For the third year in a row, the Sanford Health system this fall brought together some of the most dynamic and influential voices in health care, technology and business for engaging and thought-provoking conversations aiming to challenge the status quo and explore new strategies for transforming care delivery in rural America.
While most such innovation doesn’t begin on Capitol Hill, Congress definitely does have a role in helping to fix some problems that are proving to be obstacles to care in rural areas and across the nation.
“It may sound like a oxymoronic, but we need to have an active lame-duck session,” said AMA President Bruce A. Scott, MD, while participating in a panel discussion at Sanford Health’s Summit on the Future of Rural Health Care.
Sioux Falls, South Dakota-based Sanford Health is part of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Dr. Scott, a Louisville, Kentucky-based otolaryngologist in private practice, said immediate congressional action was needed to block a 2.8% cut in physician Medicare pay scheduled to take effect Jan. 1. Following AMA advocacy in leading the charge to reform the Medicare payment system, a bipartisan group of House members introduced H.R. 10073, the Medicare Patient Access and Practice Stabilization Act of 2024. That measure would provide a 4.7% payment update in 2025.
Legislators also needed to enact long-term Medicare payment reform, reform prior authorization and make permanent the temporary measures implemented during the COVID-19 public health emergency.
“At a minimum, we want to roll back the 2.8% cut,” Dr. Scott said, adding that Medicare officials have also estimated that the cost of delivering care to Medicare beneficiaries will be 3.6% higher in 2025.
“When you put it all together, it's a 6.4% cut,” he said, adding that this would be the fifth consecutive year Medicare physician pay was lowered.
“Inflation adjusted, physicians right now are being paid 29% less [PDF]—less—than we were being paid for the same services in 2001,” Dr. Scott explained. “No matter what industry we're talking about, a 30% cut is unsustainable.”
While only a few physicians are dropping out of the Medicare program altogether, many have decided that they cannot afford to take any new Medicare patients.
“Try to get your mother or father in with an endocrinologist, a primary care doctor, or an ENT doctor like me,” Dr. Scott said. “It's an extreme challenge. … And we all know that access to care is the foundation of health care.”
There is bipartisan legislation, the Strengthening Medicare for Patients and Providers Act (H.R. 2474), that would provide an annual physician payment update in Medicare that is tied to the Medicare Economic Index.
“We just need to push that across the goal line,” Dr. Scott said. “We don't want a first down here. We need a victory on this.”
He asked the audience to visit FixMedicareNow.com where they can share their own Medicare-related story and send a message to their senators and representatives urging them to cosponsor H.R. 10073.
“This website has already generated more than half of a million contacts with legislators,” Dr. Scott said. “This problem of Medicare funding trickles through all of health care, and it's a fix that we really need to ensure patients have access to medical care.”
Hospitals, long-term care facilities and ambulatory surgery centers get automatic, annual inflation-based updates, but doctors do not.
“So we're not talking about some radical reform,” Dr. Scott said. “We're talking about bringing physicians up to the same level.”
Congress must act on telehealth
Panelist Ceci Connolly, the president and CEO, of the Alliance of Community Health Plans, said she was “relatively optimistic” that the lame-duck Congress would extend COVID-era telehealth flexibilities—but only for the short term.
“There's still a lot of hand wringing in Washington about whether or not virtual care is adding to costs,” she explained.
Noting Sanford Health’s success with telehealth, Dr. Scott said those flexibilities need to be made permanent to help small practices improve access to care.
“We need a permanent fix of telehealth,” Dr. Scott said. “Practices are hesitant to invest the money into the infrastructure … when we're getting these one-year-at-a-time fixes of telehealth.”
Unless Congress acts, telehealth use will go back to being subject to outdated regulations enacted before the widespread use of cell phones.
Prior authorization overdue for reform
Prior authorization is another area where legislators have a role in getting rid of obstacles that impede care in rural health settings and elsewhere.
“The reality is that prior authorization has a legitimate role, but over the last number of years it has been expanded to the point that, in my own practice, I have to do prior authorization for a $10 nasal spray,” he said. “This is crazy.”
Prior authorization used to only apply to expensive or complex procedures, but now it’s hindering even routine care. The AMA is fixing prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.
A different panelist, Pennsylvania Health Care Association CEO Zach Shamberg had previously mentioned how action is needed to address nurse shortages. Dr. Scott noted how prior authorization frustrations are contributing to physician shortages.
“You mentioned the number of nurses who want to quit. A survey … said that one in five physicians are fed up and they're looking to retire or quit within the next two years,” he said. “Add that to the overall health care workforce shortage.”
Dr. Scott cited an AMA survey (PDF) that found that physicians and their staff spend 12 hours a week completing prior authorizations, filling out an average of 43 such requests weekly.
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“It wastes physicians' time, but the biggest problem is that it harms patients,” he said. “Ninety-plus percent of physicians say that one or more of their patients have suffered significant harm because of the delays of prior authorization.”
Also, 24% of the physicians surveyed noted that these delays have resulted in hospitalization, permanent disability or death of a patient.
In 2018, the AMA, the insurer trade group AHIP, Blue Cross Blue Shield Association, American Hospital Association, American Pharmacists Association and Medical Group Management Association released a “Consensus Statement on Improving the Prior Authorization Process” (PDF).
Insurance plans have been slow to voluntarily implement these agreed upon reforms. The “Improving Seniors’ Access to Care Act” incorporated much of the consensus statement into federal legislation that passed the U.S. House of Representatives in 2022 before stalling in the Senate. A new version of the Act has been introduced and has 228 House and 54 Senate bipartisan, bicameral cosponsors.
Twelve states have also passed prior authorization reform and there is pending legislation in another 13.
“So if the health plans are not willing to do it voluntarily, it's going to be thrust upon them by legislators,” Dr. Scott said. “If they don't want legislation, we all know how they can fix it.”
Dr. Scott summarized the main concerns.
“Let's add transparency: Tell the physician upfront what's it going to take to get this approved,” he said. “Tell us on the back end why it was denied so that we can appropriately appeal. And how about if we make insurance companies stop using fax machines?”
As the session came to a close, Dr. Scott thanked fellow panelist Corey Brown, the senior vice president of government affairs at Sanford Health, for the health system’s participation in a program designed to reduce physician burnout.
“I want to recognize Sanford Health for achieving the gold level, the highest level of achievement, in the AMA Joy in Medicine™ program,” he said. “This is recognition of Sanford's efforts to improve physician well-being within your system and to reduce burnout.”
Dr. Scott also appeared in an episode of Sanford Health’s “Reimagining Rural Health” podcast series.
As the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine™.
Download the 2024 AMA Joy in Medicine magazine to learn about Sanford Health and other health systems that are part of this prestigious group recognized for their dedication to physician well-being.
