AMA Advocacy Insights webinar series: Mid-year update on Medicare physician payment—and what AMA is doing

Webinar (series)
Mid-year update on Medicare physician payment—and what AMA is doing
Jun 4, 2024

As Congress has failed to entirely stop Medicare physician payment cuts over the past two years, physician practices are left with less financial stability during a tenuous time—already rocked by the challenges of COVID-19, physician workforce shortages and the Change Healthcare cybersecurity attack. It’s clear the Medicare payment system is unsustainable, and holistic reform is needed to protect patient access to care.  

Watch this Advocacy Insights webinar to hear about the latest AMA efforts on Medicare physician payment reform: what’s happening on Capitol Hill, how the AMA’s grassroots campaign is raising the volume, and what to expect on the regulatory side—particularly as the proposed rule for the 2025 Medicare physician fee schedule is expected later this summer.


  • Jesse M. Ehrenfeld, MD, MPH, president, American Medical Association


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

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Dr. Ehrenfeld: Hello and thank you for joining us this afternoon for our latest in the AMA Advocacy Insights webinar series. I'm Dr. Jesse Ehrenfeld, president of the American Medical Association, and an anesthesiologist in Milwaukee, Wisconsin. It's my pleasure to be host today for this important discussion about the latest AMA efforts on Medicare physician payment reform. Now, as physicians, we all know that there are many issues like these that jeopardize patient care, but in different ways. One issue that has been a major focus of AMA advocacy in recent years, and will continue to be in the year ahead, is sounding the alarm around our unsustainable Medicare payment system.

When you adjust for inflation, Medicare reimbursement to physicians has dropped by about 29% since 2001, which was my first year in medical school. And that's after the AMA was able to secure partial relief from the 2024 cuts. To be clear, the decision by Congress to eliminate only half of this year's scheduled 3.37% Medicare payment cut is woefully insufficient.

We are extremely disappointed that half of the 2024 cuts have been allowed to continue despite urgent calls from physicians about the impact that two decades of annual payment cuts is having on practice viability and patient access to care. They need to stop the annual cycle of pay cuts and patches, and enact permanent Medicare payment reform could not be more urgent. Because of Congress's failure to reverse this year's cuts, millions of seniors, like my own parents, are finding it more difficult to access high-quality care. And physicians are finding it more difficult to accept new Medicare beneficiaries.

The AMA continues to call on Congress to fix a broken Medicare payment system that is placing enormous financial pressure on physicians and threatening the care that we can provide. The fiscal stability of physician practices and the long-term viability of our entire health care system is at stake. And while physicians faced Medicare reimbursement cuts in 2023 and 2024, the payment schedule confirmed a Medicare Economic Index, or MEI, increase, at 4.6%, the highest this century, on top of last year's 3.8% rise in inflation.

Under the current model, the physician payments are subject, unfortunately, to a six-year payment freeze that doesn't end until 2026. And even when the freeze ends, the statutory update for most physicians is going to be capped to 0.25% indefinitely, far below even normal rates of inflation. So the AMA continues to advocate to both avert future physician payment cuts as well as promote longer term reform.

Thanks to AMA advocacy, Congress did take an important first step in 2023 towards Medicare reform with the introduction of H.R.2474, the Strengthening Medicare for Patients and Providers Act, a bill that would provide automatic annual payment updates to account for practice cost inflation as reflected in the Medicare Economic Index. We're urging our grassroots network to keep up the pressure on Congress as well. Our Fix Medicare Now campaign is building momentum for reform with hundreds of thousands of online engagements, thousands of direct messages sent to members of Congress, and nearly 1,000 earned media stories that carry the same message.

The current Medicare physician payment system is not sustainable and has to be reformed. So with that as a starting point today, our expert panel will detail what's happening on Capitol Hill, how the AMA's grassroots campaign is raising the volume, and what to expect on the regulatory side, particularly as the proposed rule for the 2025 Medicare physician fee schedule is expected out later this summer. I want to make sure we've got lots of time to discuss these important issues and also answer your questions, so let's go ahead and jump right in.

I'm really honored to introduce our panel of experts. We've got Margaret Garikes. She is the vice president of Federal Affairs at the AMA. I've got Rob Jordan, vice president of Political Affairs at the AMA, and Jason Marino, director of Congressional Affairs at the AMA.

So let's jump in by talking about, where does Congress stand with Medicare payments? And then we can get into some conversation about what's happening with the administration. So, Jason, during the last AMA Advocacy Insights webinar on Medicare payment that we held back in January, physicians were starting the year facing a pay cut from 2% in 2023 and a proposed 3.37% cut for 2024. As I mentioned at the top, we were able to get partial relief of the Medicare physician payment cuts for 2024. But unfortunately, a 1.68% pay cut still went into effect. What's happened since that pay cut started?

Marino: Thank you, Dr. Ehrenfeld, and thanks for having me on today. Let me first say, you mentioned earlier that Congress stopped part of the 3.37% cut and made it 1.68%. You're wondering, well, why didn't they just do the whole thing? Why didn't they get it to zero and give us an update? And why do we keep getting these patches? And why can't we just this year get a permanent update for inflation? Why?

And I want to give some context to this. I have two daughters, and I would love for them to go to Yale. And I was driving them, my daughters, to the pool this weekend.

And my one daughter had a Yale shirt on. And I thought, well, I read the stats that just came out. Of all the students who apply to Yale, only 3.7% of all students got in.

And so I just say that it's great that you have high ambition, but let's just be realistic. I'm not putting that pressure on you. It's a tough road. And instead of going to the math weekend camp I wanted you to go to, I'm taking you to the pool with your friends.

But you know what's harder than getting into Yale? What's five times harder than getting into Yale? That's to get a bill through Congress and signed into law. Last year, first session of the 118th Congress, only 27 bills of over 4,100 bills and resolutions that were introduced made it to law. That's 0.65% that made it to law in the first session—so more than five times harder than getting into Yale. That's what we're facing. And why is that? And it's the lowest productivity of Congress since the great depression early 1930.

And why is that? Well, part of it is that Congress is very divided. You know, House, one party. Senate, another party, very close margins. It's election season, very contentious election year. And there was a buildup to it last year.

And so it's tough. And so it's hard to get something through Congress. And we have gotten things through, even despite this environment. And so what's happened since then? I have some reason for optimism because what's happened since March, since we got a partial fix, a partial amelioration of the cut, is that the conversation has shifted a bit in Congress from stopping just a cut to, how do we reform the whole payment system?

And the Senate Finance Committee had a hearing on this, and the chairman and the ranking members that attended said the program—this is broken. It's not working. We have to fix this. And they expressed commitment to fixing that.

Then six senators on the Senate Finance Committee, a committee with jurisdiction, they got together about—three democrats, three republicans said, we got to fix this. We're going to have stake holders come in. We're going to get to the bottom. We're going to dig deep. And AMA and other groups in medicine have been in there already, and we have a dialogue going.

And then there's also been a Medicare Trustees report that's come out, a 2024 Trustees report, that said the payment's not keeping up with practice costs. There's going to be an access problem. And they said similar things last year, but they said the rhetoric went a little higher this year.

MedPAC is out there saying, we need to give an update. There needs to be some sort of update. And they did that last year and this year, but they hadn't done it in the past. And they're acknowledging there's a problem.

Then the Senate Finance Committee has also just recently released a white paper discussion draft where they laid out a series of questions and thoughts on highlighting where the deficits are in the MACRA system. And MIPS isn't working. There's no updates. How do we fix this?

And they're open for suggestions, and we're going to be going in there next week to talk about that with some other physician groups. And that's very healthy. You don't read about this because it's boring, inside-DC type talk.

But the minds, the people are realizing it's a problem. And so I have some optimism that we have some momentum going. There's the Energy and Commerce Committee. They've had hearings.

The Ways and Means Committee also recently had a hearing about how independent practices can't survive right now because the payment system is a problem. And we submitted testimony for all of these hearings. And so I am optimistic that it may seem bleak from the outside that we do have the right people with the power of the pen to write the fix that are thinking about it.

Dr. Ehrenfeld: Well, that's pretty remarkable, Jason. If I heard you correctly, 27 bills signed into law in the last Congress. That's amazingly unproductive, which makes it hard, even when there is bilateral agreement on things that we know make sense for our patients and for physician practices to actually just get through the mechanics of getting laws passed. So, Rob, let me turn to you. The AMA's Physicians Grassroots Network, our Patient Action Network have continued galvanizing support for Medicare reform. What's the message from our grassroots members to Congress right now?

Jordan: Well, and thank you, Dr. Ehrenfeld, and it's great to be here with everybody today. The message right now for the grassroots is, Congress, you need to finish the job. Partial relief in March lessened the impact of the cut, but physicians are still getting cut.

That's the bottom line. And Medicare patients are being put in greater and greater risk of losing their access to the care that they need. That situation is going to continue until lawmakers move away from a short-term Band-Aid style approach of applying partial fixes and deal with the problems by enacting permanent reforms that provide inflationary updates and make the other needed structural changes to the program.

Jason may touch on this more, but the idea that there are some in Congress who maybe aren't as dialed in on this issue and may think, "Hey, we already dealt with Medicare physician payment this year—we can't allow that mindset to take a foothold." So again, for the grassroots, the most important thing is planting that seed with the members of Congress, putting a marker down that this issue remains top of mind for their constituents. There's work to be done to take steps to fix Medicare by passing legislation like H.R.2474 that addresses MEI.

So, Jason, let me go back to you. The Medicare Access Chip Reauthorization Act, or MACRA, as we all know and love—there are a lot of reforms that we need. What are we specifically asking for as MACRA legislation moves forward?

Marino: Absolutely. First, let me say, 2015 is when MACRA was passed. And all the members and staff that were there—and they said this is a step forward. It's not the end. We know we have to fix this down the road. They're all gone.

So we recycle. They have a whole new group of people that we're dealing with, and so we've been educating them. But MACRA reform—I can break it into four components. First one, the main one, MEI update.

Physicians need an inflationary update based on MEI to keep up with practice cost. We need that going forward, so we don't have to fight every year just to get an update or stop a cut. That's one thing that can be done.

And you mentioned the bill earlier. There's a bill for that out there, the 142 co-sponsors. So we're pushing that.

The second reform is, why do we have these cuts every year in first place, these budget neutrality cuts? Well, the budget neutrality statute, the way it's written, every year, there's a fee schedule rule that comes out, and they might change how much they pay for one service, increase it, and decrease it somewhere else. And when you do any increase, you have to do a budget out across ... all across the board to cut all services. And that's what's been happening. And Congress' hands are tied because of the statute.

We have a solution to help, maybe not to help improve it, not going to get rid of it, but make it work better when they make assumptions on what drives how much across the board cuts should be, make sure they're accurate. And you can fix it down the road and make sure that what triggers budget priority is a higher threshold. There's some common-sense solutions.

There's a bill for that. We have a bill that's gotten partially through one committee, and we're trying to—that's a key component. We're keeping that alive going forward and educating members on what this budget means.

The third component is the quality program, MIPS. Not clinically relevant. It costs physicians $12,800 a year just to comply with the rules of it.

It takes physicians 53 hours a year spent on this. And I hear they feel like they could spend that time in much better ways than how they're being forced to spend it. That's not working.

But we have a proposal. I know Margaret's going to get into it. But we have a proposal out there with legislative text, with ideas how to reform that and make it work better for physicians and patients. And we're pushing. We're engaged on the Hill with that.

And then also, you've heard about alternative payment models. There are some promising MACRA that do these alternative payment models that could work for all physicians all across the country, all types of specialties. It just didn't happen. The pipeline didn't happen.

And there was also bonuses and requirements to be eligible for those bonuses that are in statute. And there's a bill to help address that to keep the bonuses that we didn't get. We didn't get these bonuses because there wasn't any APM to participate in.

So we're trying to keep those bonuses alive and make sure that the criteria to qualify for those bonuses is realistic. And how do we create a more robust pipeline so we have APMs in the future? And so that is something we're working on. Those are the four key components of MACRA reform.

Dr. Ehrenfeld: But, Jason, has the conversation in Congress been shifting? And what do you see on the congressional front on these issues for the rest of the year, recognizing that we've got, obviously, elections happening in November?

Marino: We're now in full-blown election season, so it's going to be tough to get bills through right now. But what we're doing is behind the scenes. When you have the committees engage and the committee staff, they're drafting things up, white papers. That matters.

That's the type of thing you can build from in the future. And I don't think this is the year that we're going to get all of the reforms done. This legislative process takes some time, but we are building momentum. I will say that the MEI update, the biggest obstacle of, why can't I just pass, is the cost. And it may be up to $300 billion over 10 years to pay for that, according to the congressional budget office—informally scored it, but they're not formal yet.

And then you have to remember, the context of there's a $34 trillion debt. And just this past year, for the first time, the interest on that debt was $1 trillion. So that's in the back of every member's head. What do we spend money on? And then can we all agree on it? And it's a tough hurdle to overcome, and people get overwhelmed by that.

And so we're pushing through that by making it real-world, what it means not to have an inflationary update. And there's a cost to inaction that's probably greater than $300 billion. Just because the CBO has some arbitrary scoring techniques, don't let that hold you back.

And then I think that there will be a lame-duck session this year in Congress. After the election, there's typically a package where somebody must pass bills. And we're hoping that some of the MIPS proposals I mentioned, some of the budgeting proposals, some of the APM, and stop any cuts and maybe an update. We're trying to fight for that, so when they come back in November, we are being discussed in a good way and make a down payment to a bridge so that, in the next Congress, we're well positioned to get the permanent reform.

And also, when you do this, you're creating ownership among members of Congress, that they own the issue. They do a little piece of it. They have buy-in, and they're going to be there next year to help finish it. And we are losing some champions this year who are retiring.

And you want to always work with your champions when they leave, maximize the goodwill that they have when they leave. And maybe they can leave by doing some reforms for us. And that's very much in play.

Dr. Ehrenfeld: So, Rob, let me ask you one more question before I turn to Margaret on the federal side. What's the best way for physicians to get involved? And how do you see grassroots activity ramping up throughout the year, particularly as we get into elections?

Jordan: Well, hopefully most who have joined today are already familiar with our website,—the resources and information that we have available there. There will be timely calls to action throughout the year. There will be new resources and new information, and updates coming online as we get them.

You can sign up and make sure that you stay informed. If you haven't yet, obviously, please go to the site, take action and you're signed up from there. So we'll keep you up to date.

My team is working on a number of different activities that will be ramping up in anticipation of the lame-duck session that Jason's touched on, where we're hopeful that this issue gets taken up. Promotion for the campaign, and again, just the issue, driving activity to our advocacy tools that put people in contact with their lawmakers—that's going to be targeted to lawmakers' districts, and of course, to physicians and patients in those districts that we feel need the pressure the most. It's going to unfold across a variety of media throughout the year online, social media outlets, radio in some cases, and video streaming services, local and national publication sponsorships, and things like that.

We'll also have programs specifically for physicians to take action and engage in high-level, one-to-one contacts, ideally directly with members of Congress or their senior staff, like we did last year during the recess periods, but also at other key times during the year. There'll be more to come on that in the days and weeks to come. So again, for now, just make sure you're signed up, receive our alerts. And again, I just want to mention the site in case people don't know—

Dr. Ehrenfeld: Perfect. All right, Margaret, turning to the administration, let's talk about MIPS, the Merit-based Incentive Payment System. How is that going from your perspective?

Garikes: Well, as Jason alluded to, there are some challenges, definitely, with the program, and we have some more concrete information about that CMS released recently. We have the 2022 experience report that goes into the overall performance about how physicians are doing during the 2022 performance year. And 87% of those eligible clinicians avoided a penalty or earned a bonus for the performance year 2022.

But the penalties continue to disproportionately affect small and rural practices. For instance, 27% of small practices and 18% of rural practices were penalized. And then on top of that, about 30% solo practitioners received the maximum penalty of 9%. So clearly, there are challenges.

Now, CMS attributed the issues with the 2022 performance year to several things. It had to do with the cost category. It was the first time since 2019 that CMS calculated the cost category. There was also an issue in terms of the changing of the performance category weights.

And another thing that was really problematic that we believe was, during COVID, CMS applied automatically an extreme and uncontrollable circumstances exception that the AMA lobbied for very strongly. They applied it automatically. And in 2022, that was the first year since the pandemic that physicians had to apply themselves for that hardship exception.

But the one piece that this bad news does provide us with is it's ammunition, fuel, for the discussions that Jason is having on Capitol Hill. So it helps with that debate up there as well.

Dr. Ehrenfeld: So what is the AMA doing to try to address some of these really challenging foundational problems with MIPS that you've just described for us?

Garikes: So we have a multi—we're working on several parallel tracks. First of all, the administration—we bring a lot of recommendations and are meeting with the ... with the administration constantly about fixes. And we have work groups that inform with specialty societies and so forth that inform our discussions with the agency.

But frequently, the agency will say back to us that they don't have statutory authority to implement one recommendation or another. And so what we did most recently is we put together all our recommendations and did a very in-depth legal analysis, both with in internal attorneys as well as outside counsel to identify those statutory authorities and go through every single recommendation that we've made to CMS. And we have provided that at various levels within the agency, including engaging the deputy administrator about those recommendations.

Another track that we are working on is something that CMS is calling the MIPS Value Pathways, or MVPs. And we have a workgroup on this as well with specialty societies that are most involved in the MVPs. And CMS sees the MVPs as the solution to all the problems with MIPS.

Unfortunately, we don't agree with the direction that CMS is going in on the MVPs. And so what we have done is a series of—we've had a very extensive meeting, a roundtable with CMS and all the specialty societies involved in the MVPs about that. And as an outgrowth of that in-depth discussion, the specialties and the AMA came together to try to come up with a new framework that we presented to CMS.

And these two first items that I'm talking about and what we're tracking for is we've been very aggressive in trying to get items in the proposed physician fee schedule rule, which should come out from CMS at the beginning of July. This next issue is something that we again developed with specialties and some of the more active states that have a strong federal component to them on another workgroup.

And that is to look for a way to replace MIPS. And we're calling the new program the Data-Driven Performance Payment System. And that is what Jason was referring to that we have been talking about on the Hill and starting to try and get some interaction and traction on that piece.

Dr. Ehrenfeld: So it sounds like that last piece is one of the legislative improvements that might be in the hopper for MIPS. Are there other things that you see on the horizon in terms of legislative fixes?

Garikes: Well, so as part of—so the legislative fixes—this last piece that I'm talking about is really an extensive, extensive replacement for the MIPS program. So let me talk about that a little bit. So there are a number of components in that. And one is that the current MIPS program—currently, penalties are distributed unevenly in the current MIPS program.

So what this new program, this DPP program does, it eliminates the tournament model for payment adjustments that currently exists under MIPS. And instead, it links the MIPS annual performance to a percentage of the MEI. Next, it calls for a reinvestment of the penalties in bonuses for those high-performing practices, but also for those practices that need technical assistance—the small, the rural, those practices that are serving the underserved. And it also freezes the performance threshold for three years.

Another issue that the legislation addresses that we have been very frustrated with, and that is the lack of data. For instance, I talked about the data that just came out over—the aggregate data that just came out concerning the 2022 performance year. And the first time that physicians could actually see how they were doing in 2022 performance year was back in August—so not real-time data even though MACRA called for more real-time data.

So this new legislation calls for more real-time data. And this time, it gives an enforcement mechanism to it. Right now, it just calls for more data without an enforcement mechanism.

And how it would work is that it would exempt any physicians from penalties who did not receive three quarterly data reports during the performance year. So hopefully, that makes it more meaningful. Physicians can adjust to their situation and do better.

The legislation also does more to make the program more clinically relevant and less burdensome. It breaks down the silos. It values data registries and promising new technologies, and improves the cost measure accuracy. That cost category has had a ton of problems, and we have a number of suggestions in there for that as well as for the quality measurement accuracy—so incentivizing physicians to test new and revised measures. So there are a number of things that we think will go a long way to making this new program be more meaningful for physicians and patients.

Dr. Ehrenfeld: Fantastic. Well, we are starting to get a flood of questions from those who are dialed in today. We're going to take the remainder of the time to try to get through as many of them as we can, so please do go ahead and send them in. Let me go ahead and try to consolidate a couple of the ones that we've got here. So the first one is, "When's Congress going to do a practice overhead expense inflationary increase? This has become unsustainable for those of us in private practice when you combine it with the cuts in the physician fee schedule." Who wants to take that one?

Marino: I'll jump first, and then I'll bring Rob into it. We have a chart that shows—it's called gap chart, and it shows you graphically what the last 20 years since 2001 to 2024, physicians have lost 29% to inflation. And that has an impact on people. You show it to a member of Congress.

There will be Instances where members of Congress are like, you see this chart? That's our chart. And it's effective. But it's one step. Intellectually, you get them there.

And the other part is, deep down, they're thinking, my god, this thing is $300 billion. That's a lot of money. And it makes them hesitant.

And so you can win them intellectually. They're a little hesitant because of cost. But they go to the next step. You need a physician that can tell the story of, what does that mean? What does that mean in the real world? What does that mean, back home in my district, to my practice, to my patients, to access?

And that's what Rob's doing with the Grassroots team, and that they're getting that physician face-to-face with that member of Congress to tell that story. And that really can move people and get into their head, and they're thinking about it in a real-world way than just a chart. And I know, Rob—

Jordan: Yeah, and just not much to add to that, but just to bring home what that number means, and what it means for patients, and the real access problems that it creates. And I think that makes the connection for the lawmaker when it starts, as Jason said, with the chart, but then bringing it back to the real impact that it has and how that translates into to people having their health care put in jeopardy. That's the sweet spot that I think everybody on this call can really help us to hammer home.

Dr. Ehrenfeld: Rob, let me stay with you. We've got a question here that says, "When's the optimal time to reach out to lawmakers?"

Jordan: Early and often. I think, again, right now, my concern is this lingering idea that there's not much going on right now. It's an election year. Start hitting them now and peppering them with this as a priority that needs to be dealt with.

They know that there's a lame duck coming, and that momentum will begin to build. And then contacts will need to intensify—but early and often, and then more, and more, and more. And I'll apologize in advance for continuing to tell people they need to keep it up. But that's the short answer, and I think, the right one.

Dr. Ehrenfeld: Any realistic chance that Congress will avoid further cuts this year?

Marino: I'll jump in on that. We know that the amount of cut, there's still more of the budget cuts coming. And it gets set through the physician fee schedule rule. We'll see a proposed rule in early July. The rough math is about 2.9%.

That will change a little bit, but that's what we're facing potentially January 1. And so we will be out there, pushing. You cannot be cutting. We already have a 2% cut in 2023. Now we're living through a 1.68% or basically a 2% cut this year and another 3% cut without updates or formats.

That's not tenable, and that can't happen, and you need to stop that. And so you'll hear the cry for that as time goes on. It might get lost right now, but we're making the case now, though, which is why it's so important, as Rob said, to keep pressing now and have relationships that are ongoing with members of Congress.

Every member has three or four physicians that they trust and secretly call all the time. Staff will tell you, Dr. So-and-so said this, and now we're doing all this. Yeah, I want—and I know people on this call that are that physician. That's who you want to be. It's powerful.

Dr. Ehrenfeld: So we've got a bunch of questions. Margaret, I think there's a lot of interest in the replacement vision for MIPS. People are curious where they can learn more about some of the work that we are trying to put forward. Is any of that public or available? Or is there a resource that folks can look to?

Garikes: So I'm looking to my colleagues to see if the replacement—it's been shared with the specialty societies. So the legislation has been shared. I'm trying to remember if it's posted. Jason, do you remember if we posted that?

Marino: I'm not sure it's suppose. We're in the early stages, so it's been shared with all the key committee staff of the committees of jurisdiction. And they're vetting it, and we hope to go in and really get down into the weeds of it and start selling the package.

And if it's not on the website, it'll be forthcoming. And it's not all going to—as we all know, the legislative dance, things change a little bit. But we have, I think, a very solid, balanced, reasonable proposal that's going to improve patient care and the physician experience and this new program. And we'll get it out there if it's not out there already.

Garikes: Yeah. We will. We'll post it to the Fix Medicare Now, or the MIPS website, I guess it would be, probably. So we'll post it.

Dr. Ehrenfeld: Perfect. Next question is, "How do we balance the need for payment reform with all the financial constraints faced by Medicare?" What does that look like?

Marino: You know, part of the argument I usually make when I get thrown back, :$300 billion, Jason, $300 billion, that's not realistic." Well, there is a cost to inaction. And part of that cost is independent practices is not surviving.

They're being forced to move, to get bought, to go to private equity. I'm not saying it's bad. I'm just saying that you shouldn't be forced to ever have to do anything. You should have choices. You shout have choices.

And if they're forced to go to reimbursement systems outside of the fee schedule that maybe pay more to the entity that acquires the physician, there's a cost to that. There's a cost to just a practice that closes. There's a cost to not having care close to home. And maybe CBO doesn't score it, but it's scored in the real world. So there is a big cost to not doing anything and letting this wither.

Neglecting the payment system for physicians is having a cost, whether CBO scores it or not. And I think, in the real world, people are experiencing it and seeing it. And so I think it's important to frame it that way so that members of Congress and staff realize that it's more than just one score.

Dr. Ehrenfeld: So outside of the price tag and the cost associated with doing some of these important fixes, are there other challenges that we're facing in gaining support on Capitol Hill for wholesale reform?

Marino: I think one challenge, which is just natural, there's only—what—535 members of Congress. And every issue that the world faces, they're hearing about it. And there's a lot of issues out there, a lot of people in difficult circumstances and things that need reform. And it's hard to compete sometimes for attention. You're always competing for members of Congress' attention.

And then there's also just inertia where it's easier just to hunker down and just ignore problems. And Congress tends to act at the last minute. And there's an opportunity cost to jump in on an issue, and so sometimes people just—there's some apathy, and you're just trying to break through and get people to care about the issue.

And you're competing with that. just get members to engage. They might not even be for or against. You just get them to engage and talk to you and put some spend some time on this issue.

And then when you do get them thinking about it, and you show them the graphs, and hear conditions—they realize, wow, this is worthy of my time. I should be engaged. But it will not happen on its own. None of these things of the fix will happen, but just some issues, there's defense bills that get passed every year because they have to.

This is not one of those. If we stopped engaging for a month, the Hill would stop engaging. So you can never stop, and members and staff always go and circulate, and you're always starting over. That's just part of the process.

Dr. Ehrenfeld: So we've already got a huge physician shortage. In fact, it's a crisis. 83 million Americans don't have access to primary care. That is especially exacerbated in rural areas. But what we heard today from you all is that MIPS is already penalizing rural practices, small practices. So how do we think about the opportunity to not let further cuts exacerbate the critical access problems in rural areas? If this isn't fixed, what do we think that's going to do to the overall physician shortage? Any thoughts?

Marino: I'll give an example. Let's you're a physician in MIPS, and you do bad on the score. You get the bad score and you find out, you're getting cut 9%. So not only not gotten an update for inflation, you're living with the almost 2% cut this year, the 2% cut last year, and now you're going to get 9%, and you're going to be a solo practice in a rural, underserved area.

How is getting cut 9% going to make you better? How are you going to stay around? How does that help your patients? That is not working. And we've been on pause because of the five years of COVID. When that gets fully operational, that's going to have some impact, not in a good way.

Dr. Ehrenfeld: All right. This question is for Margaret. "Are there any upcoming additions to the fee schedule similar to G2011 intended to reimburse physicians for the additional time required to document and coordinate the complex care of Medicare patients that you see coming?"

Garikes: So CMS holds issues very close to the vest in terms of what's going to be in a proposed rule. And reading the tea leaves right now, we're not aware of anything, but we can't rule out the possibility that there'll be something in the proposed rule, but we're not going to know until July. I would say, there are new alternative payment models that the innovation center at CMS has released, like the Making Care Primary alternative payment model. But regarding specifics in the upcoming rule, I'm just not sure.

Dr. Ehrenfeld: OK. Margaret, let me stay with you. This next question also is directed at you. Can you talk a little bit more about the new MIPS value pathway framework and what that might mean for practices?

Garikes: Sure. So the MVPs were something that the AMA and the specialties originally were enthusiastic about. The intent of it, it seemed to go along the lines of making the measures more meaningful for patients and physicians aligned quality and cost, and provide a transition from MIPS to APMs. But unfortunately, CMS has taken many policy directions that just don't align with the original goals that were mapped out for MVPs.

So the new framework that we worked on with the specialty societies that now CMS is considering, and we're hoping they'll be adopted in the proposed rule, but that's a heavy lift to get CMS to do that, but that's our goal. But the new framework talks about—it ensures quality measures for each subspecialty and each of the major types of diseases and conditions. It aligns quality and cost measures. It removes the current caps that currently exist in the MIPS program on the maximum points for topped-out measures and also for those measures without benchmarks for scoring MVPs. The scoring right now is really problematic.

And then it also would totally revise the total per capita cost measure, which is really problematic for many physicians as well. So those are some of the key components of the new framework. We've, as I said, heavily engaged CMS and the specialty societies on this, and we are ready to try and work through what comes next.

Dr. Ehrenfeld: All right. Let me take one more question, and then I'll go to each of my panelists for maybe some closing thoughts. "Will we get site-neutral payments this year, particularly given the political clout of the hospital association lobby?"

Marino: We'll see. I don't think you're going to see a significant change in that, but maybe on the margins. They are very well in Congress about that. There's a differential payment for the same type of service, whether it's a physician office or in the hospital outpatient setting. And it can be reimbursed more in the outpatient setting. And why is that?

And AMA, we're not saying—and we're saying that it should be equal. We're not saying, bring it down, bring them down to our horrible level. Maybe there's a way to modify it so that it stays in the physicians' pool.

But it would only be on the margins, but some of that legislation is a saver. So it could help fund things for in a lame-duck package. But at the same time, the hospital community is not going to want to just see an arbitrary cut. And their voice will be will be heard on that point.

Dr. Ehrenfeld: Well, thank you to the audience for those great questions, and thank you to my AMA colleagues for sharing what we are working on. Let me turn to each of you now, and I'll start with Rob, and then go to Margaret, and then Jason to just give any closing thoughts that you have after the conversation today. Rob?

Jordan: Really, the basic message is just staying involved, again, looking for opportunities. We will keep you all well informed and well prepared to take action. But I know from working with Jason and his team, we've made a ton of progress on this issue thanks to the Grassroots, and again, you guys imparting stories, the pressure from patients—all of it has worked together to bring people along on both sides of the aisle, republican and democrat.

And it's a very toxic environment. This is an incredibly big lift, but we've made a lot of progress. And I just would encourage people to realize a lot of the behind-the-scenes groundwork that's been laid and to stay involved, and stay engaged, and help us get this over the finish line.

Dr. Ehrenfeld: Perfect. Margaret?

Garikes: So I'll just say that, in Washington, both with the administration and with Congress, things don't move as quickly as folks would like. It's really a chipping-away process. But we have a number of initiatives going on to try and tackle these problems that we're working through with the specialties and the states. And we want to continue to hear your all's input and to continue to work through the problems so that we can ultimately find solutions to the various pieces.

Dr. Ehrenfeld: Perfect. And, Jason, why don't you bring us home?

Marino: I'll bring you home. I started with the less than 1% of bills that made it to law. But I will say big picture—seniors, Medicare beneficiaries, they spent their life working, paying into Medicare, paying their premiums.

When they turn 65 and they enroll in Medicare, they deserve to see the physician of their choice, and have an option, and not a long delay or no physician. They deserve that. And our Congress owes it to them to make sure this program is viable.

And maybe it hasn't happened yet, but we're headed not in a good way. But we are at the table, the AMA and the physician world, with solutions. We're giving them texts. We have solutions, bipartisan solutions that are viable, that can pass. And so we're there with solutions and we have a lot of the grassroots is going, and they're hearing from us.

We're getting into their heads. They know we're right. They know they want to fix it.

Yes, things are costly, but it's less expensive in the end if you fix it. You actually will save dollars in the long run. And I think we're making that point. So I'm optimistic.

Dr. Ehrenfeld: Jason, Rob, Margaret, thank you so much for spending the time with us today to talk about these important issues. As I'm out on Capitol Hill, it's clear to me that the light bulb's gone off. People recognize we are on an unsustainable path. Everybody sees that.

That was not the case five years ago. There is now a common, I think, shared understanding of the collision course that we are on that is going to drastically reduce access to care for seniors and the underpinning of the American health care system. The question is, with such dysfunction in Washington, the slow progress of change, and all of the political challenges that we've got, how do we get the vehicle, and the willingness and the courage to do what's right for America's patients and physicians? But with the team that we've got, I know we're on the right path.

Thank you all so much for your insights. To our audience, thank you for joining us today. And please stay engaged through the Grassroots Networks. And if you're not signed up for our Advocacy Insights webinar newsletters, please go ahead and subscribe through the website. Thanks.

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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