• In The Trenches

    Your Presidents Told Congress How to Invest in You Right Now

    Reforming Medicare Payment, Streamlining Prior Authorization Topped the List 

    Oct. 19, 2022

    By Stephanie Quinn
    Senior vice president of advocacy, practice advancement and policy

    Over the past two decades, according to an AMA analysis of Medicare Trustees’ data, Medicare physician payments have decreased by roughly 20% when adjusted for inflation. Meanwhile, your outlay has only increased: Some 90% of medical practices are reporting costs rising faster than revenues. That kind of financial pressure is the proverbial insult given further injury by mounting administrative burdens. The result endangers both primary care practices and the communities that most need them. 

    Even worse, the badly outmoded Medicare physician fee schedule, as I have long decried in this space, sends its negative effects rippling outward to the state Medicaid agencies, managed care plans and private payers that base their payment rates on the MPFS. So while stagnant Medicare physician reimbursement yields insufficient payments across payers and patient populations (thanks in part to the statutory budget-neutrality requirements shackling CMS), certain nonphysician providers, such as hospitals and nursing facilities, have enjoyed Medicare payment increases and upscaling to reflect actual costs.

    This is the ugly backdrop against which more destabilization is set to rock primary care practices on Jan. 1, when the historically low proposed 2023 MPFS conversion factor is slated to take effect. Unless Congress moves fast, the entire physician community, buffeted by rising inflation and the ongoing effects of the pandemic, will suffer, threatening the entire health care system.

    To drive home this urgent message, your Academy presidents last week met in person with their congressional delegations. Board Chair and immediate past president Sterling Ransone, M.D., of Deltaville, Va.; President Tochi Iroku-Malize, M.D., M.P.H., M.B.A., of Long Island, N.Y.; and President-elect Steven Furr, M.D., of Jackson, Ala., spent Oct. 12 advocating for Medicare payment reform and pushing to finalize an important AAFP win on the administrative simplification front. (These are fights you can join as well; I’ll tell you how in a bit.)

    Seeking immediate relief from statutory payment cuts as well as long-term reforms that would bring stability to the Medicare physician payment system, they asked their lawmakers to get behind the Supporting Medicare Providers Act of 2022  (H.R. 8800) and called for legislation to deliver a positive annual update to Medicare physician payment based on the Medicare Economic Index. They reminded their members of Congress that the MPFS is the only payment system within Medicare without an annual inflationary update. Hospice providers, skilled nursing facilities and ambulatory surgery centers can all expect to receive positive annual updates to Medicare payment in 2023, whereas physicians face further reduction.

    Building on the AAFP’s successful work to pass the bipartisan Improving Seniors’ Timely Access to Care Act in the House, Ransone, Iroku-Malize and Furr asked the senators on their agendas to seal the deal. The bill would streamline and standardize prior authorization in the Medicare Advantage program, protecting patients from unnecessary delays in care and bringing much-needed administrative simplification to physicians, 88% of whom say prior authorization’s burdens are high or extremely high.

    Helping the case: the damning report from earlier this year in which the HHS Office of the Inspector General confirmed that Medicare Advantage plans use prior authorization to inappropriately deny coverage and payment for medically necessary services, creating barriers to care for beneficiaries.

    There’s momentum to spare here. The House version of the bill accrued 326 co-sponsors before passing unanimously. Some of that extra energy, your presidents told lawmakers, should go into passing the Safe Step Act (S. 464/H.R. 2163), which would establish transparency guidelines to prevent inappropriate use of step therapy in employer-sponsored health plans and create a clear process for patients and physicians to seek reasonable exceptions to step therapy.

    If the members of Congress from New York, Virginia and Alabama didn’t know before, they know now: Patients in step-therapy protocols are less likely to be treated effectively compared with patients in plans without that requirement, leading to increased care costs through additional outpatient visits and hospitalizations and worse treatment adherence. They know now that you and your patients require access to clear guidelines for prior authorization requirements and timely responses from insurance plans as well as reasonable exceptions and overrides of step-therapy requirements.

    How’d we do?

    “All of the lawmakers and staff agreed that we need to prevent the Medicare cuts in January,” Furr told me after his meetings. “They all seemed genuinely concerned and understood that, in this stressful time of increasing inflation and practice costs, our family practices would have a difficult time surviving a greater than 4% Medicare cut. And everyone was on board with the need to reduce administrative burden that is caused by prior authorizations.

    “They understood our examples of patients treated with a routine generic blood pressure or diabetic medications who, due to a formulary status change, struggle to get their medication filled and sometimes lose control of their hypertension or diabetes.”

    “The majority of them stated that they agreed that legislation to address prior authorization and administrative burden was important and that this has bipartisan support,” Iroku-Malize said. “They knew who we were and understood how important our advocacy efforts were to primary care and its role in the future of health care.”

    To further that point, Iroku-Malize stressed during her sit-downs “the difficulty in recruiting and retaining family physicians in underserved and/or rural areas and the hardships faced by my colleagues and patients with regard to getting medications or diagnostic procedures due to the delay caused by prior authorization.”

    “I have spoken to physicians who are leaving their practices because they can no longer afford to keep their doors open, which will only be exacerbated by the upcoming cuts to physician payments in 2023,” she added.

    “We especially emphasized that we cannot go into January with this uncertainty of the Medicare cuts hanging over our heads, as we did last year,” Furr said.

    Your Turn

    To reform the Medicare payment system and put it on a truly sustainable path, and to increase administrative simplification in family medicine practices, I once again encourage you to add your voice to a couple of the Academy’s Speak Out campaigns. Ask your members of Congress to avert pending pay cuts and implement long-term Medicare physician payment reform, and tell your senators it’s time to pass the Improving Seniors’ Timely Access to Care Act.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.