SS: On March 26, the House had a historic day whereby, 392 to 37, they passed a bill that would repeal the SGR once and for all. That’s historic because we’ve never gotten this far for a complete repeal of the SGR, and it was a slam dunk. It was overwhelming that the House of Representatives said we’re going to do this. Last year, we did not succeed, but the policy from last year was also historic because it was the first time that both chambers of Congress—the House and the Senate—and both parties—the Democrats and Republicans—and all three committees of jurisdiction within—two in the House and one in the Senate—all voted up policy in support of repealing the SGR.

At that time, the AMA was able to get over 600 physician organizations to join in a sign-on letter supporting that policy. That’s the whole profession of medicine. I’ve never seen a sign-on letter in our profession with that many signatories. This year, we got a sign-on letter with over 700 physician organizations. There apparently were more societies who have come out of the woodwork and signed. When we have over 700 physician organizations signed on to a letter supporting the policy, if you are on the outside of that group, you are clearly the outlier because everybody has joined in supporting that this is the best opportunity we have within the political process to finally eliminate the SGR and achieve meaningful reform.

When you ask about the policy itself, the SGR every year or every six months or every three months, depending on the 17 different patches of varying durations, was like a guillotine over the head of the profession. If these cuts, 20 or 30 percent, were ever to happen, it would be devastating. It would be crippling, and it would be entirely unsustainable. To their own detriment, there are a number of folks, physicians included, who have become inured to this and say, “Oh, it’s no big deal. They’ll always patch it.” Well, that’s a risky assumption when you see that Congress has played Russian roulette with the entire nation’s economy through the debt-ceiling debates when they shut the government down. If we’re willing to go that far with the entire nation’s economy and people just take it as a given that all these patches are going to happen, they have not paid attention to contemporary politics.

The only way the federal government doesn’t already have $150 billion more as part of its debt is we pretend we haven’t spent [it] already, because the only way we haven’t spent it is if they let a 25 percent cut into play and they take it back from us by not paying us. —Steven J. Stack, MD, FACEP

All of these other changes that have to happen in payment and delivery reform for new ways to pay physicians, new ways to measure quality, and new ways to adopt technology always get bungled up in this SGR mess. It makes it harder to address those other policies because you have this much more enormous issue that affects everybody. If we pave this over and get rid of this deficit, now physicians at least will have the stability or predictability of knowing, “I don’t have that threat every year.” They’ll have to deal with all of the other regulatory burdens that the government is forcing on us, but they won’t have that burden and the uncertainty of a massive disruption in their revenue stream. Hopefully, we can focus on those other programs and make those better, and physicians and their practices will be able to better invest in the future knowing that there is some stability going forward. By any measure you look at it, the proposed policy that the U.S. House of Representatives passed is directionally better, and in some ways substantially so, than where we currently are; however, I have to qualify that and say we haven’t actually won it. There’s always more work to be done, and when this hopefully finally comes to a close by the time you publish this, hopefully we’ll be in a better position with this gone to focus on the other never-ending parade of issues we have to deal with.

KK: If I understand correctly, there’s about a $200 billion price tag on the SGR repeal. How are they paying for it? Is it all in incentives and payment reforms from physicians, or is there some other mechanism?

SS: Well, no. The “price tag” is an artifact of the way of the political process more than the reality. The only way this has not already been part of the federal debt is that we pretend we haven’t spent the money because whatever the price tag is estimated over a 10-year period, which is how the Congressional Budget Office (CBO) does it, whether it’s $150 billion, $140, or $200, you have to remember there are other things included when they quote the total price because there’s not just Medicare. There are extenders for various other payment programs, programs like the Children’s Health Insurance Program (CHIP), Tricare, and other things that are tagalongs to the SGR. What the true cost of the SGR is apart from all of these other things almost doesn’t matter. The only way the federal government doesn’t already have $150 billion more as part of its debt is we pretend we haven’t spent that $150 billion already because the only way we haven’t spent it is if they let a 25 percent cut into play and they take it back from us by not paying us. It’s actually spent money. It’s a debt, and it’s just not recognized on the books. It’s the kind of stuff that probably Enron did, and we all know what happened to Enron. It is funny accounting, and to say that it’s going to add to the debt is a fallacious premise in the first place because it’s already part of the debt. We just pretend it doesn’t exist in the first place. All the politicians say, “We’d never let a cut like that happen with docs because we know it would destroy the health system.” Even the CBO, when it shows projections, has to follow the assumption that the laws of the land will be executed, but it even creates a second series of charts that show, given that the history is they never follow the law of the land, what we really predict to happen. Because we don’t follow the law, there’s more than enough evidence that shows that this is already part of the debt.