Medicare & Medicaid

Medicare payment reform: Progress to date and what’s next with Willie Underwood III, MD, MSc, MPH [Podcast]


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AMA Update

Medicare payment reform: Progress to date and what’s next with Willie Underwood III, MD

Nov 9, 2023

Medicare must change, and the AMA is fighting nonstop to make payment reform a reality. Chair of the AMA Board of Trustees Willie Underwood III, MD, MSc, MPH, joins to discuss the AMA’s advocacy to fix Medicare now, including the campaign’s wins to date and what’s next. AMA Chief Experience Officer Todd Unger hosts.


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

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Unger: Hello and welcome to the AMA Update video and podcast. It's our final episode of Fix Medicare Now Week on AMA Update. And today, we're taking a comprehensive look at our campaign to reform Medicare payment. Joining me to discuss where we started, the progress we've made and what's ahead is chair of the AMA Board of Trustees Dr. Willie Underwood in Buffalo, New York. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Underwood, always a pleasure to have you on the show.

Dr. Underwood: It's always my pleasure. This is awesome. I'm looking forward to this wonderful conversation and extremely important conversation.

Unger: Now, you know very well that Medicare payment has been an issue for physicians for decades. And coming out of the pandemic, the AMA made reforming it a top priority. In a recap, what are the problems that we're looking to fix?

Dr. Underwood: Well, there are numerous problems. And they all need to be fixed. But we're just going to first start with the most important issue, which is the lack of an annual inflationary base update for physicians. As a result of this, physician Medicare payment has declined 26% since 2001 when adjusted for inflation. I'm going to repeat that so that we understand the significance of this, that it has declined by 26% since 2001 when you adjust for inflation. That is simply unacceptable and unsustainable.

So another problem is the budget neutrality, which is when you increase your Medicare spending for physicians in one area, you have to decrease it in another area. This is a big barrier to progress long term because now people are fighting among each other and you're having battle zones drawn around what should be taken care of and what's not. And no one wants to give up anything that they have.

So therefore, you don't really go anywhere. So physicians don't have a chance, especially since some of that payment deals with the American Hospital Association and hospitals and stuff like that. We can't fight. We can't win that battle. And we shouldn't have to. Number one, we shouldn't have to have those battles.

There's also MIPS program, which is not only a burden on physicians, but it can result in more unexpected payment cuts. So now you're sending in documentation, survey, the patients you're taking care of. And then they go, "Oh, well, this didn't work out right. You didn't submit the right things. Oh, we're going to cut you some more." So therefore, add that on top of it.

Now, wish I could say that was all because I think that's enough. But at this moment, we're still fighting to avert another cut of 3.36% pay cut from CMS in a proposed 2024 Medicare physician payment schedule. This is all incredibly destabilizing, disrupting, impossible for us to survive. So we need Medicare payment reform. And we don't need it tomorrow. We need it now. Right now.

Unger: It sounds like we've got instead of getting a bigger pie just on the basis of inflation alone, like you pointed out, 26%, that's huge, that we're having to argue over smaller pieces. And then there's a heaping serving of an additional pay cut on the table. Each of those issues that you mention places a significant burden on physicians and their practices. Dr. Underwood, when you're out talking to your colleagues about Medicare, what are you hearing about how it's affecting them?

Dr. Underwood: So also a point we must understand, it's not just Medicare. So what happens is that the private payers base their payment structure based upon the Medicare payment structure. So therefore, physicians are getting hit from every direction. So when they say, look, Willie, I understand Medicare is what we deal with, but you have to understand that this impacts our practice at every aspect.

Now, if you're in private practice, your expenses didn't go down. The cost of paper, the cost of towels, the cost of whatever, right, swabs, whatever, those prices have all gone up, especially before the inflation shot up. They've all still gone up. But when you look at every other thing, your payment has now gone down. But also, if you are in practice, like you're in a hospital practice, you are in a practice where you're in academic settings. So basically, the hospital reimbursements for you have gone down. So then the hospitals say, well, we expect an annual increase.

So therefore, you have to work harder. You have to take less time with patients. You have to see more patients. You have to do more work. Pajama time where you're at home trying to do the documentation and stuff like that. Quality of life is down. Your children are suffering. Family is suffering. But guess who suffers the most. The patients. The patients suffer because you are now spending a few minutes with them trying to solve their problems, trying to help them. And you can't do it. Why? Because you can't survive financially if you don't reduce your time with the patients. That's unacceptable.

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Unger: Dr. Underwood, you know because you've been practicing medicine for more than 20 years. And you have firsthand experience with the massive decline in Medicare reimbursement during this time. How is it affecting you? How have you experienced this throughout your career?

Dr. Underwood: Well, I mean, that's the thing, right. So as a urologist, think about the things that we talk about. We're talking to men about men issues. And we would like to have 30 minutes, 40 minutes, especially since men don't want to be at the doctor anyway. But we can get them in there, begin to talk to them. And now you realize that in order to sustain a practice, you got to spend 7 minutes. OK. 10 minutes if you're lucky.

And if you don't do that, then you can't stay where you are, even if you're in academics or you're in a hospital-based setting. So that undermines your ability to provide top notch care, and build relationships with the patients and their families so that you can optimize and really understand their issues and help them out the best.

I became a doctor—oh, you didn't become a doctor, Willie, to make money. No, I didn't. I became a doctor to influence the health and the health care system and to help our patients. But in order to do that, we have to have a practice that's financially sustainable because college tuition didn't go down.

Nothing has gone down. So why have our payments gone down? We're just trying to make sure that we have a sustainable stable practice in which we can provide top notch care to patients. And that has decreased. And burdens gone up. Burnout has gone up. And all these things have happened to the detriment of health care delivery and to the detriment of society and to the patients in which we swore to serve.

Unger: So big challenges, big impacts on patients. Let's switch gears and talk about some progress because there has been notable progress by the AMA on a number of different fronts to reform Medicare payment. Dr. Underwood, tell us more about what that looks like.

Dr. Underwood: Yeah. Indeed, there's been some really promising developments. And I'm excited about them. And the AMA is excited about them. And that we want everyone to know about them and to be excited about them. So first, we already have legislation introduced with the Medicare payment, physician payment to Medicare Economic Index. Let me rephrase that.

So we introduced medication that would tie, legislation that would tie, the Medicare physician payment to the Medicare Economic Index, which is a measure of the practice costs of inflation. So that would allow us to begin to say, OK, great. As the cost goes up, inflation goes up, yes, reimbursements should meet that, right, it should be accompanied with that because, as I said, the cost of things continue to go up. And if you don't get reimbursement of that cost back, then you can't afford to survive.

That bill is H.R. 2474. And it's called the "Strengthening Medicare for Patients and Providers Act." And that's what it will do. We hope that's what it will do. All right. And we're continuing to build bipartisan support for it. But most recently, a representative shared a proposal for legislation to reform the budget neutrality policy that affects Medicare physician payments. Again, we can get rid of that budget neutrality policy. Then we can also have sound, rational reimbursement policies that allow to look at this in a way and not have people fighting each other for a piece of the pie.

OK. This proposal is based upon work of the AMA. And it plays an important role in building the support for legislation before a formal bill is introduced. And that's really important because we can get it right the first time. OK. As for MIPS, we've been talking about it. And all our conversations with policymakers, all right, they're starting to finally really understand and see the flaws in it, as we have seen it, really, from the beginning, which is a key step toward discussing the tangible policy changes. Again, conversations, people thinking about it, people understanding it, and we can get the right policy at the right time to fix the problems so that we can improve the health and health outcomes of this nation.

Lastly, right after CMS proposed its latest cuts, we submitted 120-page comment letter that details exactly how damaging that would be. And we're hopeful that they will listen, that they will think about it. Again, we can begin to get sound policy and sound thinking so that we can think about how to improve our health outcomes instead of how to undermine the structure of the health care system.

Unger: Those are really tangible steps. And there's a lot of momentum. Heading into AMA's Interim Meeting, which is taking place this week just outside of Washington, D.C., will delegate physicians be able to hear more about Medicare payment reform at the meeting?

Dr. Underwood: Yes. And that's a prime time for the members of the House of Delegates from all 50 states of the United States. All the specialties of health care, they will be there. And it's an opportunity for us to share our information with them, and hopefully to galvanize them and get them on board and supporting these efforts. So we have a dedicated fix Medicare booth with information and opportunities for physicians to take action, with iPads for physicians to sign the petition on and then view an interactive timeline.

So they're getting to see the timeline structure. They can go into the booth. They can, sign the timeline, sign on it, begin to get information out there. We can update on Medicare advocacy and speeches with the AMA leadership. And that's coming from us, the Board of Trustees. As we're out there talking, we're going to make sure that we share this information with our leadership and our members from all over the nation, and ads about Medicare reform at the airport.

So we just don't want the doctors to see this. We want those who's traveling through Reagan National Airport and the other airports in the DC area that they actually see that we're involved here, that this is a problem, and hopefully that they will all join on board so, again, we can solve this.

Unger: Absolutely. It's going to be a busy next few months as we continue our push for reform. Dr. Underwood, I'm sure with all of this news, it could be discouraging out there for your physician colleagues across the country. What message do you have for them about the work that's ahead of us?

Dr. Underwood: As they said in World War II, we need you. We need you to get involved. We need you to join us. We need you to sign up. We need you to come out. We need you to sign on to letters. We need you to be involved. Now is not the time to sit back and say, I'm going to expect someone else to solve this problem for me.

We are stronger together. There are 1.2 million physicians in this country. And it's time for our voices as 1.2 million strong to be heard. And if you're not an AMA member, you should be. And if you're not, shame on you.

Unger: Well, you said it. Dr. Underwood, as always, inspiring to hear from you. Thanks so much for joining us today. And your advocacy on this issue, it matters so much. For the latest developments on Medicare payment reform, check out the online home for the AMA's Recovery Plan for America's Physicians at That wraps up today's episode. We'll be back soon with another AMA Update. And in the meantime, you can find all our videos and podcasts at Thanks for joining us today. Please take care.

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