AMA Advocacy Insights webinar series: What’s next with Medicare payment reform

Webinar (series)
What’s next with Medicare payment reform
Nov 3, 2023

Payment cuts and temporary fixes have become predictable in Medicare physician payment over the past decade—leaving physician practices and patient access to care at serious risk. We’re working to change that by urging lawmakers to work with the physician community to permanently reform the system. Congress needs to establish a permanent, annual inflationary Medicare physician payment update that keeps up with the cost of practicing medicine and encourages practice innovation. 

Watch this AMA Advocacy Insights webinar to hear about:

  • Where Medicare payment reform stands now
  • How the AMA, alongside state and national medical specialty societies, is pushing for permanent payment reform
  • How you can get involved in these advocacy efforts


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


  • G. Ray Callas, MD, president elect, Texas Medical Association
  • Katie Orrico, senior vice president, Health Policy and Advocacy, American Association of Neurological Surgeons/Congress of Neurological Surgeons
  • Todd Askew, senior vice president, Advocacy, American Medical Association

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Dr. Underwood: It is a pleasure to be with you this afternoon. Thanks to the AMA team for bringing together thought leaders and change makers who will be part of this very important discussion on Medicare payment reform. We've got a lot to cover today. But before I introduce our panel, I'd like to share why this topic is so important to the AMA, to physicians and to the patients that we are privileged to serve.

Physicians everywhere across every state and specialty continue to carry tremendous burdens, obstacles that interfere with our love of this profession, issues that have frustrated us and burnt us out, burdens that are forced on—that are so forcing so many physicians to turn their back on the practice of medicine.

Over the last 20 years, a shrinking Medicare reimbursement rate for physicians have pushed many small independent practices to the brink of financial collapse and jeopardized the care of millions of American seniors. When you adjust for inflation, the payment rates to physicians who care for Medicare patients has dropped 26% since 2001.

I don't know many businesses or any industry that can 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. Meanwhile, I've seen high inflation, rising personnel costs, increased practice costs that does exacerbate these payment cuts.

Considering what my colleagues went through during the pandemic, this kind of financial blow is simply unconscionable. And it requires immediate attention from Congress before even more payment reductions kick in at the end of this year. As we know, this issue doesn't affect physicians alone. The current Medicare payment system has a negative impact on our patients.

When doctors lack the resources, they need to keep their practice open. They close their offices, or they reduce their hours, or they make do with inadequate technology and equipment or fewer support staffs, or they limit the number of new Medicare patients they take, or stop seeing Medicare patients altogether.

We need Congress to pass a bipartisan bill that we introduced to the House of Representatives earlier this year, the Strengthened Medicare for Patients and Providers Act, H.R. 2474, which would do what the AMA has long advocated for—providing physicians with annual payment updates to account for the practice cost inflation as reflected in the Medicare Economic Index.

This would simply put physicians on equal footing as inpatient and outpatient hospitals, skilled nursing facilities and others who receive payment through Medicare. We'll talk about this. We'll talk about that and more today with our panel of experts.

I want to make sure that we have enough time to discuss these important issues and answer questions. So let's get started. I'm honored to introduce our panel of experts and people who I count on for information and knowledge. And let's have a good time, but let's educate you on how to best move forward.

Dr. Ray Callas is an anesthesiologist and president-elect of the Texas Medical Society, who is focused on uniting physicians in one voice around TMA's priority, medical liability reform, battling insurance companies to improve coverage and access to patients, stopping scope of practice expansion and limiting government interference in the practice of medicine. Welcome, Dr. Callas.

Dr. Callas: Thanks, Dr. Underwood. It's a pleasure to be here, and I look forward to talking with you and other colleagues about this topic we need to really focus in on.

Dr. Underwood: Katie Orrico, our senior vice president for health policy and advocacy for the American Association of Neurological Surgeons, Congress of Neurological Surgeons, where she has represented her specialty before Congress and federal agencies since 1985. She is a staff liaison to a number of health care organizations and is noted experts on Medicare reimbursement, quality improvement, medical liability reform and graduate medical education. Welcome, Katie.

Orrico: Thank you so much, Dr. Underwood for having me. It's a real honor to be part of this conversation.

Dr. Underwood: Todd Askew, the senior vice president of the American Medical Association's advocacy, where he oversees the organization's legislative government affairs, political, health policy and private sector advocacy efforts. In his prior role as director of congressional affairs, Todd managed the AMA's congressional lobbyists, developing and implementing strategies to advance organized medicine priorities before Congress. Welcome, Todd.

Askew: Thanks for hosting us, Dr. Underwood.

Dr. Underwood: So let's get down to business. I'd like to thank each of you for joining us today. I'd like to begin with the first question to you, Todd.

I briefly touched on this in my opening remarks. But Todd, can you give us some more details about the current slate of Medicare payments—current state of Medicare payment. Missaid that. The current state of Medicare payment. What are the issues with the current system and how do we—and how do we get there?

Askew: Sure. Thanks again, Dr. Underwood. As you probably heard last night or late yesterday afternoon, CMS released the payment rule for 2024, which calls for a 3.34% across the board cut to the Medicare conversion factor and a similar cut for anesthesia services. All of this is a result of the flawed Medicare payment formula known as MIPS, which came to us under the MACRA law that passed several years ago.

Now, the current system replaced the SGR, the sustainable growth rate. And at the end of the SGR, it was scheduled to produce cuts in excess of 20%. So MIPS was an improvement initially, but we are beginning to go back into this cycle where we were with the SGR, where each year medicine has to fight just to keep cuts from going into effect or to limit the size of cuts rather than making substantial improvements.

What the MACRA law gave us was this cobbled together set of legacy programs, MIPS with the promise of new physician, driven alternative payment models and a statutory payment freeze followed by very limited updates in the out years. But what's really come about is the fact that the MIPS program has really failed to produce any significant increases in quality while at the same time producing significant increases in administrative burden and practice costs.

And the promises of physician-driven alternative payment models has for many physicians gone unfulfilled. Combine that with the statutory freeze, combining the statutory freeze with budget neutrality adjustments, which are required elsewhere in statute has resulted in across the board cuts to physicians.

Now, most other payment systems in Medicare also have budget neutrality cuts to offset changes they make. But all of those other types of health care providers—hospitals and nursing homes, home health, they receive automatic inflationary-based updates every year to keep up with the cost of inflation. So the burden of budget neutrality adjustments doesn't tend to have as much impact.

Physicians are the only ones providing care under the Medicare program that don't have annual adjustments that help us keep pace with inflation. And that's our goal, as Dr. Underwood mentioned in his opening. So where we are right now is we have a broken quality reporting system. We have no way to keep up with inflation, and we are facing years of cuts that erode the value of Medicare payments because of that high inflation.

That's where we find ourselves, and that is what our challenge is to work with Congress and the administration to put ourselves on a better path.

Dr. Underwood: And that's a huge challenge. But this is a mountain that we have to climb, and we have to climb it together. And on that note, Katie, your association, the neurologic surgeons have done a lot of work with the AMA on this issue. How is organized medicine working in Washington, D.C., to develop and promote payment reform?

Orrico: Well, thank you for that question, Dr. Underwood. As you noted, we've been working—we've been at this a long time one way or another. And we did think in 2015 when Congress passed MACRA that we were on the right path and that was the reform, as Todd mentioned, that was going to really drive medicine forward, improve value and help physicians really be positioned to deliver high quality care to their patients.

That's unfortunately not what's happened in part because there have been challenges implementing the quality payment program and some of the MACRA reforms at the agency level. But also as Todd mentioned, there are some still basic fundamental challenges with the broken formula. We don't get that update, the budget neutrality where you have to rob Peter to pay Paul to stay within a fixed budget any time CMS wants to make any changes to the Medicare physician fee schedule.

So we have gotten together under the auspices of the AMA, who's convened multiple work groups. And we've been at this for a number of years. We have various work groups looking at ways to improve the alternative payment model program, ways to improve the Merit-based Incentive Program or MIPS, ways to improve the overarching structure of the fee schedule, including budget neutrality and the inflationary update.

And bringing all that together through the convening of that AMA-led work group, medicine came up with a basic set of principles that we released last year that were signed off by all the specialties and all the state medical associations. And those principles have three basic pillars to them in our efforts to seek reform.

First is to get an annual inflationary update based on the Medicare Economic Index, which is a measure of physician practice costs just like all those other providers in Medicare have. Second is to get some changes to that Medicare budget neutrality formula so that we can exempt more services from budget neutrality or modernize it in a way that will help lead to predictable reimbursement, so we don't have these wild swings or these unanticipated cuts from year to year that require us to go up to Capitol Hill and try and stop.

And then the third pillar is getting at the Quality Payment Program and making some changes there. And so through that collaborative work, we've taken those principles and now we're converting those into legislative proposals. As you alluded to, Dr. Underwood, at your opening statement, we've been successful in getting one piece of legislation already introduced, H.R. 2474, which would provide physicians with an annual payment update based on the Medicare economic index.

Just a few weeks ago, some members of the leaders of the House doc caucus, the doctor's caucus issued a discussion draft bill that addresses elements of the budget neutrality piece. So we're working through that right now, and we're waiting for some technical assistance from CMS and some other input to make sure that that bill is in good shape for introduction as well. And the workgroup is still working on some legislative proposals for the MIPS and APM systems so that that'll be our third piece of legislation that we put forward.

So taken together, we hope to move those principles into action through those legislative vehicles. And we were collaborating beyond the workgroup by doing joint lobbying visits on Capitol Hill, sharing grassroots messages and the like. So I think this is an exciting time for medicine in that we're united.

We're really trying to do the best to represent physicians, and to make a difference and get these proposals across the finish line so we can actually once and for all hopefully stabilize the fee schedule and get certainty into Medicare. So our doctors don't have to quit private practice and go join hospital employment and things of that nature.

Dr. Underwood: Right. Thank you. Now, we know that this fight is not just in D.C., right, that the battlegrounds are 50 states in the United States. They're in every specialty organization that you've laid out for us, Katie, so eloquently. So Dr. Callas, how has the Texas Medical Association been working to reform Medicare payments?

Dr. Callas: As you know, Dr. Underwood, Texas is not shy when it comes to advocacy. We're also very actively—we meet with our congressional leaders in Washington, D.C., and at home. I personally know all my U.S. senators are too, and many, many U.S. representatives and many senators throughout the United States and throughout the representatives.

But whenever I host these guys, these women and men in my home, it's always important that I educate them about Medicare payment. And the reason why I educate them about Medicare payment is because we are the only business in the last 20 years that continue to get cut after cut after cut after cut and we try to keep our offices open.

I don't know about any other business. If you decide to open a business and lose 28% every year and a plethora of your patients are Medicare, good luck to you, my friend. We at TMA, we forcibly, actively educate our members in the sense that we forcibly give them as much knowledge as they want. Let them drink through a fire hose.

But we let them know about Medicare, and we let them know that the fight is not just for private practice. The fight is for academic physicians, PE physicians, hospital-based physicians. You name the physician, everything's tied to Medicare.

Also too, our recent action that I sent out an alert recently, we had more than 800 responses, the most we've ever had. Almost up there with medical liability reform and also up there with scope of practice. We just had another tremendous year not allowing scope creep at all in the great state of Texas.

We also take time to impress on our members the importance of advocacy. It's time for you to step into the game. I will tell you, as a Gulf War veteran, if I didn't have my men and women that worked beside me working together as a team, we wouldn't have been successful to make sure we came home safe and to make a difference in this world.

Hey, look, I'm just going to tell you, our patients need our voice. Our patients need our advocating for them. And more importantly, if we don't do it, who will? So Dr. Underwood, I just want to let you know that I hope to God that everybody on this call listens.

It's not about us. It's not about you. It's about we. And we have to work together to solve this issue that is totally hurting our elderly patients, and people deserve to have Medicare because they worked hard in this country to make it to what our country it is today.

Dr. Underwood: Without question. Without question. So look, I know people are asking this, and they're beginning to wonder this. OK, so what are our goals for Medicare payment reform in the short term and then looking down the road to the longer term for more permanent fixes? So I'm going to run this through all three of you. But we're going to start with Katie.

Orrico: Sure. Thank you. Well, I think in the short term, we're staring down another pay cut. And there's no way around that fact. And so I think just as the saying, let's first do no harm, I think one of the things we are trying to impress upon and we're going to be working in the coming weeks to impress upon Congress is that first step is to prevent this cut and even think about giving us something that reflects inflation in some way.

So that buys us some more time to continue to work on this legislation that I alluded to earlier. And unfortunately, we keep getting in the same cycle every year. And as we're trying to move towards longer term reforms, every year we're faced with, again, another cut so we have to pivot and deal with that. And this year is, unfortunately, no different than the past few years have been.

So we're going to be working hard in the coming weeks to try and turn that cut into, hopefully, a positive number but at the very least, not a negative number. In the long term, we're going to continue working on those bills that I spoke of earlier. I think, again, our goal is to take those principles that medicine has come around and get legislation enacted and signed into law so that it will stabilize the system.

And I think Dr. Callas, you're correct that it's not just about private practice. It's about academic. It's about all of our physician members. But we are facing challenges as everyone tuning in knows about physicians shuttering their private practices, either going into employment with hospitals or even with private equity and other things because they cannot possibly keep their doors open with negative payment rates every single year.

And that actually is problematic because it's driving up overall health care costs with consolidation happening and the like. And so it's really in the best interests of the country to have a plurality of physician practices out there to keep costs down and to really broaden access as best we can. And the way we think we can do that is with these long term solutions to the physician fee schedule.

Dr. Underwood: Dr. Callas, anything you'd like to add to that?

Dr. Callas: Yeah, I agree with Katie. As a private practice physician that has been—a matter of fact, our practice is the oldest medical practice in the state. I'm an anesthesiologist, but I will tell you where the rubber's meeting the road right now is that if you want to do what got me involved in AMA and TMA was it was member-driven. And most of the time whenever we first started, we can all be honest here on this call, we were mostly independent practicing physicians or hanging the shingle on ourselves.

Now we're at the crossroads. I still feel that this is to maintain the practice of medicine because everything as we move forward physicians lead health care the best. And if we don't give them a platform to continue to provide for our elderly, which is payments sustainability and increased on cost of living and wages that we as practicing physicians are spending every year higher and higher and higher, where the revenue is now going this way, our cost of operating is going this way, it is not sustainable, Dr. Underwood. So I feel very strongly that members, please, let's get this done and let's work together.

Dr. Underwood: Todd, like to add anything to that?

Askew: No, I think Dr. Callas and Katie are exactly right. I think our long term goal here has to be to make sure we have a Medicare physician payment system that allows doctors like Dr. Callas, like you, Dr. Underwood to practice in the way that you feel is best for your patient. Maybe that is a large group, maybe that's a small practice, maybe that's a multi-specialty.

What is best for your patient should be the way you're practicing medicine. And you should not be forced financially to make compromises or to provide care in a way that you don't feel is best. And so that's number one for me.

Selfishly, and for all of us are involved in health care advocacy beyond just this issue. I would like to spend some time talking about other ways we can improve the health care system in this country instead of every year having to scramble to try and prevent more practices' doors being shuttered, more Medicare payment cuts, more burden being heaped on physicians.

If we can get out of this cycle and build a stable payment system, then we can get on to the business about making other improvements to the health care that's provided in this country.

Dr. Underwood: Yes, you raise excellent points, all three of you. So the issue is short term; long term, we have to create a system that's sustainable, a system that improves health care outcomes and decrease costs. And in order to do that, Medicare payment reform is necessary so that we can stabilize the practice of medicine payment-wise and we can focus on improving health outcomes, improving quality and decreasing costs, and improving the lives and the health care and the health of our citizens, awesome.

Man, I'm excited to be a part of this conversation. That's why I keep throwing in words in there so I can be real with you guys. It's not just that you're my friends and colleagues, but this conversation is extremely important. So I'm going to keep moving forward.

So Todd, I'm coming to you, all right? So the House of Delegates is convening soon at the Interim Meeting in National Harbor, Maryland starting November 10. And we will use this opportunity to highlight the needs for Medicare payment reform, particularly since we'll be in close proximity to Congress. The Interim Meeting is one of the key policy-making meetings of the AMA—that the AMA holds.

In addition to the AMA Annual Meeting in June, where representatives, delegates from the state and national medical specialty societies gathered to shape and create AMA policy, so what are some of the activities happening at the meeting surrounding Medicare reform?

Askew: So first of all, I think it's important to remember that this meeting, the meeting of the House of Delegates is the only time it happens twice a year where the whole federation, the whole family of medicine comes together in one place and has the opportunity to speak with one voice to our policy makers and to show the unity and the urgency that we put behind this issue.

And we need to keep that front and center is that we need to show—we need to show our leaders in government that the leaders of medicine are unified in the need to get this done. Now, during the meeting there's going to be a lot of opportunities for folks to engage in that activity. One of them is going to be with our enhanced grassroots booth. And I encourage all of you who are attending the meeting to come by.

There'll be information and new opportunities, new exciting ways to engage with your members of Congress and their staff virtually. But if you're staying, I know some people are staying an extra day or an extra afternoon after the House concludes, to go up to Capitol Hill. And we provide resources and information to help you take that message directly to your members of Congress while you're here in the Washington area.

Now, also importantly, on Sunday afternoon we're going to have a briefing. Dr. Underwood, you're part of this, Dr. Ehrenfeld and our grassroots experts as well. And we're going to showcase for you and talk to you about the latest developments on Capitol Hill. We can answer questions about the legislation. We're going to show you some of the resources that the AMA has made available.

So that'll be Sunday afternoon. There's no conflicts. It's an educational session. It'll be open to all the meeting—all those that are attending. But even if you're listening to the webinar today and you're not attending the meeting in person, there are plenty of opportunities to engage in this process. It's the physician voice, as Dr. Callas said earlier, is going to get this done.

And so you can find those resources and tools to engage at So far this year we've had over almost 230,000 direct contacts to Capitol Hill on this issue. It is making a difference.

I know many of your—many of the states and specialties also have resources available. I would just encourage you to contact them every day. Every chance you get, make sure your voice is heard. Encourage your colleagues to make their voice heard, and we're going to provide you the tools and the resources to do that.

Dr. Underwood: Yes, we're 1.1 million strong, right? We're 1.2 million strong. So why don't we come together and let's make this happen, right? There is no reason for us to be dealing with this.

So Todd, I'm going to come back to you again. OK, what have we—so what have you been hearing from members of Congress? Do they recognize that this—do they recognize that this is an issue, that there are differing views on how to fix it or the challenges right now and more getting the attention of the lawmakers?

Askew: Well, there's a lot going on. Let's say there's a lot going on right now. We're in very contentious times. There's a lot of acrimony. But I will tell you a year ago, over a year ago, when we started in earnest pressing this issue on Capitol Hill with specific policies, there was very little interest. Most of the policymakers didn't think it was very urgent. They didn't really put it high on the priority list.

And you can understand. It's a heavy lift. It's expensive. It's complicated. Most of the people and their staffs on the Hill have never worked really on the payment formula that much. And it is very complicated.

But I will tell you, and I bet Katie and Dr. Callas can echo this too, the more you talk to people now, they know there's a recognition. There is an acceptance even by those who don't want to do it. There is an acceptance that sooner or later, and that is sooner rather than later, Congress is going to have to step up to the plate and take on this issue because it is clear that it is not sustainable.

Even MedPAC, the Congressional Advisory Committee that advises Congress on Medicare, which has previously said all is well, access is good, people are still taking Medicare, even they have said, but we don't think this is sustainable. And we do need to start giving inflationary-based updates to physicians.

And so I think we have in our collective work together changed the conversation, changed the sense of urgency. And I think that is the kind of momentum we need just to continue to build on as the federation.

Dr. Underwood: So how can physicians get involved? Dr. Callas, we'll start with you and then move to Katie and then Todd.

Dr. Callas: Thanks, Dr. Underwood. Well, first thing physicians need to do is to make sure that they know their legislator. And I'm not talking about just know them by name. I'm talking about know them and getting in contact with them and make sure that you put your information in front of them, and let them know that not only are you a physician, but you're also an American that takes care of a lot of Americans.

And that I would give them your phone number, your email. I'd contact them any way I possibly could. You've got to get involved

We can no longer sit in our offices and just hope things are going to get better, because I'm telling you they will not. I will tell you, we have the power. We have the influence to make a difference, but we have to take action. Action is nothing more if you don't use the words behind it.

Just like when we were educating our kids, we wouldn't tell them you have to use your words. Let's use our words and let's talk to legislators. Both the AMA and TMA, and the medical resource centers that we have gives you everything a physician needs in order to make you successful to be a strong voice for our profession and for the patients that we deserve to take care of.

And for this, physician—excuse me, physicians need to use every resource they possibly can to get involved, get involved, get involved. And also guess what, guess who your biggest involvement should be. Educate your patients.

Every single patient deserves to make that phone call to a legislator because guess what, not only do you touch the lives of one, you touch the lives of many. And guess what, if you tell your patient, hey, Ms. Smith, I might not be able to take care of you anymore and local little small community of Texas, or in Massachusetts, or in California. It doesn't matter because I can't afford to stay open.

That shocks in all patients because of that commitment that you've given them throughout their whole life. And now you're going to abandon them because the government's abandoning them. I think it's totally wrong.

Let's use our allies and our assets. If we're going to win this war, let's use our patience as well. Educating our patients and getting them to talk for us is powerful than you will ever think. We use it all the time in the great state of Texas, and I highly recommend with Todd's leadership and Dr. Underwood and Katie. I think you going up to the Hill and being the physician discussing this is a lot louder than if Todd's doing it or if Katie's doing it because guess what, we live and breathe, and we take care of a lot of Americans as a group.

And you know what, I'm going to tell you what I tell people in the state of Texas. I'm tired of you saying somebody else will take care of it. You need to take care of it. You need to be responsible for this, because guess what, we all took the same oath. And guess what, we all take care of the same patients.

So I'm committing my state, I'm committing myself that we'll continue to do that. I want everybody else on this call to do the same thing. It's now time to put up or shut up, and let's lead. Physicians need to lead.

Dr. Underwood: Put up or shut up, baby. Put up or shut up. Katie, what do you think?

Orrico: Well, it's hard to—that's a tough act to follow, very evangelical. But I agree. Look, the fact of the matter is physicians as a profession are really highly regarded at the top of the polls in terms of their opinion being valued by the public and by policy makers in Washington, D.C., and in the state capitals. So you already got that going for you.

Now you just have to do what Dr. Callas said. You have to act on that. You need to take advantage of that. You want those members of Congress to have your cell phone number and be calling you. You've got to build those relationships.

The minimum physicians can do is when they get a grassroots alert from the AMA or one of their state or medical specialty societies. We make it so easy for you. All you generally have to do is put your name in and click Send. We've got draft letters that are already ready for you. So that's the minimum you can do.

You need to meet with them. And coming to D.C. is fine every year at an annual fly-in or something like the National Advocacy Conference. But you really need to meet them at home where they live. All politics is indeed local. So getting to know them back at the district and in your state and showing up more than just once a year.

There are other ways. You can participate in a town hall meetings and raise these issues in those forums. And that actually is helpful because it gets the other constituents who aren't physicians to be party to that conversation, involving your patients, like you said, Dr. Callas.

I don't know if we'll get into this a little bit, but there's a lot—writing an op-ed, making yourself present on social media. All of these things are steps that physicians and their patients hopefully can take to raise awareness. It was remarkable when we got the SGR passed, repeal passed that we were talking in acronyms, SGR this, SGR that.

Nobody knew what we were talking about early on. But with sustained ongoing year after year, day after day advocacy and the voice of physicians being heard on Capitol Hill and beyond that. I could watch a cable news show and I heard SGR mentioned. Someone in a grocery store met their member of Congress, and he said, oh, I'm getting that SGR fixed.

We need to get the same level of awareness, and that will help us get across the finish line because that's what happened the last time we had to go through this with the SGR repeal. And I know we can do it, but it's going to take all the physicians working together, driving the same messages home and engaging at every level that they can with their physicians.

Now, one final note, I realize this a policy discussion to a certain extent. But I think it's also important for physicians to get more involved in the political process. And you need to be attending fundraisers, contributing to your members of Congress, creating those opportunities to engage in the conversation and demonstrating your activity as an advocate for your practice and your patients.

And that is another essential component. So giving to AMPAC, giving to your state PAC, giving to your national PAC, giving to the candidates that are running for office and lawmakers is another important piece of this puzzle.

Dr. Underwood: Todd.

Askew: No, I think that's exactly right. I don't have nothing to add to that. That's two very comprehensive answers.

Dr. Underwood: I agree. Well said. Katie, why is it important for physicians across the specialties and states to be involved in these efforts? And you may have already answered this, but I'm going to hit you with it again, let you go a little in depth there. How do physicians voice influence efficacy efforts in organized medicine?

Orrico: Well, yeah, I think we've generally covered that question to a certain extent, Dr. Underwood. But I think that it goes without saying, and I know people like to say this, if you're not at the table, you're on the menu. There are a lot of different ways to express apathy and the effects of apathy, the effects of not being there.

But look, we are one industry that is up on Capitol Hill clamoring for relief, including money from a fixed pot that's available for these kinds of initiatives. And so it is absolutely essential that Congress hear from physicians. Otherwise, they don't hear much from us, they'll say, well, I guess they're not really hurting that much or we'll just reallocate those available funds maybe to the hospitals, or to the manage care companies, or pharma, or some other place.

And so we need to be there so we're heard and we're taking seriously. And so I think it's absolutely essential again for physicians to get involved with their state and national specialty societies, respond to grassroots alerts, keep up on what's happening, participating and watching webinars like this so you're informed. And that amount of effort, when multiplied by the 1.2 million or whatever you said, Dr. Underwood the number is now, will speak volumes and it will be heard.

And think that, look, participating in the AMA House of Delegates process and your own state and specialty policy-making processes is a way to get involved more broadly. But we really need a grassroots push from physicians across the country to really get this across the finish line.

Dr. Underwood: Well, I'm going to—I'm going to summarize this in the words of Dr. Callas. We got to put up or shut up. And it's time for us to put up, right? Because they've been telling us to shut up. So let's come together. Let's make it happen. Let's get this going.

So look, this has been great, but we got our participants, over 500, who would like to answer questions of this esteemed panel. So now is the time when you, our virtual audience, will have the chance to have your questions answered. Our AMA team will help us with the response to your questions. So if you've got questions for our panel, if you haven't already, please add questions to the chat and we'll get started now.

Now, we already had some questions added to the chat during this conversation, which is good. That means that people are engaged, they're listening, they're excited. So here's a question. I'm going to go with this one.

I believe Medicare payment reform will require a coalition of efforts, including the AMA, state medical specialties, national specialty society and county medical societies to engage non-AMA physicians and their patients. Is this being considered as part of the advocacy strategic plan? Whoever.

Askew: Let me start with that. Obviously, our advocacy and grassroots or efforts are open to all physicians., that is available to everybody who wants their voice to be heard in this conversation. In terms of working with the states and the specialties, yes, 100%. We do that every day.

Katie Orrico's office is just literally 50 yards from where I am. And she is engaged in our work all the time along with all the representatives of the states and specialties. We come together on quarterly calls. We also have letters and communications to the Hill because the strength that the AMA brings to this is the collective strength of all of medicine, not just AMA but the College of Neurological Surgeons, is the Texas Medical Association. It is everybody's voices coming together.

And when we send our communication, we come up with our consensus statements. When we come up with legislation that we can all get back together, they know they're not just talking to the AMA. They're talking to a broad coalition of physician organizations who are all united with that same goal of producing and enacting a more sustainable payment system. It is never going to be just one organization that gets this done. It's going to be all of us working together.

Orrico: If I can jump in just real quick on that too just to amplify that, there are a lot of issues that can divide us. And even within this issue, there are a few little side issues that tend to divide us. And that's because of that budget neutrality problem.

But aside from that, I think when we are working all on the same song sheet and we're pushing together, we really are able to accomplish things. It doesn't all mean under the auspices of the AMA or another group. We can all be talking and using and leveraging our unique position within our specialty or within our state to punch through.

So for example, for the past three years, the surgeons got together and we formed something called the Surgical Care Coalition. It wasn't to do something that—it was in furtherance of the same messaging that everybody was speaking to at the time about how we needed to reform Medicare, et cetera. But we had our own unique context for that conversation.

So I think there are those opportunities for the specialty states county medical associations as well to band together with what may be their unique perspective on the same issue but driving the same message of reform home. And I think that's where our collaboration across the federation has really been quite spectacular because we've been able to really zero in on those messages that resonate with all of our physicians and our physician organizations in service of the goal.

Dr. Underwood: Well said. You know, I'm listening to this and I'm saying, listen, there isn't a physician practice, right? Whether you're in private practice, large group, independent practice, employee physician and academics, non-academic settings, venture capitalists that isn't impacted by this.

And I think Dr. Callas said this. Katie backed it up and Todd added to this as well. So we're all impacted whether you're a member of the AMA or not, a member of your state specialty society or not. And if you're not, then you should be. Join in. Let's get it. Let's deal with this together because it impacts all of us, right?

So having said that, as physicians workforce continue to be stressed on increased practice expenses, and your reduction in clean claims rate and reduced employee retention rates, how can independent or small practitioner groups survive without a predictable reimbursement?

Dr. Callas: I'd like to take that first and foremost. In my hand, which you probably can tell, like I said before, Dr. Underwood, I'm a private practice physician working many hours taking care of Southeast Texas. And Texas medicine is based on a lot of independent practices and small group practices. But I'm talking to America.

I will tell you that the biggest two words that this whole problem that we're facing is practice viability. If we do not correct this, practice viability is threatened with the big noose around our neck. Reason why this is important, every morning when I wake up, I look at this piece of paper. And everybody's probably wondering, what's this piece of paper?

It's from a colleague of mine that has been taking care of Texas Medicare patients for 25 years. She closed her doors this past year due to the fact that she could not afford to keep her clinic open. When I'm telling you I get emotional even reading this, because it's like reading a letter from your grandmother who tells you how they wish they had more money to give to their grandkids so their grandkids could buy a cute outfit for a party or for an event for the holidays.

But my problem is that who's talking for the Medicare patients if it's not us? So being independent, it comes with a lot of responsibility. But the one responsibility physicians shouldn't have to deal with is payment responsibility when we're dealt with a hand that is completely a losing hand.

And I just challenge everyone to go back home and talk to your colleagues. I'll tell you right now, I agree with what Todd said, and what Katie said, what Dr. Underwood said. I have many physicians in the state of Texas that aren't TMA members, Texas Medicine members. I know a lot of my friends that aren't even AMA members.

But the one thing we all are members of, we're a member of the physician community. And our physician community should be based on taking care of all patients, all patients. But if you can't do that to have practice viability and sustainability, we're hurting Americans. And the reason why we're hurting Americans is because the government doesn't want to make it right to make your burden less.

Because I agree with what Todd said and it's echoing to me right now. If we didn't have to worry about this stuff that we're dealing with related to payment, we can move on to bigger and better things and make America a better, safer place based on morbidity and mortality too instead of us having to fight this every freaking day in order for us to maintain practice viability. So I'll be quiet, Dr. Underwood, but it is what it is. Like I said, I want to encourage all physicians to come together, and let's be one voice and talk about this. It's very vital.

Dr. Underwood: Next question. But you're absolutely right. I think that comment, boom, like many of the comments hit a home run. And hopefully, it resonates with everyone out there. So on the chat again, so this is not a new problem. We haven't been successful in obtaining increases with our strategies to date.

We have explored other avenues—have we explored other avenues to advocacy? In other words, what are we planning differently with this advocacy attempt?

Askew: Well, I don't agree entirely with the premise that we have not been successful. We were successful in enacting MACRA and MIPS. That was a $140 billion invested in the Medicare physician payment system after a lot of work by a lot of folks.

It was implemented in a way that was a complete failure. It was implemented in a way that did not present the opportunities that were promised for physicians to take advantage of new ways to deliver care and to benefit financially from healthier patients mean healthier bottom line. And so that was unfortunate, and we are where we are.

I would say most physicians don't even realize that in 2021 Medicare had scheduled a 10% cut, 10% budget neutrality adjustment. And Madison came together and stopped that cut. And what we're seeing today is just the cuts we've seen in the last two years, is Congress taking back a little bit of the bonus money that they gave each time to put us back where we would have been three years ago.

And that's a heavy lift. But that is what distracts us, having to fight this fight every year, this end of the year—stop this 3% cut, stop this 4% cut instead of focusing on the big payment reform. What it took to be successful last time was when they came up with a fix for a 20% Medicare cut from SGR. We said no.

We said, you know what will happen if you implement these cuts. But we're not going to validate this process anymore. And Congress was forced to come up with a solution.

And it may be that's what it takes this time. So the main thing is for us to maintain unity. We have a good plan. We have strong support. We have some champions on Capitol Hill. The strongest champions we have on Capitol Hill, Dr. Callas understand this, are those that have provided care to patients.

Democrats and Republicans, the physicians on Capitol Hill get it. And when their colleagues on the Hill go and ask, is this really an issue, they're answering absolutely it is. And we got the solution. And so I think we just need to maintain unity and keep fighting.

I know it doesn't feel like—it doesn't feel really good when hey, guess what, you only got a 2% cut last year instead of a 4% cut. That is not sustainable. And we understand that 100%. But we just need to keep unified, keep pressing on. We know where we need to be. We know what the goal line is. We know what the solution is. And so I think we're on the right track.

Dr. Underwood: Right. So along those lines, so will the AMA be doing a public information campaign on behalf of physicians to notify patients that unless the pay cuts are reversed, they can expect further decreases in the level of quality of services they will receive?

Askew: Well, I think Dr. Callas alluded to that as a one important thing to do is to talk to your patients about these challenges. Talk to your patients about what these cuts and what this payment system is doing to the Medicare program and your ability to continue to participate in the Medicare program.

The resources are there for physicians to use. We are pushing those out. The number one thing—we've polled this. We're not just making this up. We've asked seniors through extensive research, what's the most important thing? It's not well, my doctor needs to get paid more. It is stability in the program.

And their physicians are the ones that can tell them that this annual fight, this annual threat, this long term challenge to the fiscal viability of physician practices is what puts the stability of the Medicare program at risk. And Dr. Callas almost said the exact words we heard from patients when they were polled. They're saying, I worked for this my whole life. I've worked for this access to care. And I deserve to continue to have it. And so all physicians need to work to make sure that patients understand that that is what is at risk here.

Dr. Callas: Dr. Underwood, I'd agree with Todd. I just want to put one thing out there that I encourage all the other states and specialty societies to do. At our last meeting with the Board of Trustees, we came out with push cards, not push cards for physicians, but push cards about fixing Medicare to the physicians' offices that we are distributing and letting them put in their offices.

I think we've been very successful with that related to scope of practice. And I think that we're going to be very successful getting our patients calling our legislators and letting them know. It's a simple card. You want to make it very easy to read, self-explanation, very simple and we give them a phone number on the back.

It's very simple. And I think that I would encourage us to look at some avenues like that, where you hit home. And home is aware of the physician lives where they're taking care of these Medicare patients.

Orrico: If I could just add because I know that in terms of, are we doing anything different or what are some of the things we're doing, just to amplify a little bit what Todd said. Your professional advocates like Todd and I can go up and even on the grassroots level. You can contact your Congressman and have those relationships.

But unless you have the secret member of Congress handshake, you're not in the room and you're not the one that really controls the power. And so we are fortunate, we're beyond fortunate. And when you start looking at some of our signature pieces of legislation that we're working on in medicine, there's one common theme. And that is the members of Congress who are now elected officials in Congress are our biggest champions on the inside.

And so it's Dr. Bucshon, a former cardiothoracic surgeon from Indiana, Dr. Ruiz, an emergency physician from California, Dr. Burgess, a former OB-GYN from Texas. And the list goes on. And they have been consistently our partners in these and other issues like prior auth. I know that's not the topic of today's conversation, but it's really important.

And that's part of our strategy is to really engage with those physician members of Congress who can tell those stories and convey the messages behind closed doors where we do not have access. And so that is something that we have really been leaning into as a community to leverage those relationships and to help empower those individuals to help fix these problems.

Dr. Underwood: These are some very, very important points. And we're now coming down to what may be the last question. Also, Medicare Advantage program are not paying bills and are requiring prior—I guess must be authorization and still not paying in Southern California. And so hospitals and practices are no longer going to take these programs, which leaves patients at risk. How can we address this?

Orrico: Is it OK if I jump in?

Dr. Underwood: Please.

Orrico: OK, so now for the first time this year, Medicare Advantage plans took care of or had more Medicare enrollees than traditional Medicare. So Medicare Advantage is here. It's not likely to go away.

I think the good news is the spotlight is on Medicare Advantage right now. Congress, in fact, MedPAC today on its agenda had a couple hours of looking at Medicare Advantage in terms of how they get paid, because Medicare Advantage got a pretty steep increase this year, and they're getting another one next year.

What they're doing to delay and deny care through prior authorization, which is really harming patients and jeopardizing good patient outcomes. So the good news is it's not going unlost on Congress. Several leaders in Congress—Chairman Wyden and the Senate Finance Committee and others as well as our physician leaders who are leading the charge on prior auth reform are aware that these are problems.

And so I think we have to walk and chew gum at the same time. And so we are monitoring all of this. We're working with Congress and the regulators to try and hold Medicare Advantage plans accountable. And so I think another bipartisan issue is to really look to make sure that MA is serving the needs of all these seniors.

And so it's to be continued, but it is something that, again, that the physician community writ large, including the AMA state and specialty societies are collaborating on.

Askew: Just to add what Katie said, I think what we're seeing over the last year or two, and in fact, this year where we're actually seeing some hospitals and some large physician groups walking away from MA plans because of some of these problems. Anybody who had it in the back of their mind that MA—because everybody was just going to join an MA plan that we could just let fee for service wither away and not have to worry about what we're talking about today should take this as notice that it is not the—it's an important part of Medicare program.

As Katie said, half of seniors are enrolled. It is not going to replace the fee for service system and the stability that is needed for small physician practices to choose not to—choose to practice that way. It is important, but it is not a replacement for having to deal with the problems that we're talking about today.

Dr. Underwood: And it sounds like you may be creating other problems or risks of creating other problems. But step by step we stand together and we'll address these issues. Look, this has been great. We're now coming to a close, so I'm going to wrap this up.

But I'd like to thank you to our audience for your questions. Thank you to our panel for sharing solutions. We have heard a lot today from our experts. And through our questions, we have learned a great deal more about our collective efforts to reform our unsustainable Medicare payment system.

How much we've accomplished and what is ahead? Medicare payment reform has been central to our federal advocacy this year and will be a major focus at the upcoming AMA Interim Meeting House of Delegates in the Washington, D.C., area later this month, November 10. We hope some of you will be there.

The solutions we seek won't be found in any one session. But together we'll keep working together to find them. The AMA will continue its advocacy, and we hope you will too. We need you to stand with us, to stand strong with us. Remember, we are 1.2 million physicians strong. And together we can not only solve this problem, but we can solve all the problems that face our health care system.

Thank you very much for joining us today and thank you for your time. And we look forward to seeing you in D.C. Let's make this happen together. Peace.

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

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