In a significant setback for healthcare providers across the nation, Congress has failed to address the 2.83% cut in the CY 2025 Medicare Physician Fee Schedule. This inaction has left physicians and healthcare organizations grappling with the potential financial repercussions that could impact patient care and access to medical services.

The Medicare Physician Fee Schedule (MPFS) is a critical component of how healthcare providers are reimbursed for their services to Medicare beneficiaries. Established by the Centers for Medicare & Medicaid Services (CMS), the MPFS sets the payment rates for thousands of patient services and procedures, ranging from routine check-ups to complex surgeries. The fee schedule is updated annually, taking into account various factors such as inflation, changes in medical practice, and legislative adjustments.

The 2.83% cut in the MPFS translates to a significant reduction in reimbursement rates for healthcare providers. For many physicians, especially those in smaller practices or underserved areas, this decrease can pose substantial financial challenges. The cuts may lead to reduced revenue, making it difficult for providers to cover operational costs, invest in new technologies, or maintain adequate staffing levels.

The financial strain on healthcare providers could have a direct impact on patient care. Reduced reimbursement rates may force some practices to limit the number of Medicare patients they accept or reduce the range of services offered. This, in turn, can lead to longer wait times for appointments, decreased access to specialized care, and potential delays in receiving essential medical treatments. The impact of the reimbursement cuts is particularly pronounced in rural and underserved areas, where healthcare resources are already limited. Physicians in these regions often operate on tight budgets and face higher operating costs. The reduction in reimbursement may exacerbate existing disparities in access to care, leaving vulnerable populations with fewer healthcare options.

In response to the impending cuts, numerous professional organizations and advocacy groups, including the Alliance of Specialty Medicine, mobilized to urge Congress to take action, highlighting the potential consequences of the cuts and calling for legislative intervention to prevent the reduction in reimbursement rates. These efforts met with some success, as Congress included a 2.5% mitigation of the cut in an end-of-the-year health and appropriations legislative package. Unfortunately, most of the health provisions, including the 2.5% mitigation, were stripped out at the last minute, and the cut went into effect on January 1^st.

As the healthcare community grapples with the effects of the 2.83% cut, they also continue to advocate for not only mitigation of the current cut but also to focus on finding long-term solutions to stabilize Medicare payments. Recently, Reps. Greg Murphy (R-NC) and Jimmy Panetta (D-CA) introduced H.R. 879, the Medicare Patient Access and Practice Stabilization Act. This bipartisan bill would eliminate the 2.83% Medicare physician fee schedule cut and provide an inflationary update for calendar year 2025.

Continued advocacy, collaboration, and innovative approaches will be essential to address the financial challenges faced by healthcare providers and ensure that patients receive the care they need.

A Missed Opportunity for Healthcare Improvement

Prior Authorization Reform Fades at the End of the 118th Congress

Despite overwhelming bipartisan support, the failure of Congress to pass significant legislation aimed at reforming Prior Authorization processes at the end of the 118th Congress marked a disappointing conclusion to a highly anticipated legislative effort. Prior Authorization, a critical component of the healthcare system, has long been a contentious issue, causing delays and obstacles for patients seeking timely medical care. The inability of lawmakers to enact these reforms has significant implications for patients, healthcare providers, and the broader healthcare system.

Prior Authorization is a process used by insurance companies to determine the medical necessity and appropriateness of certain treatments and medications before they are administered or prescribed. While intended to control costs and ensure the appropriate use of resources, Prior Authorization has often been criticized for creating administrative burdens, delaying patient care, and complicating the physician-patient relationship.

Reforming Prior Authorization is crucial for several reasons:

• Reducing Delays in Patient Care: Lengthy Prior Authorization processes can lead to significant delays in receiving necessary treatments, adversely affecting patient outcomes.
• Alleviating Administrative Burden: Healthcare providers often spend considerable time and resources navigating the complex Prior Authorization requirements, diverting attention from direct patient care.
• Enhancing Patient Satisfaction: Streamlining the Prior Authorization process can improve patient satisfaction by reducing frustration and uncertainty regarding their treatment plans.
• Cost Efficiency: Efficient Prior Authorization systems can still control costs without imposing unnecessary barriers to care.

Throughout the 118th Congress, several legislative proposals aimed at reforming Prior Authorization were introduced, most notably the  Improving Seniors’ Timely Access to Care Act. This bill aimed to streamline the Prior Authorization process for Medicare Advantage plans by establishing clear timelines for approvals, increasing transparency, and reducing administrative hurdles. This bill garnered bipartisan support and was championed by various advocacy groups, healthcare organizations, and patient advocacy groups, including the Alliance of Specialty Medicine.

The failure to enact Prior Authorization reforms has far-reaching implications:

• Continued Delays in Patient Care: Patients will continue to experience delays in receiving necessary treatments, potentially worsening their health outcomes.
• Persistent Administrative Burden: Healthcare providers will remain burdened by the time-consuming and complex Prior Authorization requirements, impacting their ability to focus on patient care.
• Missed Opportunity for Cost Efficiency: The healthcare system will miss the opportunity to achieve cost savings through more efficient Prior Authorization processes.
• Ongoing Patient Frustration: Patients will continue to face uncertainty and frustration regarding their treatment plans, undermining their trust in the healthcare system.

The failure of the US Congress to pass legislation addressing Prior Authorization reforms at the end of the 118th Congress represents a missed opportunity to improve the healthcare system. However, the need for reform remains critical, and continued efforts are necessary to address the challenges posed by Prior Authorization processes. Stakeholders will again begin building bipartisan consensus, engaging stakeholders, leveraging technology, and raising public awareness.  Hopefully, Congress will respond with meaningful reforms to ensure timely and efficient patient care.

New Doctors in the House!

Six Health Professionals Elected to the 119th Congress 

The 119^th Congress welcomed six new physician members into its ranks, bringing the total number of health professionals serving in Congress to 32, which is the most ever.

Physician participation in American politics is not new.  In fact, four of the 56 signers of the Declaration of Independence were practicing physicians.  Representation by physicians in Congress has ebbed and flowed ever since.  In more recent decades, the number was down to a low of two in 1990, before its current upward trajectory as healthcare has become a prevalent policy topic, with the passage of the Affordable Care Act in 2010. The 32 health professionals serving in this Congress include nurses as well as pharmacists and dentists.  The new members represent both political parties and an array of specialties:

• Sheri Biggs, DNP (R-SC-03) – family and mental health nurse practitioner
• Herb Conaway, MD (D-NJ-03) – internist
• Maxine Dexter, MD (D-OR-03) – pulmonary and critical care physician
• Mike Kennedy, MD (R-UT – 03) – family physician
• Kelly Morrison (D-MN-03) – OB-GYN

The growth of physician membership in Congress over the years also means that health professionals hold several congressional leadership and committee positions.  These include:

• Sen. John Barrasso, MD (R-WY), Senate Majority Whip (orthopaedic surgeon)
• Sen. Bill Cassidy, MD (R-LA), Chairman,  Senate Health, Education, Labor and Pensions Committee (gastroenterologist/hepatologist)
• Sen. Rand Paul, MD (R-KY), Chairman, Senate Homeland Security Committee (ophthalmologist)
• Rep. Mark Green, MD (R-TN-07), Chairman, House Homeland Security Committee (emergency physician)
• Rep. Buddy Carter, BSPharm (R-GA-01), Chairman, House Energy and Commerce Health Subcommittee (pharmacist)

With an array of healthcare policy issues on deck for this Congress and new Administration, stakeholders like the Alliance for Specialty Medicine will be relying on their fellow specialists and healthcare professionals serving in Congress to further the cause of patient access and healthy outcomes.