What's next with Medicare payment reform, Part II


Moving Medicine

What's next with Medicare payment reform, Part II

Feb 8, 2024

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. Learn more in the second part of a two-part episode of the Moving Medicine podcast.


  • 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


  • Todd Unger, chief experience officer, AMA

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

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Unger: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode will pick up part two of the conversation with Dr. Willie Underwood and our esteemed panelists—talking about how physicians can get involved with Medicare payment reform.  

Panelists include Dr. G. Ray Callas, president elect of the Texas Medical Association; Katie Orrico, senior vice president of Health Policy and Advocacy at the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and Todd Askew, senior vice president of Advocacy at the AMA. 

If you missed part one of this series, I encourage you to go back and give it a listen. And be sure to subscribe to Moving Medicine on your favorite podcast platform.  Here’s Dr. Underwood.

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, the 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. 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're 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 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. Educating 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" in a 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 more 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. 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 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 on-going 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 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—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 taken 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 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 here's a question.

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

Askew: Let me start with that. Obviously, our advocacy and grassroots or efforts are open to all physicians. Fixmedicarenow.org, 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 fifty 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, it is the Texas Medical Association. It is everybody's voices coming together.

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 specialties, 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 by this—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, annual 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. 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.

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, you know, 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, and 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, 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 $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—a 10% budget neutrality adjustment. And medicine 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, 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 will 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 where 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 congressmen 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 programs are not paying bills and are requiring prior 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 to 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.

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.

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. Let's make this happen together. Peace.

Unger: This has been Moving Medicine, a podcast by the American Medical Association. Subscribe today to never miss an episode. Thanks for listening.  

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.