Congress is headed toward a bipartisan solution to fix a Medicare formula that threatens to slash payments to doctors every year. The so-called "doc fix" would replace the cuts with a multipronged approach that will be expensive and will have Medicare beneficiaries pay part of the bill.
Congress has repeatedly overridden the payment cuts, which are mandated under a formula called the Sustainable Growth Rate (SGR), which became law in 1997, that is a way of keeping growth in physician payments in line with the economy's overall growth. This year, unless Congress acts, rates will automatically be slashed 21 percent.
In a rare instance of bipartisan collaboration, House Speaker John Boehner and Minority Leader Nancy Pelosi are pushing a plan to replace the SGR with a new formula that rewards physicians who meet certain government standards for providing high quality, cost-effective care. If they can get the plan through Congress, President Barack Obama has said he will sign it.
The fix will cost an estimated $200 billion over 10 years. Although Congress has not figured out how to pay the full tab, $70 billion will come from the pocketbooks of seniors.
There are better places to go for the money, such as allowing Medicare to negotiate drug prices with pharmaceutical companies and tightening up reimbursements to Medicare Advantage plans. But there's no political will in Congress for that approach.
And the doc fix needs to be done. Eliminating the SGR will greatly reduce the risk that physicians will get fed up with the ongoing threat of reduced payments and stop accepting Medicare patients. "Access to physicians hasn't been a big problem, but if doctors received a 21 percent cut in fees, that might change the picture," says Tricia Neuman, senior vice president and director of the Program on Medicare Policy at the Kaiser Family Foundation.
Here's what the plan would cost seniors:
Many Medicare enrollees buy private Medigap policies that supplement their government-funded coverage (average annual cost: $2,166, according to Kaiser). The policies typically cover the deductible in Part B (outpatient services), which is $147 this year, and put a cap on out-of-pocket hospitalization costs.
Under the bipartisan plan, Medigap plans would no longer cover the annual Part B deductible for new enrollees, starting in 2020, so seniors would have to pay it themselves. Current Medigap policyholders and new enrollees up to 2020 would be protected.
The goal would be to make seniors put more "skin in the game," which conservatives have long argued would lower costs by making patients think twice about using medical services if they know they must pay something for all services they use.
Plenty of research confirms that higher out-of-pocket expense will reduce utilization, but that doesn't mean the reform will actually save money for Medicare.
Numerous studies show that exposure to higher out-of-pocket costs results in people using fewer services, Neuman says. If seniors forgo care because of the deductible, Medicare would achieve some savings. "The hope is people will be more sensitive to costs and go without unnecessary care," she says. "But if instead, some forgo medical care that they need, they may require expensive care down the road, potentially raising costs for Medicare over time."
High-income premium surcharges
Affluent enrollees already pay more for Medicare. Individuals with modified adjusted gross income (MAGI) starting at $85,000 ($170,000 for joint filers) pay a higher share of the government's full cost of coverage in Medicare Part B and Part D for prescription drug coverage. This year, for example, seniors with incomes at or below $85,0000 pay $104.90 per month in Part B premiums, but higher income seniors pay between $146.90 and $335.70, depending on their income.
The new plan will shift a higher percentage of costs to higher-income seniors starting in 2018 for those with MAGI between $133,500 and $214,000 (twice that for couples). Seniors with income of $133,000 to $160,000 would pay 65 percent of total premium costs, rather than 50 percent today. Seniors with incomes between $160,000 and $214,000 would pay 80 percent rather than 65 percent, as they do today.
Everyone pays more for Part B
Under current law, enrollee premiums are set to cover 25 percent of Medicare Part B spending, so some of the doc fix's increased costs will be allocated to them automatically. Neuman says a freeze in physician fees is already baked into the monthly Part B premium for this year, so she expects the doc fix to result in a relatively modest increase in premiums for next year, although it's difficult to say how much because so many other factors drive the numbers.