ACCURACY IN MEDICARE PHYSICIAN PAYMENT ACT OF 2013; Congressional Record Vol. 159, No. 95
(Extensions of Remarks - June 28, 2013)

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[Extensions of Remarks]
[Page E992]
From the Congressional Record Online through the Government Publishing Office []



                           HON. JIM McDERMOTT

                             of washington

                    in the house of representatives

                        Thursday, June 27, 2013

  Mr. McDERMOTT. Mr. Speaker, I rise today to introduce the Accuracy in 
Medicare Physician Payment Act of 2013. This bill will give the Centers 
for Medicare and Medicaid Services (CMS) important tools and resources 
to continue alleviating our dire shortage of primary care physicians. 
As Congress tries to come together around the challenges of how to 
repeal and replace the broken Sustainable Growth Rate formula, I want 
to make sure that we do not neglect the Medicare physician fee schedule 
and the impact it has on our physician workforce.
  It is no mystery that relatively depressed salaries are driving new 
doctors away from primary-care fields like family medicine and 
pediatrics and into more lucrative specialties and subspecialties like 
radiology and orthopedic surgery. I don't begrudge anyone for making 
that choice; when I graduated from medical school 50 years ago I could 
not have fathomed being loaded down with six figures of medical school 
debt. And to be sure, we need talented specialists. But we have a 
stubbornly small proportion of primary care doctors--just over 30 
percent, when most experts agree that 50 percent is the ``sweet spot'' 
in terms of maximizing quality and minimizing cost.
  I am proud that Congress gave primary care a shot in the arm in the 
Affordable Care Act, under which Medicaid pays higher Medicare rates 
for primary care through 2015, and Medicare makes quarterly incentive 
payments to primary care physicians through 2017. The ACA also expanded 
the National Health Service Corps, which eases the steep cost of 
medical education for doctors and allied health practitioners willing 
to practice in an underserved area after graduation. These are 
meaningful steps, but to make more enduring progress in this area, I 
believe that Medicare must repair structural inaccuracies in the 
Medicare physician fee schedule that have eroded the value of primary 
care. Simply put, Medicare contributes to this imbalance by underpaying 
for the critical yet undervalued job of managing complex patients with 
multiple chronic conditions and keeping them out of the emergency room 
and hospital.
  A major obstacle to reform is Medicare's continued reliance on a 
committee of mostly specialist physicians to help set payment rates for 
the 7,400 services on the Medicare physician fee schedule. Since 1991, 
Medicare has outsourced its work of appraising the value of these 
services to the AMA's Relative Value Scale Update Committee (RUC)--a 
31-member panel of physicians who decide how services should be valued 
and updated. Only a handful of the 31 committee members perform primary 
care. The RUC meets in private and provides limited release of the 
minutes of its proceedings. In formulating its recommendations, the RUC 
also relies heavily on anecdotal and self-serving surveys, rather than 
forensic evidence.
  CMS has begun to update misvalued codes in the fee schedule, but it 
needs more muscle and resources to do the job. This bill would 
establish a panel of independent experts within CMS that would identify 
the distortions in the fee schedule and develop evidence to justify 
more accurate updates. Medicare could continue to request work from the 
RUC, but the expert panel would both initiate such requests and review 
RUC's work product. The panel members would not have a direct interest 
in the fee schedule, and would include beneficiary representatives. It 
would be subject to the Federal Advisory Committee Act, which requires 
advisory bodies to hold open meetings and publish the minutes of such 
  In addition to payment accuracy and fairness, this is also about 
reining in a conflict of interest. After looking at this for several 
years I believe that we give the physician specialty societies, through 
the RUC, an undue influence on their own payments. In no other area--
whether it be hospitals, skilled nursing facilities, or any other 
setting--does Medicare ask the providers to play such an active role in 
setting their own reimbursement amounts. Medicare certainly needs 
clinical expertise to evaluate the resources necessary to perform 
physician services but should not look to an outside organization whose 
members directly benefit from the fee schedule to apportion some $70 
billion in annual public spending, without some checks and balances. No 
matter how well-intentioned, such a system contains structural biases 
that need safeguards to prevent abuse.
  Medicare is not only one of America's most important social insurance 
programs and a bulwark of the middle class, it also establishes 
economic incentives that ripple through all of health care and 
contribute to our shortage of primary care physicians. As we continue 
to pursue a permanent doc fix, let's also talk about how we will use 
Medicare to incentivize the appropriate mix of physicians in the 
workforce to serve beneficiaries and the public health.