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As Another SGR Patch Deadline Approaches, Is a Horrifying Sequel in the Works?

March 12, 2015
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The annual temporary Medicare “doc fix” is the “Saw” of healthcare policy measures and the latest sequel could be another gruesome tale for healthcare IT leaders.

Let me explain. “Saw” was a horror movie that came out in the mid-aughts. When I was a freshman in college, it was all the rage. Everyone was talking about the mind-blowing finish. The movie did incredibly well at the box office, grossing more than $100 million off a $1.3 million budget.

Because Hollywood is a business first and foremost, the success of that movie spurned a sequel. Some sequels are necessary. Most are not. Some are actually pretty good, even better than the original. Most are not. It’s usually just a money grab.

Thus, “Saw II” came out one year later and despite not being nearly as good as the original, it also did really well. So guess what? “Saw III” was born one year later. Then “Saw IV”, V, VI and “Saw 3D.” Seven movies in seven years, six sequels—each (from what I’ve heard—I had to stop supporting them after Saw III) worse than the previous one.

Every time a new Saw movie came out, most people would roll their eyes and express their disbelief that this was still happening. Despite the cynicism, it kept happening.  In fact, I have read that it could happen again, in 2016. Why does it keep happening? The answer is simple. With a low budget and a high gross, the franchise makes a profit for its studio. It doesn’t matter that the concept of the movie has been played out, ripped off, and done to death. It’s all about the almighty dollar.

This takes me to the Sustainable Growth Rate (SGR), Medicare’s formula for reimbursing doctors, which will likely be temporarily fixed when it expires at the end of March. Year in, year out, we get a temporary fix that prevents a 21.2 percent cut in payments. Year in, year out, we get a promise that a permanent fix is on the horizon. This upcoming one would be version 18 of the temporary fix.

Why do these temporary fixes keep happening? The answer, of course, comes down to money. As explained in a Wall Street Journal article, Congressional officials cannot agree on how to pay for a permanent fix. Should there be cuts to Medicare? An increased budget deficit? Who knows? So let’s just delay this “one more time” and get back to it in a few months or a year.

Why are measures like the ICD-10 transition sneakily crafted into this legislation, as was the case last year? Again, it’s money…and politics. When lobbyists know something is guaranteed to pass, they use their “influence” to get something they oppose embedded. Certain medical groups have a ton of influence, which explains why ICD-10 gets targeted. This isn't new. We've seen this movie before.

If a temporary fix is up for a vote again, I am guessing ICD-10 will be targeted. It was already targeted a few months back for a different temporary measure and was spared. The effort will happen again.

As I said, the ICD-10 debate isn’t as one sided as we saw during the House of Representatives’ Energy and Commerce Committee’s Subcommittee on Health’s hearing. Just last week, nearly 100 physician groups representing state and specialty medical societies wrote a letter the Centers for Medicare & Medicaid Services (CMS) regarding ICD-10 concerns that the groups say the agency has not addressed. 

I really hope ICD-10 gets spared. There are valid concerns over the transition still unanswered but I think the industry is ready for it to happen. Studies have shown that providers are optimistic, CMS testing is going fairly well, and costs aren’t as bad as previously reported.

I also hope a permanent fix for the SGR is reached. Doing something 18 times in 13 years is embarrassing. It’s time to figure out a long-term solution for reimbursement of physicians.

Mostly though, I hope we don’t have to keep doing this. I have my doubts. The is a reason most healthcare policy observers are so familiar with this story that they could probably tell it backwards in their sleep, just like movie nerds could probably predict what will happen in the next Saw movie. It’s because it keeps happening.

Please feel free to respond in the comment section below or on Twitter by following me at @GabrielSPerna



My concerns are the insurance companies, Who is regulating their processes and payments? Why is it that Our Physicians sign up with various insurances to see their clients/patients and never hold up to their contracts and no one cares. Example: Health Net they have a call center in Philippines, very hard to understand when you call more than 99% of transferred calls are disconnected, this makes for a very long day working on one issue. UHC largest ins co. in the US same scenario. The EOB (explanation of benefits are very difficult to understand) you call to get help and you only get attitude. VA-we contract to care for our vets and never get the referral or authorization that is required even though we request it weeks in advance. Currently I have over 80,000 in outstanding fees dating back to 2013. for the VA. When we call we get told you can't bill pt. per your contract, I say we know but, we aren't getting anywhere with calling VA about outstanding claims, perhaps pt. needs involvement. Yes, we signed up but not to provide free services the contract stated we would be compensated for our services. WHO IS GOING TO BAT FOR THE PHYSICIANS AGAINST INSURANCE COMPANIES? THEY OFTEN TAKE BACK PMTS FROM YEARS PAST AND YET THEY ONLY ALLOW PHYSICIANS TO APPEAL A CLAIM WITHIN (90-DAYS). What is wrong with that picture? They make the mistake in processing a claim then they take the money they never paid back on another claim which went out as a clean claim, again what is wrong with THAT PICTURE? The other issue is educating patients, more than half of my day is taken up by sitting with patients and educating them on their insurance benefits/policies, something the insurance companies should be doing. They sign up these poor elderly people with the Advantage plans (HMO's) and don't explain that it is a Medicare replacement therefore, when the patient arrives at a physicians office they give the Medicare card and list the other ins. as a secondary. Patients 100% of the time tell me they are not aware that the HMO/Advantage plan was a replacement, they have no clue how it works. Most people tell me they would never have surrendered their Medicare and secondary ins. had they been educated on how their new plan works. Physicians all over the nation need help with getting their rightful payments from insurance companies. Insurance companies need to be held to a standard as well as the Physicians. Payments trickle in and then what is paid is later taken back due to some internal error by insurance. This is very frustrating and I welcome anyone, who wants first hand examples to visit our office to hear and see how bad insurances treat physicians and patients. One example: Patient needs an injection to the painful knee, can barley walk the injection would give relief for approx. 1-6mo. ins was contacted weeks in advance to approve the injection and costly med. we are given an authorization # procedure is done patient feels great and claims is sent out with all information needed for adjudication of claim. We get a denial due to the expense of the med apparently it was suppose to be obtained by a specialty pharm. we are never told this is the protocol for that particular plan. However, when we contacted the insurance in advance they never said a word about this regulation. I'm told we should be using the verbiage "buy and bill" when requesting that particular med. My response to that was, "When we called, weeks in advance why weren't we told about this and why were we given an authorization to perform the procedure, since the very first thing out of our mouth is," we need to provide patient XYZ with an Orthovisc injection does this require prior authorization or referrals." When all this is then presented to the so called resolution specialist, they then state well it wasn't medically necessary. Even though our medical documentation clearly stated the need for this type of injection what the medical benefits would be. What, we should send our veterans away in pain after what they did for our country, I don't think so. They deserve relief and more from everyone who they come in contact with when they need help. The example above is not only happening to our Vet's but to all pt's with various insurance coverage. What is a Physicians office to do? we feel we are upholding our contract to provide exceptional medical services for our patient's and yet an Insurance co. can choose to not pay us because of Verbiage they prefer, was not used and only in an article written very small is where I found out that when sending a corrected claim they do not want that verbiage used they want it to state RECONSIDER!!!!


Frustrated Biller