Congress Agrees on Tentative Budget Deal; Mostly Reverses Docs’ Medicare Pay Cut

Congress reached a tentative budget deal Tuesday that largely — but not entirely — reversed a 2.8% cut in the Medicare Physician Fee Schedule and that will extend certain telehealth flexibilities and attempt to rein in pharmacy benefit managers (PBMs).

The deal, which still must be passed by both the House and Senate, increases payments under the Medicare Physician Fee Schedule by 2.5%, largely offsetting the 2.8% cut finalized by CMS, but still leaving physicians with a 0.3% payment decrease. However, it does not include the Improving Seniors’ Timely Access to Care Act, which would have established an electronic prior authorization process for Medicare Advantage (MA) plans that would standardize transactions and clinical attachments, increase transparency around MA prior authorization requirements, and require HHS and other agencies to report to Congress on their efforts to improve the electronic prior authorization process.

“MGMA [Medical Group Management Association] is pleased that Congress heeded our call to extend telehealth flexibilities through the end of 2026 [and] increase APM [alternative payment model] incentive payments to 3.53%,” Anders Gilberg, the group’s senior vice president for government affairs, said in a statement. (Disclosure: Gilberg is a member of the MedPage Today editorial board.) “These are big wins for medical groups.” Telehealth flexibilities include removing geographic requirements and expanding originating sites for telehealth services, as well as expanding the type of practitioners eligible to provide services via telehealth.

“On the other hand, we are deeply disappointed that Congress failed to fully remedy the looming 2025 Medicare payment cut to physician practices,” Gilberg continued. “Any cut, however fractional, is unacceptable. Finally, not including legislation to reform prior authorization, which has the support of a bipartisan majority of the House and Senate, nearly 500 endorsing stakeholder organizations … and little to no opposition, represents a huge congressional end-of-year failure and another win for big insurance to the detriment of America’s patients.”

The Regulatory Relief Coalition, a group of physician specialty organizations advocating for regulatory burden reduction in Medicare, said it was “outraged” that the legislation wasn’t included. “Our nation’s seniors have been counting on Congress to act to restore their timely access to medically necessary healthcare,” the group said in a statement. “Unfortunately, this Congress is failing them by putting aside smart policy in favor of political bickering. This colossal failure to respond to the public outcry for better oversight and transparency of the MA program is completely unacceptable.”

The tentative deal also includes legislation to more tightly regulate PBMs. Provisions include a requirement that PBMs provide detailed data on drug spending to group health plans, and also that they pass along 100% of drug rebates and discounts to the employer or health plan they negotiate on behalf of. The legislation also requires CMS to define “reasonable” contract terms for Medicare Part D drug plans, and to allow “any willing pharmacy” to serve Medicare patients. It also bars PBMs from tying their compensation to a drug’s Medicare price.

Other elements of the deal include:

• A 5-year reauthorization of the SUPPORT Act, aimed at combatting the opioid crisis
• A 5-year extension of the Teaching Health Center Graduate Medical Education program, which is designed to increase the primary care workforce
• A provision to prevent cuts to the Medicaid Disproportionate Share Hospital program
• A 2-year reauthorization of the Pandemic and All-Hazards Preparedness Act

Sen. Ron Wyden (D-Ore.) praised the deal’s inclusion of “improvements to Medicare, especially cracking down on ghost networks in Medicare Advantage that prevented seniors from finding a physician or psychiatrist in their health plan.”

“There’s a lot more work to be done to improve mental health care for all Americans, but making sure you can find a doctor when you need care is step one,” he said in a statement.

Please enable JavaScript to view the comments powered by Disqus.