AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.


In today’s episode of Moving Medicine, a discussion with Todd Askew, the AMA’s senior vice president of advocacy in Washington, D.C., about the AMA’s latest advocacy efforts. Topics include details from the Build Back Better Act that impact physicians and preventing Medicare payment cuts at the end of the year.

Speaker

  • Todd Askew, senior vice president, advocacy, AMA

Moving Medicine video series

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.


Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're joined by Todd Askew, the AMA's senior vice president of advocacy in Washington, D.C., will give us an update on the AMA's latest advocacy efforts and there are a lot. I'm Todd Unger, AMA's chief experience officer in Chicago. Todd, the House of Representatives is currently taking steps to advance a three and a half trillion dollar social spending and tax package known as the Build Back Better Act. Why don't you start by just kind of describing what's in it? And then we'll talk a little bit more about what's in it for physicians.

Askew: Sure. Todd, so you're right, the House is ... They're trying to consider it, it's really a struggle right now to try and find the path forward. The Build Back Better Act, it's kind of a mouthful is being considered under what we call reconciliation rules. And that allows the Democratic leadership in the House and Senate to avoid a filibuster in the Senate, which means you only need Democratic votes to pass it. Unfortunately, that means you need basically all the Democratic votes because the margins are pretty tight. You can only lose three votes in the House and you can't lose a single vote in the Senate. And so that means any disagreement within the Democratic caucus scraps the bill and they have to come to some sort of agreement.

And so there are plenty of disagreements on the current makeup of the bill. Moderates in the House, especially have insisted that before they passed the social spending part, the three and a half trillion dollar bill that the House passed. The Senate already passed infrastructure package, which was their initial priority, the progressives in the House say, "Well, if we pass that, then the moderates have no reason to go along with us on the social spending package," which is a valid point that's part of the problem they're having right now this week and trying to schedule a vote.

The progressives would like to see the Senate pass the social bill. So they're guaranteed that they would have something to vote on but the Senate hasn't even come up with an agreement on what their package would look like other than the broad outlines. And so they really find themselves in sort of a stalemate. We don't what the Senate bill's going to look like at the end of the day. And therefore the progressives are not really that excited to go along in the House. And it's created a bit of a stalemate. And so the speaker, the president and the Senate leader, Senator Schumer are trying to craft a path forward. And we got to hope they get there because there's some really important stuff in the bill. That's really important for health care. There's basically ...

Unger: Let's talk about that. What hangs in the balance here for physicians?

Askew: So I'll mention a few major provisions. Of three and a half trillion in that package, almost a trillion is dedicated to health care provisions. Some of the big ones are the bill would fill the Medicaid gap in those 12 states that did not expand Medicaid under the ACA. You have a lot of individuals, up to 138% of poverty, several million of them who don't qualify for Medicaid and they don't qualify for ACA coverage. So they would fill that gap with the new federal program, which would be immensely important to gain coverage for more than two million individuals.

It also makes permanent the changes that a earlier bill made in the Affordable Care Act, which expanded the subsidies for health care to make the plan to the Affordable Care Act affordable for folks, and also provided cost sharing assistance to help with deductibles and copays for those individuals with particularly low incomes. And the other big, huge one, which you probably heard about is an expansion of Medicare benefits, the largest expansion of Medicare benefits, basically in the history of the program and their popular benefits. It's a dental benefit, a vision benefit and a hearing benefit. And so those are getting a lot of attention. They're very high priorities for different groups of members of Congress. And that's why they're so desperate to try and find the path forward.

Unger: Now, I know it's a little bit like looking in your crystal ball, but as you look out here, what do you think the final package is likely to retain?

Askew: Yeah, so one of the problems is the Democrats are not only divided on what should be in the package but how big the package should be. And of course, as you start making the package smaller to address the concerns of some of the moderates, you have to start trimming benefits. And so it's pretty unlikely that if you start chopping down a three and a half trillion dollar package, that the full amount of health care spending is going to remain, they're going to have to start trimming some of the health care provisions. And the House, though they're obviously supportive of the additional Medicare benefits, a lot of the focus has been on the coverage pieces on building on the basis, the Affordable Care Act that people have gained, millions of people have gained coverage this year under the ACA and also the Medicaid pieces, which really hit a group of individuals who have no other options.

So that's really been a major priority. Over on the Senate side, particularly led by Senator Sanders, who heads the budget committee, they've really been more focused on the expansion of the Medicare benefits. There's expansion of Medicare benefits was included in the House bill but like it doesn't start till 2028 and there's high cost sharing. Because they wanted to money for their priorities. When the Senate, they want to move more money into those benefits. And if that happens, then something has to give the package, shrinks, more money gets spent on benefits.

They're going to have to start cutting elsewhere. So that's the kind of game that's going on right now. And they're looking at ways, how do we reduce the cost of these benefits? Some people have floated the idea of letting the coverage pieces, for example, expire in five years, which would mean in five more years, you would have the deadline that either people are going to lose this coverage or you have to come up with the resources to extend the coverage, which is a difficult proposition in and of itself.

Other folks have said, "Well, that's means test the Medicare benefits." The American Dental Association for one, not a big fan of being brought into the Medicare program. They've seen the troubles that physicians have had in having their services adequately covered. And so ADA has suggested, "Well, maybe we should means test at like 300% of the poverty level. Those people that can't afford dental coverage now." Problem is most Medicare benefits are not means tested.

And so that would be a whole new concept in the Medicare program. So it's really hard to discern how this is going to fall out. But as I said, the talks are ongoing. The president is deeply involved trying to define not only the size of the package but once you define the size of the package, then you can understand the changes you have to make to the policies to fit in those limits.

Unger: Question for you Todd, how does all of this impact the fact that Medicare payments to physicians are scheduled to fall at the end of the year?

Askew: You're absolutely right Todd. We forget with all this stuff going on that payments are scheduled to be cut under Medicare more than 9% under current law. You remember that at the end of last year, in the face of pending cuts that were caused by budget neutrality. And also obviously the fiscal pressure practices had been under with the disruptions and care due to the pandemic.

Congress provided an additional Medicare payment bump, if you will, of 3.75% at the end of the year. They also suspended the 2% sequester, which is basically in across the board cut. That's been with us in Medicare for a decade now, so that effectively provided another 2% increase in Medicare payments. Added onto that during the year in passing some of these COVID relief packages, there is a PAYGO reduction, which is a requirement that we pay for so much of what we spend.

And so Medicare payments are scheduled for an additional 4% across the board cut due to the PAYGO requirements at the end of the year. So it totals overnight almost 10% in pending cuts. And the PAYGO cut it's for a broad range. It's not just medicine, it's for a broad range of federal payments but it all adds up to a significant problem for physician practices. Generally, and this is a good thing and I think it's a testament to all the work that physician organizations and AMA and all of our partners have done in bringing attention to this problem.

There is broad bipartisan support for addressing these programs before the end of the year. However, if Democrats are worried about trying to keep the package, trying to shrink the package, they're not going to put something in there that costs billions of dollars that has bipartisan support.

They figure we can take care of this at the end of the year. So it's disappointing, but it's not really surprising that the cuts aren't being addressed in the reconciliation package but given the path that is on that may actually be a good thing. We do think though, that there is strong support for addressing this at the end of the year, there will be an end of the year package.

And we think that most ... We hope, and we continue to work hard to make sure that most, if not all of these potential Medicare payment reductions will be addressed but that's really our job as advocates is to continue reminding members of Congress, that if they get through this reconciliation package, their job is not done. They still have a significant responsibility to ensure the stability of the Medicare program, to make sure the physicians can continue to afford to take care of Medicare patients.

Unger: With everything that's going on. It just seems like this annual exercise to prevent Medicare payment cuts, that's a tough situation. Why does this happen?

Askew: Well, you're right. We're always patching the system up. It's created the system that was passed in Macro with good intentions to kind of put value in the system really has not of come to fruition largely because of how it's been implemented. So that Macro, MIPS, QPP program that people are familiar with really has failed to meet congressional intent. The program's complex, it changes frequently, it's burdensome, it's costly to participate in, it's got four different components that are really independent. It's like four separate programs you have to comply with. There's no real cohesiveness among those.

And Macro, remember, was supposed to kind of put us on a pathway and on-ramp to value-based payment system but that's really not come to fruition. Despite the fact that a lot of physician groups, a lot of physician organizations, are like the AMA and the specialties have worked very hard to put forward alternative payment models. They've been just largely ignored by CMMI and those proposals haven't been adopted. So the system we have now, that's constant patching the leaks and avoiding cuts is absolutely not sustainable

Unger: How do you manage in this scenario, Todd? What do you, the advocacy team and AMA do, given that, to confront all of these issues, which have really big implications for health care and physicians.

Askew: Sure. And it's not just us, it's working with our partners across the specialties and with the states and other organizations to kind of reimagine the payment system and kind of think of one, what would it look like? How do we get to a system that's simple, that's relevant for the providers that are participating in it, that the different pieces are aligned and that the payments and the outcomes are going to be predictable, right?

We want a system that's going to reward value as opposed to right now, I think a lot of physicians feel like all they're doing is data entry. They get paid for doing data entry and the patient care seems really secondary to the program. We want a system that encourages innovation. We want practices to be able to redesign how they deliver care, including providing services that are not traditionally covered by Medicare to targeted groups of patients to improve their care. And practices obviously need financial stability.

We can't have these wild swings year to year. If practices are going to plan and implement innovation, they've got to know that they're going to have a steady and predictable reimbursement or payment for the work that they're doing for the care that's being provided. And we've got to meet practices where they are. One-size fits all systems are not going to work for a system that is as diverse as the different types of physician practices. You have some very advanced practices that can really take on a lot. They can take on a lot of risk, they can do some really amazing things. You have other practices who are much smaller. They can't take on a lot of risk but they can provide really personalized individualized care to their patients and can kind of build a care delivery around that.

So those are the type of things that we're working to emphasize and to figure out how do you come up with a system that rewards those things, as opposed to just data entry and constantly trying to stop cuts that are caused by random events or we fix one thing and next year it causes another cut and you never know where the next cut is coming. So it's really critical, I think, to the future of Medicare and to the sustainability of physician practices in the long term.

Unger: Well, Todd, thank you so much. And as you point out the advocacy team and the entire Federation for all the work they're doing to advance the voice of physicians and all of this. It's complicated and big implications coming out of Washington right now. That's it for today's episode. Todd, we'll catch up with you as this situation develops in an upcoming episode. We'll be back soon with another Moving Medicine video and podcast. Never miss an episode by subscribing to AMA's YouTube channel, Apple, Spotify or wherever you listen to podcasts. Find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us. Please take care.


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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