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Senior and Post-Acute Healthcare News and Topics

Doc Patch in the Works

Yesterday, the Speaker of the House (John Boehner) announced that a compromise is forthcoming to alleviate, for one year, the pending 24% payment reduction to the Physician Fee Schedule arising out of the current SGR formula. Ten days or so ago I wrote a post regarding a House bill that repealed the SGR but contained a “poison-pill” provision assuring its death in the Senate ( http://wp.me/ptUlY-gm ). As is the common methodology in Congress today, this initiative is a “patch”; another extension of the current status quo, delaying any SGR implications for one year.  Alas, while the SGR demands fixing, permanently, no traction is available among the parties to resolve the issue.

What the compromise does and doesn’t do is as much the center of debate as any efforts to replace the SGR with a more permanent formula.  In summary, the compromise;

  • Staves off the 24% cut but doesn’t restore any cuts related to sequestration.
  • It delays the implementation for hospitals of the 2 midnight rule for another six months.  The 2 midnight rule essentially reduces Medicare payments to hospitals for short in-patient stays.  It requires admitting physicians to have justification for the inpatient stay and if the same is lacking, the stay could be deemed (by RAC auditors) outpatient observation and thus, paid under Part B  at a lower rate.  The Bill would delay RAC auditors ability to review such stays until March of 2015 and give CMS authority in the interim and beyond, the ability to probe and educate but not re-classify stays.
  • It extends the implementation of ICD-10 for one more year.
  •  It extends certain programs that provide additional funding for rural hospitals.

While no one wins under these compromises, the Patch is likely to pass both houses quickly, viewed as a better alternative than the SGR cuts.  For post-acute providers, this is good enough news as the therapy fee schedule was subject to the same 24% reduction.

Interesting to note is that while the Bill extends the implementation of the 2 midnight rule, it doesn’t address the backlog of Administrative Appeals that continues to mount due to the Medicare RAC initiative.  This backlog is enormous and growing and it is the sole source initially, for providers to appeal RAC decisions.  I know of multiple providers today in the appeal queue waiting for a review of what appears to be, many erroneous determinations and shabby reviews of claims.   More on this in another post – later.

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March 27, 2014 Posted by | Policy and Politics - Federal | , , , , , , , , , , | Leave a comment

House Passes Doc-Fix Bill Destined for Nowhere

Earlier today, the House passed a bill that repeals the SGR formula used to derive physician reimbursement under Medicare.  For more specifics on the SGR, see a previous post I wrote at http://wp.me/ptUlY-ae .  The legislation is title SGR Repeal and Medicare Payment Modernization Act.

Unfortunately, the fate of the legislation is predestined as the bill includes an amendment from the Ways and Means Chairman (Rep. Dave Camp) that delays implementation of the tax/fee penalties concurrent with the Individual Mandate. It does not repeal or delay the mandate, simply the punitive measures for those that don’t comply.  Recall, the Affordable Care Acts requires all individuals above a certain income limit (tax filing limit) or without expressed hardship, to obtain health insurance by April of this year or face a penalty.  The penalty embedded within the act is a flat dollar floor with amounts increasing based on gross income.  With certainty, the inclusion of the amendment in the legislation spells a death sentence in the Senate where Senate Democrats hold a majority and Leader Reid, controls the flow of legislation for vote.  The bill will never see a vote in the Senate due to the Camp amendment.

The sticking point on repeal of the SGR is cost.  The Congressional Budget Office estimates that a repeal of the SGR, shifting to an indexed option with market baskets and productivity adjustments, will cost $138 billion over 10 years.  The dollars would need to come from an already shaky Medicare program that today, doesn’t really have another source of revenue save tax increases or contra-revenue infusions via reduced provider payments elsewhere in the industry.  The funding dilemma that occurs with the Camp amendment is that such an amendment actually saves the government $169 billion.  The savings is achieved by a projection of fewer people, sans the mandate penalty, having health insurance including under Medicaid and SCHIP (or CHIP).  With fewer people accessing the government-funded entitlement programs, the outflow is less, savings in amounts greater than the SGR repeal costs.

Once again, a fascinating insight into current federal health policy and the economics at play…

March 14, 2014 Posted by | Policy and Politics - Federal | , , , , , , , , | Leave a comment

Policy News: A Black Friday Edition

Full of turkey and the trimmings and avoiding any retail outlets, Black Friday seems perfect for a quick synopsis of what is happening with health policy.  Fortunately, I’ve maintained a good inventory of “stuff” (not stuffing, though I have an inventory of that too) to cull for content.

  • OIG on SNF Payments: This falls into my “news but not really news” category; another report from the DHHS OIG on Medicare overpayments to providers.  I have the full report for anyone who would like a copy – just e-mail me (e-mail can be found on the Author page) or comment to this post with a contact.  Essentially, what this report indicates is that in spite of repeat changes to the RUGs PPS system and changes primarily to the therapy sections thereto, providers continue to overbill Medicare unnecessarily.  The begging question is whether the overpayments depicted are a function of fraudulent activity (intent) or negligence and misunderstanding of proper billing requirements.  As I work with SNF providers regularly, I’ll state that elements of both are at play.  As I have written before, the system is inherently flawed and thus the incentives align to contribute (greatly) to fraudulent claims.  As intensive therapy services calculated by minutes provided are rewarded at significantly higher rate levels, providers seeking to gain (this is what providers do) additional revenues and cash flow, migrate toward care services and patient mix as determined by assessment and coding, that pays the most.  The intentionality of certain, possibly fraudulent behavior, arises when “upcoding” and a gap between coding for care level and actual service level, is evident.  Per OIG, upcoding accounts for the bulk of the erroneous claims.  Thus, in the majority of specious claims, SNFs identified the resident as requiring more therapy than actually provided and documented.  As a result of OIG’s analysis of the SNF billing practices, they make the following recommendations.
    • Increase and expand the amount of SNF claims reviewed.
    • Use CMS’ fraud prevention tools to identify SNFs that consistently bill higher RUG categories and/or have a disproportionately higher level of certain therapy RUGs than regional or national averages.
    • Monitor compliance with new therapy assessment criteria.
    • Change methodology for determining how much therapy is required by a resident.
    • Change to improve accuracy, certain MDS sections/items.
    • Follow-up with SNFs that have improperly billed claims.

My comments on this report and “what happens next” are simple.  First, SNFs need to heighten their own internal controls and increase their billing knowledge.  All too often I talk with administrators ecstatic about their case-mix and their per diem.  When I ask these same folks when was the last time they looked at their experience compared to regional levels or national levels, I get too often, the “deer in the headlights” stare.  Bottom-line: Audit and benchmark.  No single facility should have such disproportionate claim experience and if so, should have a very solid business case as to why, backed by third-party audits that substantiate the difference.

The CMS OIG workplan on SNF overpayments is titled, “Operation Vacuum Cleaner”. Interesting?  Not so much.  They know this is a huge issue and with the various fiscal issues on the table concerning health policy, a strong vigilance on Medicare overpayments is operative.  I have the 2012 OIG Workplan and again, for anyone interested, contact me for a copy.

Where this report leads is to a complete revamp/overhaul of the Medicare payment system for SNFs.  In the interim, additional rate rebasing is certain to occur as are heighten assessment requirements and again, more changes to the RUG levels and MDS. 

  • Fiscal Cliff: A ton of issues are wrapped in the Fiscal Cliff negotiations and among some the most “sticky” are health policy related.  Republicans are thought willing to concede on certain tax increase components but in return, are requiring a new look at Obama Care provisions and entitlement spending.  Wrapped front-and-center in the Fiscal Cliff debate is the targeted expiration of the current “doc-fix” patch.  Without a settlement, the present patch which temporarily derailed required cuts set by the Sustainable Growth Formula (roughly 26%) kick-in January 1.  On Wednesday, the CBO issued their opinion on the cost of a one-year fix; $25 million.  This number is $7 million higher than an earlier CBO forecast.  The fix would forestall the cuts and restore current-level funding for one year.  Important to note here is that Part B therapy rates are also tied fo the Sustainable Growth Formula and subject to the same levels of cuts.

This is the classic example of how interwoven health policy and entitlement spending is when viewed against issues focused on overall government spending, deficits and taxation.  The real issue here is that the SGR formula is flawed and requires a longterm solution although the same will cost substantially more dollars than any Congress is willing to deal with. What we know is that physicians are already nervous about Obama Care and particularly, the Medicaid expansion components.  Cuts to Medicare payments, already viewed by physicians as less than adequate, will only narrow the supply of principally primary care MDs willing to care for any government payer source.

  • Shortage of Primary Care Doctors: In light of the last point, on Wednesday the Annals fo Family Medicine published a report that by 2025, the U.S. will require and additional 52,000 primary care physicians to meet population demands.  The cause for the increase need per the report is an expanding and aging population coupled with changes in health policy.

This number is interesting but I think a bit misleading.  The two major sub-components that need analysis are the need for “geriatric” trained physicians and the number of physicians needed to care for a patient population with a government payer source.  I hear too often from the physician community, a strong desire to de-aggregate their practices from Medicaid and Medicare patients, principally due to meager reimbursement and increased regulation.  With a major entitlement expansion coming under Medicaid and more states opting to shift administration of their Medicaid plans to manged care insurers, physician participation bears watching.

  • 2013: The Year of the Health Plan: I’m already catching a great deal of scuttlebutt about employers seeking to fundamentally alter their present health insurance plans or, drop plans entirely.  This comes in tandem with the Obama administration’s release of new rules for health plans and insurers effective in 2013.  These rules prohibit insurers from adjusting premiums based on pre-existing conditions or chronic conditions, expand the drugs that must be covered by insurers, specify essential coverage levels on state health exchange plans, and provide flexibility to employers choosing to reward healthy behaviors.  As of today, I’ve only glanced at the rules.  Suffice to say, and based on what I am already hearing, 2013 will be the year of the health plan and it is already interesting to hear the discussions from trade associations, business groups and employers.

November 23, 2012 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , | 1 Comment

Medicare Doc Fix Redux

The failure of the Super Committee to achieve any measure of “go forward” spending reform left unresolved, a whole host of Medicare program spending messes, many of which will rear their ugly heads come January 1.  While many lament the Committee’s failure to resolve equitably, what is set to become automatic cuts, the truth of the matter is that the automatic cuts are literally far-off (politically speaking) and unlikely to occur as specified by current law.  More problematic at current are issues such as the continuing (sad) saga of the Medicare Physician Fee Schedule.  Recall that for the literally the past years, Congress has employed a series of stop-gap legislative measures staving off cuts to the fee schedule.  The latest legislative band-aid will expire on December 31 and if not again patched, cuts of 27.4% are set to occur.  Additionally, the same formulaic mess that calls for the reduction in physician payments rolls through to other certain providers such as outpatient therapies (Physical, Occupational, and Speech) inclusive of the reinstitution of a hard cap of $1,800 on outpatient therapy charges.

For readers somewhat unfamiliar with the “devil in the details” of this issue, here’s a brief summary.  The current system, based on a formulaic provision known as the SGR (Sustainable Growth Rate) enacted in 1997 as part of the Balanced Budget Act.  The purpose of the SGR is to constrain the rate of expenditure growth under Medicare for fee schedule related services (physicians being the most prevalent).  Under this system, spending is constrained by annual GDP growth, growth in the number of Medicare beneficiaries, inflation in practice costs for physicians and other outpatient providers, and spending required by regulation or law.  Weighting these four factors leads to a change (plus or minus) in the schedule of payments that is fundamentally influenced by economic activity or more precisely, changes in GDP.  In simplest terms, if spending in any one year exceeds GDP growth for the same period, the formula looks to reign in spending via cuts in future years.  As volume is a contributor as is inflation in practice related costs, the issue becomes somewhat of a ratio analysis; the rate of change in one is offset somewhat by the rate of change in the other or others.

In the earliest years of implementation, GDP growth was healthier than programmatic outlays (the target).  The net result until 2001 was a series of fee schedule increases, often at rates greater than inflation for the affected year.  Since 2001, expenditures have exceeded the growth target (fundamentally GDP growth) and the formula has triggered cuts.  With  the exception of 2002, Congress has acted to override the required cuts.  Each action by Congress, up to 2007, produced a growing negative balance under the SGR methodology, leading to the current forecast of required reductions equalling 27.4%.  Given the requirements under current law and the SGR, forecasts for 2013 and 2014 foreshadow additional cuts.

Logical and illogical arguments abound as to why the system has failed so dramatically; perhaps most logical is that payment discussions  (increases and decreases) correlate with beneficiary access.  Illogical is that payment reductions impacting certain specialties would lead to wholesale access problems for heart procedures, neuro procedures, etc. Most acutely impacted would be primary care access, already a significant problem in rural and distinct urban areas.  Additionally, access to other fee schedule providers such as outpatient therapies would certainly be negatively impacted.  In the end, Congress has proven unwilling to allow cuts of the current magnitude to roll forward.

As January 1 is rapidly approaching, here’s my insight into what happens next.  First the backdrop of reality.  This issue is square on the tables of the group (Congress) that proved incapable of finding $1.2 trillion in deficit reduction over ten years.  Being honest, finding $1.2 trillion over ten years is akin to finding apples on the ground in large orchard; this isn’t even low-hanging fruit.  Further, this is an election year issue during a period where the economy is stuck in near-neutral.  Finally, political cover is scarce and the back and forth rhetoric is furious; tough to find cooler heads.  The best that will come forward is a quick D.C. two-step; a patch to resolve the immediate fear of cuts followed by other patches that serve the same purpose but in pieces, appear small while continuing the saga of an aggregate amount of dollars that simply, won’t go away.  In as much as it is time or has been time long past, to fix this issue, nothing immediate will occur of this sort.  For providers, more nail chewing for Christmas.

December 5, 2011 Posted by | Policy and Politics - Federal | , , , , , , , | Leave a comment

MedPac Report to Congress: 2012 Recommendations

MedPac (Medicare Payment Advisory Commission) just released its March report to the Congress on Medicare program and rate recommendations for the FY 2012 (beginning October 1, 2011).  The full report is available in PDF form on the Reports and Other Documents page on this site.  Below I’ve provided a summary of the key recommendations contained in the report.

Important to note about this year’s report and the recommendations contained therein is the political context in which this report will be received.  Congress has often been politically unmotivated to take MedPac’s recommendations fully to heart as the same often involves program and payment reform following a path of curtailed spending.  As MedPac was officially created/established as part of the Balanced Budget Act of 1997, a critical element of its charge is to monitor payment adequacy in light of Medicare’s beneficiary’s access to care and the quality of care delivered.  Most notably, MedPac has gradually evolved to an organization that advocates for more aggressive programmatic reforms combined with rate reduction and/or spending reduction.  For routine readers of the annual payment reports (issued in March), the opening tone within the Executive Summary section has grown more pointed regarding Medicare’s solvency issues (lack of sustainability) and the Commission’s view of Medicare and the broader economic impact it has on the global U.S. economy.  Today (presently) within a House that is demonstrably pushing spending reforms and reductions and an overall Congressional environment stuck in debate regarding fiscal reforms that include entitlement reform, MedPac’s report certainly will receive more review and deliberation than in other years.  Similarly, health care is a front burner issue given the politics (anti-reform) that surround the recently passed PPACA, effectively producing a wholesale shift in political power in Washington.  Wrap the Washington political issues with a moribund economy that hasn’t yet established its recovery footing, significant Medicaid deficits across the States, and local political wars focused on labor unions, contracts and unfunded and/or expensive benefit packages (including health care).  Summarized: The ancient Chinese proverb applies, “It is better to be a dog in a peaceful time than to be a man in a chaotic period”.

Opening, MedPac provides a quick context for their recommendations noting that Medicare’s share of the total GDP is expected to rise from 3.5% to 5.5% by 2035.  More important and a point too often missed by economists and analysts is that Medicare’s cost growth is not separate from the larger health care economy as it is directly linked to other cost drivers within the health care system that today, are rising far faster than GDP growth (especially given the current and recent pace of GDP growth).  Overall, including the payroll tax funded Part A, Medicare consumes 18 percent of all income tax revenue.  The CMS Office of the Actuary, taking into account the purported Medicare spending reductions contained in the PPACA (see my last post on the Unraveling of the PPACA for more on Medicare and the PPACA) forecast a slower rate of spending growth – 6% vs. 9% under current law.  Critical to this assumption is the realization of spending reductions totaling $575 billion as well as a more stabilized, normative GDP growth pattern combined with historic levels of employment.

Key to this year’s payment recommendations (FY 2012) is MedPac’s philosophy and charge of balancing equitable payments that maintain or improve access, redistribute payments within a particular PPS sector to improve equity among providers and/or adjust for biases in patient selection and service (the term “cherry picking” applies), correct unusual patterns of utilization (over incentivizing) and to attempt to tie payments to quality outcomes and efficient practices (pay-for-performance).  The report covers 10 PPS sectors of which, I follow and work within 6 primarily.  As a result, I won’t summarize or comment on MedPac’s recommendations for hospital inpatient, hospital outpatient, ambulatory surgery centers, and outpatient dialysis.  Readers with interest in these sectors can download the report from my site page titled “Reports and Other Documents”.

  • Physicians and Other Health Professional Services: MedPac dances through this topic without adding any substantive input regarding physician fees, let alone any other allied health professions with fees tied to the physician fee schedule (outpatient therapy for example).  Primarily the avoidance is due to the political “hot potato” that is the SGR (Sustainable Growth Rate) issue. Per MedPac’s analysis, overall beneficiary access to physician care is good, physicians continue to accept Medicare patients, service volume continues to grow, quality is stable, and payments for service run at 80% of the typical PPO payment for similar care (unchanged from last year). MedPac does note however that some regional problems in terms of access to primary care are present, attributable to moderately low levels of reimbursement (in some cases, half as much as payments to specialists) and the inherent flaws of the SGR.  MedPac comments on the need to reform this reimbursement mechanism but offers no insight into what it may propose, merely that projected fee cuts of 25% in 2012 are untenable and as a result, MedPac will continue to work on developing alternative SGR approaches along with other formulaic options for the fee-schedule.  Their overall rate recommendation is a 1% increase in fee-schedule service related payments.
  • Skilled Nursing Facilities: Per MedPac, Medicare spent $26.4 bilion on SNF reimbursement in 2010 and per their analysis, the majority of indicators examined showed payment adequacy.  Prefacing their rate recommendations, the reports notes that the average Medicare margin for a free-standing SNF was 18% in 2009.  Specifically, MedPac notes that facilities with wider Medicare margins have aggregated more days into higher paying PPS groups, particularly rehab focused groups as opposed to the medically complex groups.  Additionally, provider costs remained relatively stable while rate increases paced above cost inflation. Per MedPac, successful facilities have found ways to have costs well below industry averages, high quality and corresponding high Medicare margins.  As a result of these conclusions, MedPac is recommending no rate adjustment for SNFs for 2012 while recommending continued categorical revisions within the PPS to move payment focus away from rehab to clinical care – more focused on patient care needs.  Additionally, they are recommending quality of care modifiers, providing incentives for high quality providers and creating rate reductions (disincentives) for sub-standard quality such as “avoidable” re-hospitalization.  As required under the PPACA, MedPac is also charged with reporting on Medicaid utilization.  Interestingly, their comments are boiled down substantially, indicating that total Medicaid certified beds have decreased while utilization and spending has increased.  They note that Medicaid margins are negative  and fundamentally, that all non-Medicare margins are negative but total margins for the industry are positive. 
  • Home Health Services: As it has in prior reports, MedPac continues to advise that access is adequate (90% of beneficiaries live within a zip code containing a certified agency), the number of agencies continues to grow dominated by for-profit entities within a limited geography, the volume of episodes of care continue to increase (25% over the period 2002 to 2009), quality measures are fundamentally unchanged from previous years, and the major for-profit organizations have sufficient access to capital.  As in the most recent prior year reports, MedPac notes that the PPS system continues to produce high margins for providers (17%), principally because payments exceed costs and growth in cost per episode remains below the assumptions used in the market basket update.  Using these conclusions combined with a cautionary statement regarding discovered fraud in the industry, MedPac recommends that the Secretary be charged with re-basing home health rates over a two year period, starting in 2013 (October of 2012).  Re-basing of rates would target a reduction in the therapy “incentive”, modulating more rate toward medical care while incorporating a revised case-mix system.  Additionally, MedPac recommends the development of a cost-share for home health, thereby instituting a beneficiary payment for services.  MedPac believes, like in other Medicare post-acute payments, that imposition of a cost-share will charge the beneficiary with more consumer awareness of the benefit and the utilization thereof.  Finally, MedPac recommends that the Secretary charge the Office of Inspector General with enforcement responsibility in areas/regions where fraud has been evident, removing payments, reducing enrollment and de-certifying agencies engaged in fraudulent activity.
  • Inpatient Rehab Facilities: Although a relatively small segment in the post-acute continuum ($6 billion), MedPac is recommending a zero percent increase in IRF rates.  They conclude that access is adequate, quality as supported by improvement at discharge is stable to improving, and as most facilities are hospital based, access to capital is not an issue.  They note that the average margin for IRFs is 8.4%.
  • Long-term Care Hospitals (LTACH): As with IRFs, this segment is relatively small – $4.9 billion.  MedPac notes that in spite of the limited moratorium placed on new LTACH and additional beds in existing facilities (July 07 to December 2012), the number of facilities increased by 6.6%; worked through the exceptions provided within the moratorium. LTACHs are not required to submit quality data to CMS though MedPac reports, based on claim reviews, that readmissions and deaths within 30 days of discharge are stable or marginally declining compared to prior years. Per MedPac, payments between 2008 and 2009 increased 6.4% despite costs increases of 2%.  The average Medicare margin in 2009 was 5.7%.  Within the PPACA, LTACHs are subject by 2014 to a pay-for-reporting program, though “reporting of what” is yet defined.  MedPac also believes that a pay-for-performance element should be introduced.  The recommendation for a rate increase or update for 2012 is zero.
  • Hospice: Per MedPac, hospice services received $12 billion in Medicare reimbursement 2009.  In the same year, hospice use increased across virtually all demographic areas and across beneficiary characteristics. Between 2000 and 2009, the supply of hospices increased by 50% with for-profit organizations accounting for virtually the entire amount of growth.  During the same period (2000-2009), the use of hospice increased from 23% of all decedents to 42% of all decedents with average length of stay increasing from 54 days to 86 days. In 2012, CMS is required to publish quality measures and in 2014, hospices are required to report on these quality measures or receive a 2 percentage point reduction in payment.  For 2012, MedPac recommends a 1% rate update. As in previous reports, MedPac recommends that the hospice PPS be altered to create higher payments for days early in the stay and late (near death) in the stay with lower payments applicable during the middle of the stay.  As stays continue to move slightly longer, this payment system is supposed to reflect more accurately, the intensity and cost of services provided to the typical hospice patient.  MedPac also recommends that the Secretary of HHS investigate the relationships between hospices and nursing homes and the differences in patterns of referrals between nursing homes and hospices. MedPac also calls for an investigation into agency enrollment practices where lengths of stay are unusually long as well as an investigation into the marketing and referral development practices of these agencies, particularly as they pertain to length of stay. This recommendation is unchanged from last year.

March 27, 2011 Posted by | Policy and Politics - Federal | , , , , , , , , , , , , , , | Leave a comment

House Approves Doc Payment Fix

Last night via a 243 to 183 vote, the House approved a bill that would stave off the projected 21% cut in physician (fees) reimbursement under Medicare, set for January 1, 2010.  The “Doc Fix” has been a hot-button issue within the health care reform debates as both the House and the Senate have not been able to incorporate the costs within their reform bills without busting the President’s deficit spending targets.  President Obama has stated that he will not sign a reform bill that is anything less than budget/deficit neutral. 

The House bill would cost the Federal government approximately $300 billion with no projected revenue offset.  This $300 billion is presumed to be all debt or certainly, the majority share will be debt.  The Bill does somewhat create a more permanent fix to the flawed formula presently in place.  The original formula, in place since 1997, ties physician reimbursements under Medicare to a GDP index, designed to theoretically reduce the overall growth in Medicare spending (the Sustainable Growth Rate formula).  Since 1997 however, Congress has seen wide swings in physician reimbursement levels and in periods or times when the rates would be reduced via the formula, the physician community has lobbied heavily for a “new money” infusion to avoid fee cuts.  What has occurred since the formula’s installation in 1097 has been far from a stabilization of physician fees and a near yo-yo battle every year between the Medical Community and Congress.  The “fix” in the House bill ties physician fees to GDP growth but provides a plus 1% add-on for all non-primary care physicians and a 2% add-on for primary care physicians.   

The Bill faces unlikely embrace in the Senate where earlier in the year (October), the Senate rejected a similar measure designed to stave-off physician fee cuts.  The Senate appears to approve of a pay-as-you-go approach or methodology rather than a wholesale restructuring of the current formula, despite strong sentiment among all Senators and Representatives that the present formula isn’t working.  In reality, the final issue will come down to money and how much the Senate is willing to allocate beyond a one-year fix.  With the House version of reform and the soon to be released Senate version of reform foreshadowing $1 trillion plus spending programs on health care, there may be little political muster left to add an additional long-term debt of $200 plus billion for a more permanent “doc fix”.

November 20, 2009 Posted by | Policy and Politics - Federal | , , , , , , | Leave a comment