This Week – March 21, 2015

This Week in Washington DC:

  1. SGR Reform Package Released: What You Need to Know
  2. ACG on Capitol Hill for Colorectal Cancer Awareness Month

ACG Working to Get a Permanent SGR Fix

ACG is actively pushing Congress to repeal the SGR formula. The latest developments on SGR and Medicare reimbursement reform:

The Background:

Absent congressional action, all Medicare providers will receive a 21% cut in Medicare beginning April 1st due to the sustainable growth rate (SGR) formula. It is designed to slow Medicare spending when actual spending is higher than targets for each year. It is no secret, however, that the SGR formula is broken and Congress should have passed real Medicare reimbursement reform years ago. However, Congress has been unable to pass this repeal legislation but has instead stepped in 17 times to avert massive automatic reimbursement cuts using temporary moratoriums or “patches.” By doing so, the debt from the projected cuts gets carried over into the following year. Thus, since Congress has stepped in 17 times, we now face a 21% cut.

The Latest Proposal:

In a rare move of bipartisanship, congressional leaders on Thursday released a draft bill that would avert this looming April 1st cut and also repeal the SGR formula altogether. While repeal of the SGR formula is good news, there are serious questions about how they will pay for this and how the new structure will impact clinicians.

The proposal replaces any looming cut – and accumulated debt from previous cuts – with the following updated for Medicare providers: a 0% update to June 2015, a .5% update from July to December 2015, a .5% update for 2016-2019, 0% update from 2020-2025, and .5 to 1% updates from 2026 and beyond. The draft legislation also combines the meaningful use program and the physician quality reporting system (PQRS) into one program beginning 2019. This program is called the Merit Based Incentive Payment System, or “MIPS.” This program will consist of the following components: quality, resource use, clinical improvement activities, and meaningful use. Each category will be assigned a weight and each provider would be given a score for each component. The Secretary of HHS will determine an overall threshold “composite score” benchmark for each provider, then compare this threshold benchmark to each provider’s individual composite scores in order to determine whether the provider gets a reimbursement cut, a neutral update, or a bonus. Providers scoring a “0” or are in the bottom 25% will receive a reimbursement cut ranging from 4% in 2019 to 9% in 2022+. Providers with higher scores will receive higher payments (capped at 10%) assuming the money is there from cuts to other providers with low scores. This is called budget-neutrality.

The proposal also encourages the Secretary of HHS to develop more alternative payment models for Medicare providers, with incentives for providers to participate in these payment models. The draft is not specific about what these alternative payment models would be, but does encourage Medical Homes for both primary and specialty care.

What is ACG’s Position?

ACG is cautiously optimistic when comparing the draft to the current reimbursement structure, even when assuming Congress would always step in and avert SGR cuts under the current system. ACG supports this work and continues to fight for permanent SGR repeal on your behalf.

Why is ACG still hesitant to provide unqualified support for this legislation? As clinicians you know that judgment without data is just a guess. While this draft is worth supporting, and ACG applauds Congress for tackling this problem in a rare, bipartisan manner, there are many details of the package that have yet to be released. For example, the offsets that must be used to pay for the bill have not been released. Thus far, there is no indication that there are any alarming offsets that would negatively impact ACG members, but any effort to pay for the bill by eliminating in-house pathology services or expanding the “misvalued code initiative” to squeeze more savings from Medicare specialty providers remains a possibility as the process moves along. ACG members are unfortunately familiar with the misvalued code initiative as this caused steep cuts to upper GI endoscopy services in 2014 and potential cuts to colonoscopy loom in 2016. Congress may also try to find a way to extend expiring Medicare primary care bonuses authorized by the ACA but were paid for by cuts to specialty providers.

The rumored offsets will be coming from Medicare beneficiaries, hospitals, and post-acute care facilities, traditionally very powerful interest groups. It is still unclear whether members of Congress will be willing to vote for SGR repeal and help physicians if it is perceived as paid for by senior citizens and Medicare beneficiaries. This begs the question: if more offsets are necessary to pass the bill, where will they come from? Could it come from the offsets impacting GI clinicians mentioned above? Will Congress require CMS to find additional savings in the 2016 Medicare Physician Fee Schedule via the “misvalued code initiative,” the same year as CMS is expected to publish changes to colonoscopy reimbursement? To be clear, right now there is no indication that these issues are at the top of anyone’s list, but there is still a long way to go in the process. ACG is working hard to answer these questions for you and also working diligently with congressional leaders to further improve the substance of the bill. Thus, the goal is to better determine the impact to clinical GI and your patients.

Can You Help?

Yes! We have a rare opportunity to reform Medicare reimbursement. Congress needs to hear from you as it is important that we keep up this momentum of repealing the SGR formula and accurately pay ACG members. Let’s keep up the pressure to achieve full repeal of SGR.

Please reach out to your members of Congress with this important message! Click here:

ACG Participates in Congressional Briefing on Colorectal Cancer

On Wednesday, ACG Governor for the District of Columbia, Kathy Bull-Henry, MD, FACG, spoke to a large audience of policy makers, staff, and stakeholders as part of the “Fight Colorectal Cancer” Capitol Hill Briefing. The briefing featured key policymakers and patient advocates who addressed the impact of colorectal cancer, the importance of increasing screening rates, and the role legislators must play in this initiative.

Members of Congress, including Reps. Mike Fitzpatrick, R-Pa.; Joe Courtney, D-Conn.; Charlie Dent, R-Pa.; Donald Payne, Jr., D-N.J.; and Leonard Lance, R-N.J., said they "want to make sure every American has access to critical – and potentially lifesaving – cancer screenings. That means removing detrimental roadblocks that could keep someone from receiving the treatment they need."

ACG thanks Dr. Bull-Henry for taking time away from her practice to participate in this important event.

Kathy Bull-Henry, MD, FACG, ACG Governor for D.C.,
speaking on Capitol Hill this week.

Please stay tuned for further updates. Please also share and discuss your thoughts with fellow ACG members on the ACG GI Circle. To login and share your comments, go to and sign in as a member. Once you have done so, click here and then click the orange "Visit ACG GI Circle" button to be taken to the GI Circle site. If you have not yet activated your ACG GI Circle account, please email us at

Contact Brad Conway, VP Public Policy, with any questions or for more information.

Brad Conway