With Tom Price in charge, doctors are winning again in Washington

By Erin Mershon
STAT, August 1, 2017

As the Senate was barrelling toward one of its votes to repeal the Affordable Care Act earlier this summer, Tom Price was corralling a small group of doctors into a tiny, dimly lit conference room in a nondescript building in downtown Dallas.

It was, on its surface, another of the health secretary’s many meetings with “victims” of Obamacare — this time with some of the conservative physicians who felt the law was hurting their patients and their own bottom lines. An official readout from Price’s staff trumpeted the eight participating physicians as “witnesses” to Obamacare’s failings.

But that wasn’t Price’s only message to the doctors, according to two participants in the meeting. The health secretary also signaled he would protect the doctors from a raft of regulations that were put in motion by the Obama administration. And although Price, a former orthopedic surgeon, didn’t address specific regulations, he made clear he was listening to the physicians’ complaints about issues like Medicare payment rules and burdensome electronic health record requirements.

Quietly, away from the spotlight cast on his effort to dismantle Obamacare, Price has been rolling back regulations that have been criticized by his former physician colleagues. And, unlike with the ACA, he has been able to do so without the blessing of Congress.

He’s given an American Medical Association committee (RUC) even more power over how much the federal government pays for different medical services. He has pitched retroactively reversing certain Medicare rules to ensure some physicians no longer face penalties they would otherwise have had to pay. He has proposed using almost $1 billion in savings that would be achieved through cuts to certain hospital payments to boost spending on physicians.

And over and over again, he has delayed Obama-era regulations that would have penalized doctors who aren’t ready or able to move away from Medicare’s longstanding “fee-for-service” approach.

As the congressman for Georgia’s 6th District, Price made no secret of his strong relationship with doctors and their specialty societies. He fought for industry wish-list items like malpractice reform and a legislative change to let doctors charge Medicare patients higher prices.

Doctors rewarded him in turn. Health care providers and groups like the AMA and the American Academy of Orthopaedic Surgeons together donated nearly $500,000 to Price’s 2016 campaign and leadership committees, according to the Center for Responsive Politics’s OpenSecrets website.

In one of his first acts as secretary, Price took aim at a bipartisan 2015 law overhauling the way Medicare pays doctors. The law — referred to by its acronym, MACRA — gives bonuses to doctors who do an especially good job at certain activities like using electronic health records, coordinating care, or improving patient safety. Those who don’t get hit with penalties, which ramp up over time.

Price voted for the law in Congress, as did many of his Republican colleagues. The AMA and other physician groups supported it, largely because the package also eliminated a different payment program (SGR) that they had been fighting for nearly two decades.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” Seema Verma, the administrator of the Centers for Medicare and Medicaid, said in a statement unveiling the proposal. “That’s why we’re taking a hard look at reducing burdens.”

The agency wants “to be responsive to the concerns of the clinician community,” it wrote in the proposal.

The regulatory changes backed by Price are about more than avoiding penalties. He has promised that his administration, unlike the previous one, will accept the recommendations of an AMA committee (RUC) that lets physicians themselves decide how much Medicare should pay them for individual services.

The controversial and secretive committee lets doctors fight out among themselves whether to pay a certain specialty less or more, as procedures become less time-intensive or less expensive (or more so), despite what critics say is an obvious conflict of interest. The AMA and many specialty societies have defended the panel, saying doctors know best which services are most complicated.

CMS is proposing the values for individual services that generally reflect the expert recommendations from the [committee] without as many refinements as CMS has proposed in recent years,” the new administration said openly in a press release.

It’s a major concession to doctors and especially specialists, who perform more of the procedures that some primary care doctors have suggested are overvalued.

“The idea they would tell staff to just leave the [panel] alone is a concession to physicians, and in particular, physicians like orthopedists,” said Dr. Bob Berenson, an internist and a fellow at the Urban Institute, who has been critical of the committee. “The specialties that do procedures do very well with these misvalued codes, like orthopedists.”

HHS, moreover, may just be getting started in its work to improve Medicare for physicians. Attached to nearly everything the agency has released this year has been a very straightforward request to doctors, hospitals, and other health care stakeholders: Tell us what regulations you want us to nix.

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HHS Secretary Tom Price, an orthopedist and former Congressman from Georgia, has long supported measures that benefit physicians, often to the detriment of patients. His positions on MACRA and RUC exemplify this.

As a member of Congress, Price supported the Medicare Access and CHIP Reauthorization Act (MACRA) with its Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). He did so in order to relieve physicians from having to comply with the Sustainable Growth Rate (SGR) which otherwise would have caused a reduction in physician payment rates. But, as we warned repeatedly, MACRA and its predecessors would create a major burden for physicians.

It is reassuring to see that Price and CMS administrator Seema Verma now recognize this burden and want to provide regulatory relief. The problem is that their concerns are directed towards physicians rather than patients. They support other policies that would reduce coverage and expose patients to greater health care costs. Even Verma’s physician husband refuses to accept Medicaid patients.

Price strongly supports the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC). It provides advice to CMS on physician payment rates. It has long been criticized because of its bias toward procedures resulting in specialist rates that are much higher than rates for primary care. As an orthopedist, Tom Price fared very well under RUC. Again, Price is advocating for physicians when it is the patients that should be his primary concern.

What can we do? Let’s intensify our advocacy for a system that puts patients first – a single payer improved Medicare for all. We need to reach a threshold of support at which our nation’s leaders have no choice but to enact and implement a system that works best for all of us. Physicians and other health care professionals would do just fine under such a system.

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