5 Things the SGR Bill Does Besides Fix Doc Pay

The Congressional bills to permanently remove the problematic Sustainable Growth Rate (SGR) formula for calculating Medicare physician payments also contains provisions that impact more than just physician pay. Besides repealing the SGR and replacing it with a very modest (below inflation) half percent annual increase in physician pay for the next 5 years, H.R. 4015/S. 2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, includes the following:

1. Creation of a clinical decision support mandate.
   The bill would require ordering physicians to consult appropriate use criteria developed by national medical specialty societies to ensure advanced medical imaging tests or procedures that they are ordering are the right ones for their patients and not a waste of health care resources. Specialists in fields like radiology vastly prefer clinical decision support tools to straight cuts to reimbursement or requirements that an expensive test or procedure must be pre-approved by a third-party benefit manager. They say it is faster, fairer and leaves the ultimate decision in the hands of the ordering physician. However, some critics have warned that clinical decision support carries its own dangers, particularly as the specialty societies developing the criteria and the payor (Medicare) may have different perspectives on what the risk/cost of a procedure is compared to its potential benefit to the patient.
    
2. Ending of Meaningful Use penalties.
   The incentives for adopting electronic health record (EHR) systems that meet Medicare’s “meaningful use” criteria famously switch from incentive payments to penalties between 2016 and 2017. If passed into law, H.R. 4015/S. 2000 would eliminate penalties for noncompliance and allow EHR incentives to continue as part of the new Merit-Based Incentive Payment System, or MIPS. “The carrots are renewed in a sense, because it's part of the value-based purchasing model,” said Farzad Mostashari, the former head of the Office of the National Coordinator for Health Information Technology and now a visiting fellow at the Brookings Institution, a Washington, D.C.-based think tank, in an interview with Modern Healthcare.
    
3. Requiring CMS prove fairness of a cut to radiologists’ pay.
   The Centers for Medicare and Medicaid Services and diagnostic imaging providers have been locked in a battle over whether or not there are cost savings when radiologists read multiple scans taken of a patient in one 24-hour period. CMS has imposed a 25 percent multiple procedure payment reduction (MPPR) to the professional component of imaging services (the radiologists read of the scan). However, radiologists say they are etically obligated to give the same time and attention to each image they read, which means there is no real time or cost saving in the professional component of multiple scans taken at one time. Furthermore the MPPR reduction ignores the role of subspecialists within radiology. A severe trauma or advanced cancer patient may have multiple scans done of different body parts at the same time, but these scans are not all read by one radiologist. Rather, they are divided up among different subspecialists who each examine the images they are most qualified to read. The provision would require CMS to produce data to show that the MPPR savings the agency says exist in radiologists reads is actual and real. If CMS can’t prove the savings are real, it must end the payment reduction.
    
4. Allowing patients to learn what their physicians earn from Medicare.
   In addition to allowing the government to more easily share Medicare claims data with outside organizations, the bill instructs the government to help patients get more specific information on individual Medicare physicians. The law requires putting information on the government’s Physician Compare website on the number of services furnished by the eligible professional under part B of Medicare, including possibly the most frequent services furnished or groupings of services, as well as the submitted charges and payments for these services. Recently, such data became available to organizations that file a Freedom of Information Act (FOIA) request, but this is cumbersome process rarely used by private citizens.
    
5. Adding teeth to interoperability in EHR system requirements.
   Having EHR systems easily share patient data is a key requirement for achieving cost savings in health care through reductions in repeats of tests that can’t be found and missed diagnoses. The bill adds some force to this requirement. Not only could EHR systems now potentially lose their meaningful use certification from CMS if they are not truly interoperable with other systems, but physician and hospital networks now also bear some responsibility. Recognizing that there is a financial incentive for large multispecialty physician groups and hospital networks to minimize leakage of patients to outside providers, the bill would change the law to make it illegal for any health care group or hospital to knowingly and willfully restrict the compatibility of their EHR system with the systems of other providers.

To avoid an estimated 24 percent mandatory SGR cut to Medicare physician payments, Congress must pass H.R. 4015/S. 2000 before April 1, when the temporary SGR fix passed in December of last year expires. Legislators leave Thursday for a 12-day-long recess, leaving only four working days to get the bill passed before March 1 and so far, there is no provision for how to pay for the bill — a cost estimated by the independent Congressional Budget Office as at least $115 billion over the next decade, more if payment increases for physicians who participate in MIPS and other alternative payment methodologies are figured in.