With SGR dead and buried, what's next for ACP advocacy?

It's been a long time coming—18 years!—but the Medicare sustainable growth rate (SGR) formula is finally history.

On April 16, President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law. MACRA, which had previously passed both the House of Representatives and the Senate by overwhelming bipartisan majorities, repeals the SGR (which dates back to a law passed by Congress in 1997), reverses the 21% SGR cut that went into effect on April 1, and provides stable and positive Medicare physician fee schedule updates over the next 4.5 years. Starting in 2019, physicians could receive higher or lower annual payment updates for successfully participating in a new quality reporting program, called the Merit-Based Incentive Payment System (MIPS), or in alternative payment models, such as accountable care organizations or advanced patient-centered medical homes.

No more will physicians have to worry about the next scheduled SGR cut. No longer will Congress allow the deadline to pass and the cut to go into effect only to retroactively reverse it. No more short-term “patches”—17 patches over 12 consecutive years apparently were enough for Congress! No more so-called “doc fixes.” No more sending hundreds of physicians to Capitol Hill on ACP's Leadership Day each year to lobby Congress to repeal the SGR (not that Leadership Day isn't needed now; it's just that we will now be able to address other issues, as discussed later).

Why did organized medicine win the SGR fight after so many years of seeming futility? For one, organized medicine was more unified than at any other time I can recall, with over 750 physician membership organizations, national and state, spanning all of the specialties from primary care to surgery, coming together to support MACRA.

Organized medicine also recognized it needed to be open to new ways of paying physicians; that is, we couldn't get SGR repealed unless we were willing to sit down with Congress and help develop an SGR replacement policy that rewarded value rather than volume. Which we did—helping to craft policies in a bipartisan and bicameral SGR repeal bill that despite the agreement on policy to replace the SGR got derailed last year because Congress couldn't agree on how to pay for it.

Our contributions then were not for naught, though, because they became the basis for this year's MACRA legislation. What finally made the difference, this time, is that with Congress having been beaten up so many times over the SGR, House Speaker John Boehner and Minority Leader Nancy Pelosi decided that they, together, would negotiate a package that would appeal to both parties, including how to partially pay for it. Which they did, and the Senate, despite some resistance to being “jammed” by the House, ultimately accepted the Boehner-Pelosi agreement.

Now that MACRA is law and the SGR is gone, does that mean that physician advocacy organizations can fold up their lobbying shops and go home, that our days of lobbying Congress are over? Hardly. Removing the SGR opens up the opportunity for ACP and other physician advocacy organizations to talk to Congress about other important issues-some with considerable urgency and immediacy, others involving longer-term policies to improve health care—that otherwise would have been overshadowed.

For internists, one issue of considerable immediacy and urgency is the Medicare Primary Care Incentive Payment Program (PCIP), which since 2011 has paid internists, family physicians, and geriatricians a 10% bonus on their primary care visit codes. The program has provided these specialties with thousands of dollars in added Medicare revenue. Because the program was authorized (by the Affordable Care Act) for only 5 years, it is schedule to sunset at the end of this year. ACP is urging Congress to extend the program, making the case that allowing primary care payments to be reduced is contrary to the shared, bipartisan consensus that primary care is undervalued yet essential to a high-performing health care system.

We are also trying to persuade Congress to restore the Medicaid Primary Care Pay Parity Program, which expired at the end of last year. This program, also created by the Affordable Care Act, increased Medicaid payments to primary care physicians for their visits and vaccinations to no less than the applicable Medicare rates for the same services.

Getting these 2 programs continued (in the case of Medicare) or restored (in the case of Medicaid) is challenging, because most Republicans are loath to support continuation of anything created by “Obamacare,” plus they cost money. And without a “must-pass” SGR repeal bill on the horizon, Congress could figure that it doesn't need to do anything else this year to address physician payments.

An issue that has longer-term implications is reform of Medicare financing for graduate medical education (GME). The United States is facing a large shortage of physicians in many specialties, including internal medicine, yet federal funding for residency positions remains capped. Lifting the caps, though, would cost the federal government hundreds of millions of dollars annually. At the same time, there are calls by the Institute of Medicine and others to take some of the federal dollars now going to teaching programs and put them into a performance-based innovation pool, making them available to programs only if they can show results based on measures of accountability for the skills and specialty choices of their trainees. ACP is currently working with some of the most renowned leaders in internal medicine training to issue our own proposal for sustaining and increasing GME funding on a prioritized basis, while ensuring accountability for the dollars spent.

Getting the SGR repealed was a great win for ACP and others in organized medicine, but it's no time to rest on our laurels. We have more much on our plate that requires action by Congress or federal regulators, so as we did on the SGR, we will continue to offer our ideas and alternatives on how to make health care better, with determination and persistence, no matter how steep the obstacles or how long it takes.