The Story Behind the SGR Fix
How ACR advocacy influenced policy and protected members and patients in the most divisive Congress in decades.
You already know how this story ends. But in a lot of ways, it starts on New Year's Eve 2012.
The country was about to plunge over the fiscal cliff when a small group of influential leaders, headed by Vice President Joe Biden and Senate Minority Leader Mitch McConnell (R-KY), ducked into a room at the last minute and negotiated a deal. Unfortunately, the deal contained an SGR extension that significantly slashed technical component reimbursements to radiology. "It was a mess," says Rebecca Spangler, director of congressional affairs. "It was one of those deals where everything happened really fast behind closed doors and there was nothing you could do about it."
As the government relations team formed their strategy for the coming year, the dramatic cuts were never far from their minds. "That served as the motivation, at least for me, to make sure that our language would stay in the next SGR short-term patch," says Spangler.
Pushing for Repeal
In late 2013, Congress was moving toward repealing the SGR. The government relations team pushed to include three provisions: 1) to mandate that referring physicians consult clinical appropriateness criteria for medical imaging prior to ordering advanced imaging services for Medicare patients, 2) to pass MPPR legislation to stop a 25 percent cut to the professional component of radiology reimbursement and to require CMS to release the data used to calculate the MPPR, and 3) to implement CMS dampening/code capping policy.
Repeal of the SGR falls under the jurisdiction of three congressional committeess: the Senate Finance Committee and the House of Representatives Energy and Commerce and Ways and Means committees. Each committee would put together a bill to address the flawed SGR. In July 2013, the House Energy and Commerce Committee passed its bill (H.R. 2810) unanimously. With aggressive lobbying from radiology leaders and the government relations team, ,the bill contained appropriateness criteria and MPPR provisions. The dampening policy was not present. In early December, the House Ways and Means Committee and Senate Finance Committee released their own proposals to repeal the SGR. Both contained appropriateness criteria and dampening provisions but nothing about MPPR.
While all of this was happening, a clock was ticking down the days until March 31, 2014, when the previous patch would expire, triggering a 24 percent drop in payments for physicians treating Medicare patients.
A Looming Deadline
It's never been easy to get policy through, but it's rarely been harder than it is in the current polarized Congress. "It used to be common to have hundreds of bills pass both the House and the Senate. Now it's down to a fraction of that," says Cindy Moran, executive vice president of government relations, economics, and health policy.
To make things happen in this environment, the government relations team has honed a process that includes three key elements: grassroots (widespread advocacy efforts from membership), "grasstops" (efforts from constituents with close ties to their legislators), and relationships formed with members of Congress and their staff through lobbying.
However, none of these strategies will be effective without good policy. "We developed a policy that was non-partisan, a policy that was hard to argue against. It was also a forward-thinking policy that works to improve the current Medicare program," says Moran. Spangler agrees: "It falls right into line where Congress is trying to go as far as health care delivery reform. We're offering to be part of the solution."
"There were many, many times throughout this process that this whole effort could have just ground to a halt," says Moran. "We don't control the process — nobody does from the outside — but we felt that we had such a strong argument to make on why these policies were good. People realized that we were trying to get ahead of the curve and our policies were a way of putting some kind of sanity to the madness of inappropriate utilization."
As the March 31 deadline neared, the three congressional committees agreed to work together during the holiday recess to combine their three respective SGR reform bills into one. On February 6, the committees released a final proposal. "We were fairly confident that dampening and CDS would be in there, but we literally turned to the end of the last page and there was a miscellaneous section and MPPR was in there too," says Josh Cooper, senior director of government relations. While the legislation stopped short of eliminating the MPPR, it stipulated that CMS release the data behind the policy, which the government relations team had been requesting for years. "It was as if the MPPR transparency fell out of the sky," says Ted Burnes, director of RADPAC. "I mean, we really worked on it, but if you had to ask us with truth serum, 'Hey, is it gonna happen?' we would have given it maybe a 30 or 40 percent chance."
With a policy on the table, Congress began the debate on how to pay for the repeal, which is estimated to cost between $121 and $175 billion over 10 years. "While they had an agreement on the policy, it's considerably more difficult to get an agreement on funding," says Spangler. As Congress debated the various proposals, it became clear that there was a real possibility the repeal would not pass. "Once we'd made it into the legislation, we enjoyed being at the top of the rollercoaster. But now we were starting to plunge downward, realizing that Congress may not pull it off and get the legislation passed," says Cooper. Without a repeal, the only option would be another short-term patch, a stop-gap solution that would delay the cuts without doing away with the SGR. The previous patch would expire in two weeks.
Many medical societies opposed another patch, refusing to settle for anything less than full repeal. "Our feeling was that if it's a patch, we wanted to be included, and if it's a permanent fix, we wanted to be included. We decided to break with the rest of the house of medicine and support the patch," says Spangler.
Patching it Up
The government relations team contacted staff on both sides of the aisle, in both the House and Senate, to make the case that its provisions should be in the patch. These provisions were non-controversial and appeared in the full-repeal legislation (which was losing considerable momentum in Congress by this point). Another plus was that they didn't cost anything. While it seems simple, the government relations team faced opposition to adding anything at all to the patch. "The more you put into a patch, the more you can potentially scare someone off," says Burnes.
One key was the relationships the team had formed on Capitol Hill, which led to calls from congressional staffers looking for opportunities to work together on the patch. "Usually when they reach out to us it's either really, really good or really, really bad. Fortunately it was the former this time," says Burnes. "And without the relationships we have, this would not have happened." During this time, the Radiology Advocacy Network actively supporting the government relations team's efforts, with responses to calls to action sometimes reaching four time their normal rates. "Membership played a significant role in making sure Congress knew this was something that they were very interested in and wanted to have included," says Cooper.
As the patch came together, Congress included all of the imaging provisions. On March 25, 2014, the patch came up for debate in the House. The government relations team gather to watch on CSPAN. ("We're among the few people who actually watch CSPAN," says Cooper.)
During the debate, something unusual happened. "All of the sudden we noticed that debate was suspended. We're scrambling to figure out what was going on. Rumors were running rampant that the House didn't have enough votes to pass the patch because practically all of the other physician groups were mounting a charge in opposition," says Cooper. The leaders of the House left the floor to consult. The team was stunned.
"Then in one of the quickest votes I've ever seen," says Cooper, "the House came back into session and called for an immediate voice vote on passage of the SGR patch bill. No sooner than the words requesting the vote been spoken, the vote was gaveled down and the legislation declared passed." Passing a piece of legislation is typically an hours-long process and usually includes further debate. "We were looking at each other going, 'Did that just happen? Did we win?'" says Cooper. The patch had passed in 29 seconds.
Six days later, the Senate passed the patch. The team watched as the vote tally climed closer and closer to the 60 votes needed to pass. "When that 60th vote was cast, it was a great feeling," says Chris Sherin, director of congressional affairs.
On April 1, President Barack Obama signed into law H.R. 4302. Instead of the 24 percent drop, Medicare physician payments will increase by 0.5 percent through December 2014 and then remain steady through March 31, 2015.
The bill contained three more pieces of good new for radiologists. First, referring physicians will be required to consult, but not adhere to, appropriateness criteria at the time of ordering. This is the first time this type of provision has been included in any form of Medicare legislation. "It's shifting the direction of radiology toward what the government and the policy-makers see as the next frontier for health care, which is moving away from fee-for-service and toward value-based care," says Sherin. "It's designed not only to preserve radiologists' role in the health care system but to elevate their role and increase their involvement."
The second piece of good news relates to the MPPR. CMS will now be required to reveal the data it used to justify the policy. The third victory affects the dampening policy. Starting in 2017, CMS will be required to phase in any single year cuts of more than 20 percent over a two-year period. This level of stability is crucial to physicians, especially radiologists, who have faced the uncertainty associated with pending SGR cuts on a near annual basis.
Now that is has passed, the legislation has to be made into a law. "We have to make sure that it is implemented in a way that will have real impact," says Burnes.
The majority of the regulations pertaining to this policy will most likely be issued by CMS over a series of years. First and foremost, by no later than November 2015, CMS must deem various sets of appropriateness criteria as acceptable for consultation by ordering physicians. These guidelines must be developed by national medical specialty societies, such as the ACR. By April 2016, CMS will choose a clinical decision support system to administer the appropriateness criteria. ACR Select will be among the choices and contains the most comprehensive evidence-based guidelines for diagnostic imaging selection. Starting January 1, 2017, ordering physicians will be required to consult the imaging appropriateness criteria through a clinical decision support tool.
The details and timeline for CMS to release its MPPR data have yet to be decided upon, but once this information is available, radiology and other specialties can analyze (and potentially dispute) the statistics behind damaging cuts to reimbursement. "We're hoping that it will become clear to Congress that there was no justification for this MPPR reduction. At that point, we will pursue a legislative remedy or look to the courts to remedy this policy," says Moran.
"As we run our advocacy program, we look at radiology-specific issues, but we also look at broader reforms that we think would improve the Medicare program," says Moran. "The dampening policy, appropriateness criteria, MPPR — all of these issues contribute to Medicare as a whole, benefiting not only radiologists but also patients and other physicians."
Meanwhile, this latest SGR patch is a temporary fix to a systemic problem. In the coming months, it will be up to Congress to determine whether to repeal the SGR or resort to another short-term solution. The current patch expires on March 31, 2015.
By Lyndsee Cordes