a time when the federal government, Center for Medicare and Medicaid Services says that when the ball fell, physicians should have gotten a 4.6% increase for MEI, Medicare Economic Index, that was the inflation cost for physicians. Should have been 4.6%, but instead, when the ball fell, they find themselves getting cut 3.4%, after getting cut 2% in 2023. That's what's at stake.

And I'm not all doom and gloom, because let me tell you, since your successful webinar you had a two months ago, things did happen in Congress in November, where we did get the Senate finance committee to at least help mitigate some of the 3.4% cut by putting 1.25% relief in a package.

And also, at that markup that happened, there was an exchange between Senator Thune on the committee and the Chairman Wyden, where they—where he agreed, yes, after being pressed, we do need to reform the Medicare payment system, and I commit to doing that. And yes, physicians are the backbone of our health care system and we need to fix MACRA. We need to fix this payment system to have a successful health care system, and I commit to doing that. That's progress.

Over on the House side, the House Energy and Commerce Committee, they put together a package that also included another 1.25% relief from the cut, and also include some reforms that you mentioned, Dr. Underwood, some of the reforms to how to reform the budgeting neutrality system in bigger picture.

Why do we have these cuts that seem random every single year? Where do they come from? Can we reform the payment system on that—in that level? And we have ideas out there and we've got a bill dropped, and that was included to help us a down payment, as a first step on some policy reforms that make sense. That was in there.

And at that markup, I will say, we actually got the committee to put on their screen, if you could have followed it if you watched on your computer on C-SPAN 2 or C-SPAN, you'd see the AMA gap chart actually made it an appearance on the committee screen. And everyone got to see the difference between what physicians have gotten updated in the last 20 years since 2001, compared to hospitals, nursing homes, hospice and right in front of everyone.

And it's hard to ignore when it's right in that big screen that showed on the little screens on their—on their phones. It was everywhere. So there's a lot of awareness, which is a good thing. You need awareness people recognizing, why is that? And everyone's asking, why is it that? Why is it such a disparity? And what can we do to address that? And so that's some progress.

And then I'll also say, we got a bill introduced that would be a clean to stop the whole 3.4% cut entirely, erase the entire cut after those—after those committees marked up on finance and economy. So that's a step forward, but we want to get the hole cut reversed. We want the hole 3.4% wiped out. And so we found a champion—a bipartisan champions in Dr. Murphy, and Congressman Davis and Panetta, and Bhushan and Burgess. And we had five people introduced say, now, it's 32 members that support that bill.

And we knew that we need a bill in place, so that when physicians go to member of Congress, they can say, it helps in the advocacy efforts. Here's the bill, H.R. 8863, that would reverse the entire cut. Please take it up and pass it and stop these cuts. And so we're socializing that, we're getting the word out there on that bill.

But I will say big picture, last year in 2023, was the divided—Congress is very divided, as everyone knows. There's what? There's three or four—three votes, could be two votes, depending on who's sick or not in the House, the majority margin. Senate is almost break even and so there's a lot of issues of the day that are difficult to deal with the $30 plus trillion deficit. Social issues, other issues that just divide Americans. And the representatives are a bit divided.

And to give you context of what we were facing last year. The House voted on 724 bills and only 27 became law. So 724 bills were voted on, about 27 became law, and some of them are post office named after so-and-so post office. So it was a tough year. That's almost a 50-year low as far as productivity. So it was a tough environment.

And Congress, basically, at the end of the year, said, "You know what? We're not going to do the typical end of the year Christmas time, massive bill, and call it a day, which is usually how we're dealt with at the end of the year." They actually punted. They punted into January. And they—where they punted was the funding for the federal government.

That's usually what drives the conclusion of a given year, the funding for the federal government is 12 bills. And so they kicked it to January 19 and February 2, in this year. And so that's where we find ourselves, Congress now, is just getting back. Literally, they're just flying back this week and they're caucusing amongst each other. And they have a lot of work in front of them, and that's where we find ourselves right now in the days ahead.

Dr. Underwood: Wow. There's been a lot of activity, a lot of action, a lot to come this year in 2024. So Rob, how is the AMA Grassroots Network responded to the ratcheting up of pressure on Congress over the past couple of months?

Jordan: Yes. Thank you, Dr. Underwood. The response, it's really been great. It's been steadily building since, really, I think the Interim meeting. That event in particular has helped us to rally physicians and spur them to action. Look at a few key metrics, the campaign had achieved back in November compared to where we are now.

We've ramped up across the board. Our website page views at have more than doubled since then. We're now at over 425,000. Other things that we measure, ad impressions, social media engagements, they all have increased dramatically. Just the context of Congress reported at Interim, we were at 226,000. Now, we're at 288,000. So we've seen a great response, which has been steadily building from the grassroots. And not just physicians, obviously, from the patient community as well.

The other thing that I would highlight as part of that is that the feedback from the Hill, offices are seeing our messages. They're hearing from constituents, again, not just doctors. There's something that Jason and his team have reported to us pretty consistently, is this theme that we know we get it. We're hearing from people. It's obviously a little more anecdotal, but it helps to show that our message is taking hold, and really breaking through the noise inside the beltway.

Dr. Underwood: And that's extremely important, especially as we hear that. January 19 is the first deadline to pass legislation to prevent a government shutdown. So Jason, why is the AMA pressuring Congress on this issue so heavily leading up to the deadline? And how do we see the Medicare payment being potentially incorporated into a larger package?

Marino: So where we are today, is that they're trying to reach agreement big picture on the funding level for the first package. And they reached some agreement on the overall levels of funding for the federal government for the 12th Appropriation Bill, so they can start writing those. There's also an outstanding disagreement on Ukraine aid, Israel aid, Taiwan aid, border security. So there's a lot of—lot of issues have to get resolved that are way beyond our issue right here, But they have to get resolved that we can't control.

And so a lot of distractions out there. People are focused on that. And we have to remind people, and remind the Hill and remind members of Congress and their staff, that here we are. It's now January and we are facing the cut. The cut is happening. We're living with this 3.4% cut, on top of a decade of not getting—more than a decade, 20 years of not getting adequate or any adjustment for inflation. And this could be the straw that broke the camel's back.

And you often hear about a hospital that's going to shut down in a community. It's a big deal. It's a local news story. Everyone gets involved. It's impactful. When a physician practice is struggling to make clothes, you don't always hear about. The immediate community will know, but not everyone around will hear about. It's not a local news story, per se. It happens quietly and it's not really tracked very well.

And so it's very important that our voices are heard right now, and that we're having a cut and this is what it means. And you don't want members of Congress to say, "Well, wasn't there a cut? But I never heard anything. No never said anything like that." So overblown. You don't want that. You want it—

And some advice to when we're competing with other interests and just so many issues are out there for remember, we have good stats. We have—go to That's on our website and we have some great charts. And one of the charts that I use a lot is the one that talks about, what I just mentioned. Over the last 20 years, there's no adjustment for inflation. And look at where hospitals are versus physicians and it tells a story.

But you can't rely on just statistics and charts. You got to actually tell a story. And if you want to move a member, you got to have a little bit of motion. You got to meet them where they are. And people can relate to maybe a relative that can't find a physician or themselves, and what could happen if a—if their physician went away, or their mom's physician went away, what that would mean.

And everyone knows the story. Tell that story in your own—own terms, so people don't just think when we talk about Medicare payment, it's about dollars to a physician's pocket. It's not. It's about staff. It's about software that to run your HIT systems. It's retaining your employees. It's investing in equipment and supplies. It's the run—it's the cost to operate your practice, and that's where that money goes. And that story needs to be told.

And what would happen if all these small practices slowly went away? That's not a good thing, but you have to have a story that relates—that you can relate, that you can share, that brings it to life. Otherwise, people get used to this chart and they just tune it out. They feel like, oh yeah, that's terrible, but then they kind of move on, whereas the story sticks with them. And then they go back and look at the chart to validate the story. That's what you need.

And we got to repeat that over and over and over, and that's how I think we'll start breaking through a bit. And then we're in the immediacy of, we have this cut and we got to reverse it. But the bigger picture is, once we get through this cut and get it reversed, we got to get back on track to permanently reform this broken payment system, and make sure that they feel the pain that members—feel the pain of why are we doing this every year.

This is a very painful exercise. It's not healthy for anyone. It's not good, and we need to once and for all resolve this. Remember how bad it was in January when that cut happened? We got to make some paint and get to harness that into—well, we do have a bill out there that we've been working that now has over 100 plus co-sponsors.

There's about 87, this is the MEI bill, permanent MEI. So we do have an inflation update like the other Medicare providers. There's about 37 members waiting to get on, but that, we got to commit it back to that because that would help solve a lot of the problems, if there was just an update on Medicare. And we got to get to that. And then we do have some reforms that we aim to work with other physician groups, with specialty groups in the States, to say, here's some proposals to reform, for instance, budget neutrality? And we got to get that in motion.

We did have two hearings last year. We are making some progress. It's going to take a while because it's expensive to permanently reform a payment system. It's hundreds of billions of dollars, but it starts with starts—right now, with telling stories and staying constant, and constantly being engaged. And so, I'm hopeful in that sense.

Dr. Underwood: So this is excellent. So we're hearing a couple of things. There's movement, there's pressure, we need to continue the movement and continue to pressure, so we can get this over the goal line. But once we get this over the goal line, and that's the elimination of the reduction altogether, we still have to process. Keep marching down the field so that we can fix the total problem overall, so that we get the same thing that everyone else gets, right?

We're not asking for some special. We're just saying, treat us like you treat everyone else. So whereas they're able to expand and get top notch technology to do the things, we—you can create all the technology you want, but physicians can't afford it, then we won't be able to use it for—to improve health outcomes for Medicare patients, and for all patients across the board, right? So this is our opportunity.

So Rob, you said something earlier, and in your question, I want you to repeat this. You gave the stats on our grassroots effort. right? You said, we had X numbers before, it increased to another number. We sort of went by that quickly. I want you to focus on that a little bit in your answer because that was pretty impressive to me.

Because we're seeing that physicians are engaged and patients are being engaged, and this grassroots effort is extremely, extremely important. So here's the question, but tied it in for me. I'd appreciate it. So what are the AMA grassroots networks focusing on now? And how will we ramp up in the days to come?

Jordan: Sure. And it's—they go hand in glove. I mean, we were at 226,000 contacts total into Congress, right at interim. And now, we're at 288,000. And I think that's—it's a big number, but really, what it's communicating is that drumbeat of pressure is steady and really steadily increasing.

And right now, we're issuing new calls to action, to both the Physicians Grassroots Network as well as our Patients Action Network. Again, just building support. Right now, we're very much focused on the Murphy bill and repealing the full cut. We have two new alerts to both of those networks that are going to be going out, possibly as soon as today. But just urging people to keep the pressure up on Congress.

Beyond that, we're ratcheting up all of our other activity, our ad placements, the keep up ad that we that we showed at Interim, other Fix Medicare Now ads online, in social media, in mobile advertising. There's a comment that came through the chat that somebody saw that our ads are still up at Reagan Airport. They're actually not supposed to be, so, we're actually—we're getting some free—we're getting some free ad placements there, but that's great and that's fantastic.

But, it does, it—and Jason will tell you, it seeps into the consciousness of these members. Flying back to D.C., leaving to go home. They're checking their phones, checking scores on ESPN and a Fix Medicare Now ad pops up. So we're just continuing that activity, and intensifying it as we approach the deadline.

Marino: And I'll just add on to that. Let me just add.

Dr. Underwood: Go ahead, Jason. Please.

Marino: There's nothing like when Rob and his team do their magic, and they've outreach, and then someone in my team. And I have a great team of my Congressional affairs team. When we go into office after Rob's send some grassroots their way, boy is it—heard there is a cut there. They are a lot more knowledgeable.

One member said, "You really ought to have a Senator. You really ought to have a chart." There's a chart out there that talks about that you really should do a chart like them. Chart, chart, chart. That is the power of that. And then when you have them like that, you're moving them. You're moving them, in a good way.

Dr. Underwood: And it's also when someone says, "Hey, have you guys seen this chart? This is awesome." You go, "Yeah, it's ours. We created that. Great. Thank you." So we're glad that you sent information out, it's awesome when it comes back to you and no one even thinks that it's yours, right? They're trying to share something with you, but the truth of the matter is, you started it. And that's when you're having great impact, and great—and your teams are doing a wonderful job.

But you can't do that job without us, without physicians doing our part, making the phone call, showing up, participating, bringing our patients, getting our patients engaged, having conversations with them so that they understand that it's in their best interest to stand with us on this issue. And contact their members of Congress and say this is unacceptable. And if you want to sit in that seat next round, you don't let this happen, right? Because this is not in our best interest, and in turn, it won't be in your best interest.

All right, right? That's how we think about this. So this is for Jason and Rob, for both of you guys. So what happens after January 19, or whenever we hopefully reverse the Medicare payment cuts? What's the AMA pushing for long term? And how will the AMA grassroots networks work to amplify the message?

Marino: I'll take that first. It's going to be a long journey. And there's a—there's a book I've read, Atomic Habits, by James Clear. It talks about the 1% rule, 1% compounding. And after a few years, it really, really compounds. And that's what we need to do on this issue. We need to keep reminding people over and over. And you think you told them five times, you got to tell them six times.

And you got to repeat the message and keep telling the stories. And we do have the bills out there. That's the good thing, is we got these bills introduced that are out there. Well, what's the solution for MEI? Here's the bill. There's actually a bill out there that would offer an MEI. Please co-sponsor that. Help us move that bill. We have reforms out there. We're developing more reforms.

A lot of people on the Hill comment now. I know you guys have problem, but we do appreciate that you guys come with solutions, and we do. So we have solutions. I know it costs a lot. We can't control the divisive politics in Congress. We can't control some of the big issues, but we can control this issue. And when they're ready, when there's a moment, an opportunity, we want to be ready. And so we need to keep powering through, keep reminding people one co-sponsor at a time, one markup, one hearing at a time, slow and steady. And keep building champions.

We're losing two big champions, Dr. Bhushan, Dr. Burgess have announced retirements. There are two physician members that are so helpful, such institutional knowledge, true champions that we're very thankful for. And we're going to have to build the next generation of champions, maybe someone on this call, physician is going to run for Congress and be our next champion. But we're always looking at bill champions and grow champions, and that's a slow and steady exercise.

And also, get people to see the bigger picture if you neglect this issue. Why is there a physician shortage? Well, there's many reasons, but one reason is, if you're a physician now, do you want your kids to go into medicine? Is it a great—is it is the future of independent practice that enticing? That's part of the variable. You want people to want to go into medicine, the next generation. And you have to think long term. And I think people get that when you—when you show them all the pieces of it.

Jordan: Yeah. In terms of the grassroots, just to build on what Jason said. I mean, once—we'll get the lay of the land after this next deadline passes. We take our lead as we always do from Cindy, Jason and our colleagues in Congressional affairs as to exactly how we reposition the messaging. But I think two key things.

Obviously, we want to make sure systemic reform is an important part of the overall message. This isn't about a patchwork of cuts, us fighting cut to cut, and trying to lessen the blow as much as we can each time. This is a system that's clearly not working. It hasn't worked. Big picture changes like MEI, other things need to be part of the solution.

The other thing is just not losing the momentum, and Jason's touched on a little bit of this. I think regardless of what happens with this latest deadline, we have made a ton of progress. And Jason and his team, individually, can tell you. With legislators who in the past, this was not on their radar at all. And we've changed the way that they've thought about this holistically as a payment system.

We don't want to lose that. So we need the grassroots to stay engaged, and we will do our part in providing the platform. But really, Jason said, Robin, his magic. I had to laugh because it's not me, it's—we'll provide the way for you guys to contact Congress, but it's you guys. It's the people on this call, the state folks and the docs, and their network. Getting doctors involved, patients involved, just staying engaged and showing, this is an issue that's not going to go away until it really gets fixed.

Dr. Underwood: Right. All right. So I want to thank you guys for the wonderful conversation, but you're not off the hook yet. We have more to come. All right. So now, this is the time when you, our virtual audience, have a chance to have their questions answered. Our AMA team will help us in responding to the questions.

So if you've got a question for our panel, if you haven't already done so, please add your questions to the chat and we'll get started. And we have some questions already, but keep them coming. So first question, is the government considering increasing reimbursement due to inflation and the cost of running a practice?

Marino: That's the—I'll jump on that one. That's the heart of what we've been pushing, is that there is no inflation at all adjustment in Medicare for physicians, zero. And that's got to change. And we do measure—the federal government does measure. It's called the Medicare Economic Index, MEI. They measure practice cost inflation so they can tell you what it should have been and what it—it should be 4.6% this year. And why is it we're not getting that? Why is that?

And people get. How do I—my suppliers don't come to me and say, 'Well, we're going to lower your equipment. We feel so bad for you guys. The ball fell and you got cut. We're so sorry.' They're not. They're going to raise their prices. Tough, that's how the world works. And so it's not sustainable right now.

Dr. Underwood: Rob, you want to add to that?

Jordan: Well, I'd certainly defer to Jason on the policy ins and outs. I did want to mention, along with the grassroots push and encouraging everyone to keep it up, a new or the next touch point I think, and real good opportunity for people to get involved directly, face to face with their members. The NAC is happening on February 12 through the 14th.

So if you haven't already, register for that. I think a link just went out in the chat to register. But we're working this time to really get people in front of legislators as much as possible, trying to help with arranging meetings to the greatest extent that we can. And I think that that's a really important thing for people to take part in if they're able to.

Dr. Underwood: Yes. The more we involve, we have to participate, we have in our state ledge advocacy meeting later this week. We have the NAC meeting, as you said, National Advocacy Conference. So it's important that we participate, that we get involved, that we show up, show out, put up and let's take care of business, right?

Because it can't just be, hey, we're representing the AMA. When they look out the window, they have to see the massive number of physicians, and their patients when possible, involved saying that this is unsustainable, it's unacceptable and now it's the time, right? To fix it. And this goes in perfectly to our—to our next question, because this is something that's always really baffled me as well.

What justification is Medicare claim for reducing reimbursements year after year, while the cost of living soars, as do the profits? And I'm not adding this piece but this is part of the question, as do the profits of large corporations.

Marino: Part of the problem is that, is—it wasn't as if there was a moment in time where there was a design of the Medicare payment system for all providers. Because who would—I couldn't imagine if they had sat down, and Congress sat down and said, we're going to devise the payment system for every provider going forward. That they would have devised it this way, where physicians are so—are the only ones not getting an update. It's just the nature of Congress where they lurch from issue to issue, and big bills and not big bills.

And over time, it—the payment system evolved. And the hospitals were on a different track, and nursing homes and hospice, and it just so happened that along the way, and we lost a lot during those years when it was the SGR, if you remember that. And we used to have, instead of cutting you 5%, we're going to we're going to make you 0%, but then we're going to cut you 10% the next year.

Then the next year came, and they said, instead of cutting 10%, we're going to cut you 15%. Then eventually, went to 25% cut and it was a charade and it was all the debt. And those were tough years. And we got that system erased and repealed, but there was—it was not a rational system we were dealing with on the front end.

And so it's been a series of decisions made that haven't been the best. And this just stands out. And so we're seeing many reasons why we got here, but here we are right now and we have a solution. Why can't you as my member of Congress step up and fix it? Because we know how to fix. It it's not rocket science here. It's willpower and doing the right thing to preserve patient access to their physician.

Jordan: Yeah. And people understand that, by the way. When we've done—going back to last year focus groups where we've laid out the system and just how absurd it is. And they look at it and they say, I couldn't operate a business. Every day, people look at this and they say, this is absurd. For them to not accommodate physicians like they are other providers, that just doesn't make sense.

So when we lay that argument out, and we've seen this come back through some of the stories that have come in on, and we're going to continue to promote that as an outlet for people. And I would encourage physicians to share that with their patients as well.

They've said, "Hey, I get this. I get the argument here. And while I may not have a problem seeing a physician now, this is headed towards disaster and you have to get serious about fixing this." So it's something that, to Jason's point, it is absurd. It doesn't make sense, but regular people understand it. It's not just physicians who are just complaining about it.

Dr. Underwood: All right. Do we have other questions in the chat? All right. So this may or may not take us off the track a little bit, but it is one of the questions. What is the AMA position on value-based payment program?

Marino: I'll jump in there. Part of the MACRA system there's what's called alternative payment models and payment systems that was set up, when MACRA was created. And there's legislation and there's rules that were set up. There was a promise that many specialties and physicians located all over the country would have access to if they wanted to have an alternative payment model. They would do some value-based care. It's broadly defined.

And unfortunately, a lot of those models never came online. There was a PTAT system for a number of physician technical advisory board, where physician organizations develop models and they were all rejected. And so for many reasons, there was not a lot of APMs to choose from. There are some ACOs that have had some success, the ones that have been able to develop.

And there's an effort to keep that program at least going and make it realistic, so that there's incentive payment and Medicare through that program that expires. And there's a threshold determine if you qualify for that payment system, that Medicare bonus that you can get that. And that's out there because we have to remind people that no one's going to get rid of fee-for-service. That's always going to be there.

And it's a complicated system. And physicians, you want to have many options for our physicians. If you want an alternative panel, that's great. You shouldn't be forced to go into one. If you do go in—if you are part of one, make sure it works for you and your patients. And so within reason, some of the complaints we hear—I hear about from physicians on the MIPS program, for instance, which is the Merit-based Incentive Payment System, which is the fee-for-service part of Medicare where there's some quality value metrics. Some of that can be a little arbitrary.

Sometimes, people at CMS move things around the Excel sheet, in a way that makes sense to them, but not necessarily to you as the physician or your patients. And I would imagine, that doesn't—that drives people crazy. That's not a positive. You just checking a box to check a box or you actually doing something to advance care? That's frustrating, and that happens too. And we mine—

A lot of good intentions, people want to have good value-based care, but we're always very cognizant of, how do you define that? What does it mean? And we've had some bad experiences with HIT when it's designed by CMS in a very rigid way, with penalties associated with it. So we're careful. We all—everyone wants to have good quality care provided to patients.

Dr. Underwood: It is one of those things where the name sounds good, value-based payment. The greater the value, the better the base of your payment. But that's not how it would actually works out, right? So it sounds like it does, but in the interim, and in the process of moving forward, this was built in a way that it—that it doesn't—it adds to the problem and not the solution. So also, came question going on the same lines. You mentioned MACRA. Do we have an outlook on MACRA reform going forward?

Marino: So I'll just—I'll just say that it's good that we have the chairman of the Senate finance committee as committed this year to engaging in MACRA reform. And we've done a good job educating the Energy and Commerce Committee, the Ways and Means Committee. They're very well aware of the problems, and so we hope to build on the hearings we had last year, this year.

We have ideas on how to reform the mix thing I just talked about to make it work better for physicians and patients. And we're going to—we're introducing those to the Hill to take up. We have the budget neutrality reforms out there. Already passed one committee, that's one step. We know we need an update. So we have—it's going to take a slow and steady approach.

One of our biggest obstacle, it comes down to dollars. To pay for a permanent MEI update could cost up to $300 billion over 10 years. That's a big ask. No other group has an ask like that, in a time when the deficit, the debt is $30 plus trillion, and everyone's very conscious of spending. And so that—we have to create the will to find a way to spend that money to fix the system, and that—

And some people, just frankly, want us to go away, or we just hope we just fade away. It's natural because when you give someone a big problem, and you get a little bit overwhelmed, you want to just—that's why it's important, as I mentioned it, to slow and steady. It's not insurmountable. It's just not—it's a lift, but it's a very lift that's doable, and we have a good story and a good case to make.

Dr. Underwood: But also, there's a cost to inadequate health care, lack of access, lack of opportunities and have technology to you can utilize to improve patients' outcome, to improve the quality of care. So although you're saying, well, listen, this investment you're asking for is $300 billion. However, there's a—there's an opportunity on the other side that you're missing by not making that investment. But it's difficult for the way our system is structured, for members of Congress and even for society in general, to be able to see how all these things come together and interact with each other.

Marino: That's an excellent point, because Congress has to follow the congressional budget office. And they just see, OK, if you give an update—Physicians over 10 years, this is what it cost. They cannot—under the rules that they have to follow, they can't say, well, people chose to then get purchased by a hospital or get bigger or go out of business and then there's a new payment system.

And what would you have spent over 10 years if you let this thing wither as it's withering away? And people migrate because they got to do something to survive. They're going to ... and it could be more expensive settings. And then if people aren't getting care up front, what about more ER visits, more chronic care? That's not captured.

We support a bill in Congress that would require CBO to look at downstream effects. If you prevent an illness, prevent an ER visit, you should get savings down the road. That actually is not shocking to people when you realize that doesn't happen. They have these very rigid economist, econometric guidelines that aren't always real world. But when they put a score out, that's the real world members of Congress. They have to follow that.

Dr. Underwood: Right That's right. So- and again, this is one of the questions. And Jordan, answer this if you can in a way that you can. So what they're asking for, are there any representatives who we should advocate to or toward around these issues, specific ones, or are you really saying that what we need to be all hands on deck for all members of Congress?

Marino: I'll jump on first. I think you should be—we should have an all hands on deck approach and here's why. Sometimes, when it gets to the end of the year or when it comes to the big package, and there's only a handful of people in the room, when it gets to the very end game, usually, it's the leadership in the House and Senate and then the committee chairs and rankers. And then they decide.

And once they put something that, we're going to give physicians this much, and they want to just put it aside and negotiate the rest, we need—we need to get the rank and file, people are not in the committees, that have a voice, certificate of election. They may not be on the committee or in leadership, to go and say, well, I'm hearing from my doctor back home. You're giving 1.25, that's not enough. I'm hearing that that's not enough. I don't know what the committee agreement was, but that's not working for me. I'm not in the committee, I just can tell you what I'm hearing back home.

And we need to get some disruption, because a lot of people, they want us to go away. You got you got a partial fix. Now, go away. And it's uncomfortable, but sometimes, you got to make it uncomfortable if you want to get a little more. And we have a great case to make. Remember, all the other groups are fighting for how much of an increase they get, we're fighting just to get to the surface of the water, just to get to zero, to stop a cut. That's the difference, and I have to remind people of that. And that's an important distinction.

And one more thing I remiss, one retiring member that I forgot to say, I don't want the staffer to email me, is Dr. Wenstrup is another champion who's also retiring. And I will say that the physician members of Congress get it. They practice in their lives and they're a great ally.

And so I can't emphasize enough how important it is to keep building the bench. And I know Rob and his team and others are help with that, but how important that is, to have members who understand, not just a lawyer. There's a lot of lawyers. Not saying anything against lawyers, but we do need people that can speak physician.

Jordan: Yeah. I would echo what Jason said in terms of an all hands on deck approach, and in particular, because with the retirements that he's talking about, the landscape is going to start changing after next year, and we all know that this is a long term battle. The folks that you're talking to, perhaps not on key committees now, could be in the future. And regardless, they have influence and yield a great deal of influence, based on the fact that they might have close elections, or a variety of other things. So I wouldn't count anybody out.

Again, I think we've made progress, this year in particular—last year—going back to last year, in particular, with members that this wasn't a big time issue for them. So as many different types of legislators representing all sides of the political spectrum, that we can get this message to take hold with, I think is helpful to our cause.

Dr. Underwood: Excellent. Again, these questions have been awesome. The discussion's been awesome. The answers' been great. So do we have any more questions in the chat?

Marino: Until you do, I have something I could jump in with.

Dr. Underwood: Please. Please.

Marino: I just want to draw on some experience I had when I worked in the Senate, and I was the health advisor for a Senator, a very senior member. And there was always one doctor, no matter what the issue was, I had to call him. And it was Medicare, NIH, anything with health care. I couldn't get a decision from my boss until this one doctor was called. And I was like, why is this one doc have all this say?

And if he ever said, "No, I don't like you." Even though he should vote this way, he would go the other way or not co-sponsor a bill, and he had this outsized power. And I would always ask, how does this one doc? And he was—just some meeting he did 20 years. This was—remember that my boss had been there 40, 50 years.

This is someone that 20 years earlier had gone to some meeting his day, he went to D.C., and did something that impressed the Senator. And then he was sacrosanct. And everything he said was like, that's what you go with. And that's who you want to become. That's who we want to—you want to become that physician who always gets called and takes the call, and offers your opinion, and you don't realize how much sway you have because that's how things move around in Congress.

Dr. Underwood: Correct. I agree. So we're going to begin to wrap this up. But it was a question, and I'm hesitant to ask it, all right? Because I don't know what's way the answer is going to go, but I hope it goes in one direction, right? But I'm just going to throw it out there. What are the realistic chances of successful eliminating or mitigating the cuts?

Marino: I'll go first.

Dr. Underwood: All right.

Marino: I'll just say, to start, when we started the year last year, we were told by the Hill, look, we gave you—in the Appropriations Bill, at the end of 2022, we gave physicians a two-year fix. We provided relief for two years. And so for the early part of the year when we said this cuts come in, we know that there's going to be a new add on code. It's going to—no, you guys already had a fix. We're not—

And in some of the services are being increased because that's a part of the equation, is that when there was a new E&M, E&M services were increased for the add-on code, for the new G code, there are services that were increased. And so they're throwing that back at us. Well, you are getting increases over here, and you can make up for it on using those codes. And we were told, hard no. So to get to move from—to get even anything, to get 1.25 was movement.

So that took a lot, and that didn't come—didn't come through until November. After your webinar, you had two months ago, an E&C, Energy and Commerce and Finance put in 1.25. And so that's real money. That's—so that's over $600, almost $700 million that's in the—that's there. And I think we're in good shape to at least get that partial fix. I don't see that, and I know they have to resolve some bigger unrelated issues. But whenever they do, I think we're well positioned to get at least that 1.25. And that would be a big lift to get that, given all we had to go through.

But I think we can, and should. We can have a chance to get more. There is money out there. It's Congress's job to find the offset to pay for it, but there is more dollars out there to get—take us the whole way. And that's what Dr. Murphy, who's our champion on the on the—on the bill to reverse the whole cut saying, there's—this is a member caucus. He's a freedom caucus member.

He's on Ways and Means, and he's saying, we can do this. There's money there. We got to push for the full cut. We got to go on offense, and not just take 1.25. I know a lot of people in Congress want us just to take that and go away, but we got to push for more and we have a chance. I will—I will say it's going to be a big lift. It's not going to be easy. But it's not going to happen unless you're fully engaged, and all in on it.

Dr. Underwood: Rob, were you trying to jump in there too?

Jordan: Well, I would just say, I've seen grassroots achieve some amazing things, not always good either. But you would be surprised how many political obstacles are removed when a certain lawmaker, all of a sudden, is flooded with constituents from all over telling he or she that they need to fix this. And forget CBO at that point. He's going to the chief of staff saying, hey, we need to get on the right side of this issue.

So for the grassroots, I would just—I would suggest that there is nothing impossible so keep the pressure up. And we'll see what happens and we'll do our best, but I certainly—I certainly would encourage people to remain engaged.

Dr. Underwood: I agree. So let's think about it. As Jason said, when 2023 started, they were saying, "You don't stand a chance. This goes nowhere. This is what's going to happen. Use those E&M codes. If you can't use those to get it, stuck—suck it up. Deal with it." To, wait a minute, we have several bills out there now. I think count four, that's out there now. That is a huge change from, you don't stand a chance, to where we are now, right?

That's like, hey, we've been marching down, marching down, marching down, and we're going to continue to march down. And what we're saying is this, we have to continue to be in this for the long haul together in lockstep. We're not surgeons, we're not primary care, we're not urologists and pediatricians. We're not rural and urban. We're not private practice, employed or academic.

We are physicians, and we have to be in this as one together, in all 50 states, in all specialties, lockstep, to say enough is enough, and too much stinks. And now is the time to fix this once and for all, right? That's what we're saying. We've been doing that and we've made progress. But now, it's the time for us to cross the goal line once and for all.

And I want to say, thank you to our audience for your questions, for your participation, for listening, for our panel with the engaging, wonderful answers, great discussion, for sharing this. We heard a lot today from our experts, and through your questions, we have learned a great deal more about our collective effort to reform our unsustainable Medicare payment system, and how much we have accomplished and what is ahead.

The solution we seek won't be found in any one session. But together, yes, together, in lockstep together, we will keep working together to find them. The AMA will continue its advocacy, and we hope that you do too. Thank you very much for your time and effort, and for joining us today. Have a wonderful rest of the day, and we'll hope to see many of you at the SAS and everyone at the NAC as well. And let's keep the fight and let's keep the fire going. Thank you.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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