By Rebecca Adams, CQ HealthBeat Associate Editor
October 15, 2013 -- While the clock ticks on the debt ceiling, other financial deadlines also are approaching, including the last chance for Congress to block a nearly 25 percent cut in Medicare physician payments and a range of expiring provisions that affect everything from therapy caps to hospital payments.
On Dec. 31, a long list of health policy provisions will expire. Traditionally, Congress has continued the payments—also referred to as "extenders"—one year at a time, although sometimes lawmakers have missed the deadlines and had to apply the provisions retroactively. The uncertainty leads to an annual lobbying frenzy.
This year, interest groups are hoping for solutions that will last for at least a few years, if not a decade. But the longer Congress remains flummoxed by negotiations over the government shutdown and the debt ceiling, the slimmer the chances become for a multi-year solution, or even a short-term fix before the Dec. 31 deadline.
One practical problem is that some of the staff experts at the Congressional Budget Office (CBO) and the Centers for Medicare and Medicaid Services are furloughed. Some lawmakers are pushing both organizations to bring back some analysts so that they can offer technical advice and produce new cost estimates for legislation to address the so-called "doc fix" and other expiring provisions.
Earlier this year, the CBO estimated it would cost $139 billion over 10 years to get rid of the Sustainable Growth Rate formula now used to pay doctors. Because the price tag was lower than in previous years, advocates that lawmakers would see a long-term solution as more cost-effective than year-by-year patches.
The House Energy and Commerce Committee did pass a rare bipartisan bill (HR 2810) this summer that would give physicians 0.5 percent annual raises through 2018, use pay-for-performance requirements and get rid of the flawed existing formula. The committee did not identify ways to pay for the $175 billion cost over 10 years.
Neither the House Ways and Means Committee nor the Senate Finance Committee has publicly released a long-term bill.
The American Medical Association (AMA) is continuing to prod lawmakers to act this year on a long-term change.
"With 10,000 baby boomers aging into Medicare each day, we need to repeal the SGR and give Medicare a firm foundation so physicians can pursue delivery innovations that help improve care and reduce costs," AMA President Ardis Dee Hoven told CQ HealthBeat via email. "It's the only fiscally prudent path."
But since any of the efforts now being considered to prevent a government default and open the government will last only a few months at most, lawmakers' attention for the rest of the year is going to be focused on those talks and the Medicare fixes could fade as a priority.
Some groups are acknowledging that getting even a short-term extension will be difficult. The expiring provisions include changes to caps on patients' therapy, additional payments for ambulance providers in rural areas, higher Medicare payments for low-volume and rural hospitals, and authorizations for programs to help low-income Medicare patients.
"Given the current political climate and what is feasible given the current government shutdown and debt ceiling discussion, we are also continuing to send a message to the Hill that should there only be a short-term fix to Medicare this year, the therapy caps exceptions process with modifications to the medical review process needs to be included as well," said Ingrida Lusis, director of federal and political advocacy for the American Speech-Language-Hearing Association.
The American Speech-Language-Hearing Association and the American Physical Therapy Association (APTA) are working on a coalition campaign that is set to launch on Nov. 4 and will accelerate on Dec. 2, which is 30 days before the deadline. About 50 groups will encourage their members to call and write lawmakers both at home and in Washington, D.C.
The coalition is concerned about the expiration of language that prevents patients' therapy from being cut off from Medicare coverage once it costs $1,900 if a doctor says more therapy is needed. Patients and their physicians can circumvent the cap through an exceptions process but the authority for that appeals process expires at the end of the year. With or without legislation, Centers for Medicare and Medicaid Services officials are expected to increase the cap slightly in 2014, but in many years, the increase has been only $20 or so higher.
"Everybody is waiting to see what comes out of the discussion on the budget and debt ceiling," said Mandy Frohlich, APTA senior director of government affairs. "Everyone who lives in the extender world remains hopeful there will be time to talk about long-term solutions for these. But we're preparing for whatever direction this goes."