Lawmakers must act this year to fix Medicare reimbursement for physicians

Christina Downey: ©Christina Downey, MD

It may be tempting, now that we’re past this chaotic election period, for lawmakers to coast into the New Year and turn their attention toward the next Congressional session. But as a practicing rheumatologist, I’m reminded every day of the urgent, ongoing, and growing challenges faced by medical providers as we work to deliver quality care to our patients – especially those of us who treat America’s increasing aging population.

Medicare now provides insurance for one in five Americans, and the number of beneficiaries is on track to continue growing. Yet the program that pays physicians remains chronically underfunded and hamstrung by flawed policy. On the right, on the left, and in between, stakeholders are sounding the alarm: decades of unaddressed Medicare cuts to physicians, soaring practice costs, and ongoing workforce challenges threaten the practice of rheumatology and our health care system as a whole.

As this Congress nears its end, it is more important than ever that lawmakers act to address the acute and long-term issues faced by the Medicare system, ensuring that the more than 60 million patients living with rheumatic diseases in our country have access to the best available care. At a minimum, before the end of the year, Congress must address the devastating cuts in provider reimbursement included in the final CMS physician fee schedule, set to take effect in 2025. Before the calendar turns, Congress must also tackle expiring COVID-era telehealth provisions that allow expanded access to care – particularly for rural and other underserved areas.

Inadequate annual payments from Medicare have led to financial insecurity among physician-owned practices, putting patients’ access to care at risk. Since 2001, the cost of operating a medical practice increased 39%, thanks to continued inflation. In that same time period, doctors have seen a cumulative Medicare pay cut of 29%, according to the AMA. Thankfully, the bipartisan Medicare Patient Access and Practice Stabilization Act (H.R. 10073) —introduced by Representatives Greg Murphy (R-NC) and Jimmy Panetta (D-CA) proposes tocancel the impending CMS cuts and provide a slight upward adjustment for physician reimbursement under Medicare—is a welcome first step, but Congress must also begin to consider longer-term solutions to support and sustain health care providers nationwide. Reform must include bringing physician reimbursement in line with all other Medicare payment schedules by passing legislation to update the Physician Fee Schedule annually based on inflation.

Beyond reimbursement, legislators must urgently address telemedicine access before the end of the year. One silver lining from the COVID-19 pandemic was the expanded use of telemedicine, which is now used by an estimated 74% of practices. But without action from Congress, Medicare reimbursement for telehealth services will return to the far more restrictive level seen before the pandemic, threatening patient access to care that has been enormously beneficial, especially for older Americans. It is time for lawmakers to facilitate continued Medicare support for telemedicine by removing interstate licensing restrictions and ensuring payment parity of qualified video and phone visits vis-a-vis face-to-face visits.

In addition to tackling the immediate threats of physician payment cuts and telehealth reimbursement under Medicare, policymakers should also consider changes to payer utilization management policies to strengthen our health care system.

Prior authorization continues to be a substantial barrier to care for rheumatology patients. By creating hours of burdensome administrative work for rheumatologists, patients are forced to suffer unnecessary care delays and denials that put them at risk for serious harm. The bipartisan Improving Seniors Timely Access to Care Act of 2024 (S. 4532/H.R. 8702) will help to reduce administrative burden and undue delay of patient care imposed by prior authorization in Medicare Advantage (MA) plans. In addition, the Safe Step Act (S. 652/H.R. 2630) can help streamline care by creating a clear process for exceptions to step therapy requirements and ensuring timely delivery of the right treatment.

Finally, high out-of-pocket costs for patients make treatment adherence difficult, leading some patients to ration medications or skip care altogether. Congress should consider policies to cap costs and bring more transparency to Pharmacy Benefit Manager (PBM) practices that commonly inflate prices and limit patient choice.

The end of the year is not just a time to toast health at holiday parties – it is a critical window for lawmakers to address pressing challenges that threaten the ability for health care providers to offer quality care to patients nationwide. I therefore ask lawmakers to view the remainder of the year as an opportunity. First and foremost, to prevent cuts to physician reimbursement and telehealth coverage under Medicare, but also to unite in support of legislation to fix prior authorization, step therapy, and drug price issues. It is only through action that Congress can ensure that patients remain able to access high-quality care from their providers.

Christina Downey, M.D., is the Chair of the American College of Rheumatology’s Committee on Government Affairs.