Blog from Louis Wilson, MD, FACG, Chair, Legislative & Public Policy Council

When Congress returns from recess on November 12, they face a daunting to-do list for the lame duck period. Beyond funding the government for the rest of the fiscal year, ACG and the larger physician community remains hopeful that Congress will reverse the impending 2.8% cut to Medicare physician reimbursement, as well as ensure access to telehealth in 2025.

In this blog, we’ll preview the healthcare priorities we expect to be under consideration in Congress’ post-election session.

Again, Congress Must Act to Avert Physician Payment Cut

Physicians are set to endure a payment cut for the fifth consecutive year, unless Congress intervenes. The proposed Medicare Conversion Factor (CF) for CY 2025, at $32.36, represents a 2.8% decrease from the current 2024 CF of $33.29, and more than 10% less than the 2020 CF of $36.09.

Note: There are two Physician CFs in 2024. On March 9, 2024, the Consolidated Appropriations Act of 2024 offset a portion of the payment cut that went into effect on January 1, 2024.

This cut, if implemented, will significantly worsen patient access to GI services and harm our practices.

SGR All Over Again? ACG Urges Congress to Act

ACG shares member frustration with this annual ordeal that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was supposed to fix, where Congress must step in at the last minute to reverse these detrimental cuts.

After these cuts were first proposed in July, ACG submitted comments to CMS on the inadequacy of the proposed 2025 CF, especially given rising medical practice costs.

ACG has also been working with the American Medical Association and a coalition of other medical specialty societies urging Congress to not only address the proposed 2025 payment cut, but to implement comprehensive, long-term payment reforms that reflect the true costs of providing critical patient services and would create a stable payment system for the years ahead We are grateful to the bipartisan group of more than 230 members of the House that signed a ‘Dear Colleague’ letter to leadership about providing an annual CF adjustment that reflects measures of inflation.   

Not unlike last year, lawmakers in Congress say they are optimistic that they can delay or reduce at least part of the proposed 2025 cuts. It is clear, however, that more substantial reforms will not be addressed until the next Congress begins its work in late January.

A Reminder of How We Got Here

MACRA revamped Medicare’s physician payment system and established the Merit-based Incentive Payment System (MIPS), a quality program for healthcare professionals.

In the years since, there has been almost universal agreement from providers, Congress, and policymakers that the system is broken and needs to be fixed.

Critical flaws that have been identified include the lack of an annual inflationary update (which is included for all other Medicare payment systems), an outdated budget neutrality threshold of $20 million which has not been updated since it was established in 1992, and a quality program that is administratively burdensome, ineffective, and can result in incentive payments that do not cover the actual costs of participating.

Congress Considers Extension of Medicare Telehealth Flexibilities, Reforms to Pharmacy Benefit Managers

Telehealth flexibilities established during the pandemic and extended for an additional two years will expire on December 31, 2024. These flexibilities created broad access to telehealth services for practically all Medicare beneficiaries, not just those living in rural areas.

As one of the top reporting specialties for telemedicine services, this is a critical issue for GI providers and patients.

While at this moment, Congress seems reluctant to make telehealth flexibilities permanent, we have seen support for modest, short-term extensions. ACG will continue to monitor legislation in this space, including the Telehealth Modernization Act of 2024, which was advanced in September by the House Energy and Commerce Committee and includes a two-year extension for telehealth flexibilities.

Currently, the reforms under consideration in Congress do not address in-person vs. telehealth reimbursement disparity that existed before the pandemic. As a reminder, without specific Congressional action, in-person and telehealth evaluation and management (E/M) services would be reimbursement at different rates beginning on January 1st, 2025. ACG has expressed the importance of this issue to key lawmakers and will update members on any changes to telehealth reimbursement.

There is also continued interest in Congress to pass pharmacy benefit manager (PBM) reform by the end of the year. ACG leaders and advocates discussed this during our annual Washington, D.C. fly-in. Of note, the popular Safe Step Act has its largest bipartisan group of supporters yet, including 234 House Representatives and 46 Senators. The Improving Seniors’ Timely Access to Care Act could also be included in this year-end package. We remain hopeful that the bill will be included in a larger end-of-year PBM reform package. While requiring a significant increase in federal spending, there has also been discussions on Capitol Hill on passing legislation that allows Medicare coverage of GLP-1 drugs for obesity treatment. Currently, Medicare coverage is allowed to help treat beneficiaries with diabetes or at risk for cardiovascular disease. ACG is supportive of this change and continues to advocate for the Treat and Reduce Obesity Act.

Timeline for Congressional Action

A table with dates on the left and descriptions on the right. It reads:
Nov. 1, 2024: Release of CY 2025 Medicare Physician Fee Schedule; typically released on or around Nov. 1, the final rule may have a cut that is more or less than the proposed 2.8%
Nov. 12, 2024: Congress returns from their campaign recess
Dec. 20, 2024: Government funding runs out for FY 2025
Dec. 31, 2024: Telehealth flexibilities expire
Jan. 1, 2025: 2025 Medicare Physician CF is effective

While we know Congress is scheduled to return from recess on November 12th, it is unclear (nor guaranteed) when Congress will act on their remaining work.

ACG understands and often communicates to Congress and policymakers that such uncertainty and resolving major issues so close to the end of the year creates a challenging environment in which to manage a practice.

The ACG Legislative and Public Policy Council is closely engaged and continues to monitor the situation. We will provide updates as it evolves.