New Report Examines Federal Perceptions of SGR

Congress might not reform the sustainable growth rate, or SGR, formula used to determine physician payment rates under Medicare for at least another two years, even though congressional staff members are convinced the current system is not economically or politically feasible. That's the conclusion of a preliminary study report that evaluated the views of key congressional staff members and federal agency employees on physician payment and primary care.

"Congress would like to get rid of the SGR," said Brian "Yoshi" Laing, a medical student at the University of California, San Francisco, and a visiting scholar at the AAFP's Robert Graham Center in Washington. Laing is well along in the process of researching and writing a report on views in Washington about the SGR. Congress, he said, has to spend about $4 billion each year to "patch" problems created by using a Medicare fee schedule based on the SGR, which has become a political liability because of its punitive effect on physician payment rates.

But the cost of replacing the SGR with a more accurate index is considered prohibitive -- at least $300 billion during the next 10 years, said Laing. As a result, Congress may not be willing to address the issue until after the 2008 presidential election or until it is clear that use of the SGR-based formula is adversely affecting patients, say congressional staff interviewed for the study report, "Primary Care on Capitol Hill: A Case Study of Politics and Physician Payment."

"Some staffers predict the SGR will be patched for another two years," Laing said. A few congressional staff members noted that a broad "physician consensus" about the SGR does not exist, creating what they described as a "spilt between primary care doctors and subspecialists," said Laing, who presented early findings from the report during a March 27 forum at the Graham Center.

"One person said, 'I have not seen the medical community come together yet,'" Laing related. He added, "They are not blind to the infighting among physicians."

The report is based, in large part, on interviews with congressional staff who either work directly with House and Senate committees with jurisdiction over Medicare or who work for members serving on those committees. The committees include the Senate Finance Committee, the House Ways and Means Committee, and the House Energy and Commerce Committee.

Laing interviewed 13 congressional staff members -- seven Republicans and six Democrats -- four of whom serve on health committee staffs and nine of whom work for individual legislators who are on the committees. The length of their experience with health care issues ranges from three months to nine years, with an average of 4.3 years, Laing noted. The congressional staff members completed a questionnaire and an interview with Laing that focused on physician payment under Medicare and primary care.

Laing also interviewed primary care advocates and staff from the Congressional Budget Office, the Government Accountability Office and the Medicare Payment Advisory Commission, or MedPAC, which makes recommendations to Congress on Medicare payment issues.

"Many congressional staffers and MedPAC staffers are hungry for ideas to reform physician payment, and they are very willing to listen," said Laing.

Several congressional staff members want comprehensive health care reform to include physician quality and performance measures, making it imperative for family physicians to incorporate these factors in their health care proposals to Congress, Laing said.

Congressional staff members also want "hard evidence demonstrating definitively that primary care improves quality and saves cost," according to Laing. Most staff members said the nation's health care system is "short-changing primary care physicians," and cited low physician payment rates as an example, according to Laing.

In addition, there is a general awareness among staff that the number of primary care physicians is falling, said Laing. Many expressed concerns about the decreasing number of medical school graduates who choose primary care as a profession and the effect of that decline on access to care. Yet most staff members still are not convinced there is a lack of primary care access, Laing added.

Robert Berenson, M.D., a senior fellow with The Urban Institute, said this last point was an important one to consider. Family physicians should not focus on access-to-care issues at the expense of other issues that may carry more clout on Capitol Hill, he said. It probably is more important to point out that the shortage of primary care physicians will make it difficult to adequately care for the growing numbers of patients with chronic conditions, driving up health care costs, Berenson stressed.

MedPAC staffers, meanwhile, said they would push the "medical home" model promoted by the AAFP and other organizations if they had the choice of advocating just one health care issue, Laing noted.