Acknowledging that the status quo in health care is unsustainable and that issues of access to coverage, quality of care and cost control must be addressed, and given legislative momentum in Congress, the Academy is advancing components for bills that protect patients and physicians. While reform discussions are still ongoing and no pending legislation is perfect, we are committed to continue collaborating with health leaders in Congress to improve bills being considered. The Academy is actively engaged with other physician organizations as key House and Senate committees debate legislation that puts a long-term sustainable growth rate (SGR) fix in play, in addition to other top issues.

Medicare Physician Payment
While recognizing that compromise language will likely occur, we have established some important policy priorities. Key provisions that we have fought for include:

• Repealing the SGR, wiping out the nearly 40 percent in payment cuts that are scheduled to impact physicians under the Medicare program  (cost: $230 billion)
• Replacing the current SGR with two new conversion factors that will place major surgical procedures and office-based codes in separate “buckets” with separate targets
• Providing bonus payments for primary care that are not paid for by cuts in payments to other groups of physicians.

To date, we achieved an agreement to test new Medicare payment reform options as pilots, rather than permanently implementing untested models, including:

• Medical home concept (Should some specialists be permitted to serve patients as a medical home?)
• Accountable care organizations (physicians, hospitals, etc., working as an integrated system of care under a spending and bonus target)
• Bundling all services in one payment for an episode of care

Quality Improvement Initiatives and Comparative Effectiveness
Several Medicare Physician Quality Reporting Initiative (PQRI) program improvements sought by medicine are included in health care reform legislation:

• Timely feedback to participating physicians
• Appeals process
• Continuation of ONLY positive incentives/bonus with no penalty for physician non-participation

A public/private commission would be established to provide leadership, priorities and support for comparative effectiveness research. However, the commission is prohibited from mandating coverage, reimbursement or other policies to any public or private payer.

Public Plan Option to Compete with Commercial Insurance Plans
The proposed public health insurance option in the House bill raises a number of concerns. In response to questions from the Academy and other medical groups, the public plan option will not mandate that individual physicians participate. The legislation clearly allows for physicians to opt out of the program with no penalties for doing so. A 5 percent bonus is offered to Medicare physicians who participate in the “public option.”

A significant win for the Academy is the agreement in the House bill to drop ultrasound and other office testing from Medicare imaging payment cuts. The new utilization policy under Medicare will be limited to major imaging: MRI, CAT and PET.

In addition, we are working on a compromise on Medicaid language mandating coverage of services provided by optometry to ensure that scope of practice is not expanded beyond what is currently allowed under state law.

As the reform process moves forward, it is important for medicine to stay engaged and affect the final wording of any major health reform legislation. As important as are the “broad brushstrokes” of bill language, the details of bill language and final rules of implementation may well decide the legislation’s ultimate impact. We must continue to thwart inclusion of cost-control mechanisms such as a Medicare Payment Advisory Commission-type commission with authority to automatically cut Medicare and other payments to providers, as well as implementation of untested reforms without input from medicine.

We continue to work to improve the House bill through additional changes, such as the ultimate inclusion of medical liability protections -- similar to California’s Medical Injury Compensation Reform Act -- and refinement of “sunshine” or industry payment disclosure language.