Trump Signs Budget Deal, Cuts Medicare Fee in 2019

Alicia Ault


February 09, 2018

WASHINGTON — President Donald J. Trump has signed a massive budget agreement that keeps the government in operation until March 23, but provides funding for many programs for 2 years. It also will cut Medicare physician fees in fiscal year 2019 (FY19), add payment for stroke telemedicine services, and extend many health programs that had expired or were in danger of running out of money soon.

The package was approved by Congress in early morning votes that came after a brief government shutdown, forced by Sen. Rand Paul (R-KY). He blocked earlier voting, saying the spending package added too much to the deficit. The Senate voted 71 to 28 in favor of the package, and the House voted 240 to 186. Most of the Democrats who voted in opposition (119) did so because it was not accompanied by a promise from House Speaker Paul Ryan (R-WI) to take fast action on the future of immigrants who were brought here illegally as children and whose protected status expires on March 5.

The spending package will cost about $320 billion over 10 years, according to the Congressional Budget Office (CBO). It lifts mandatory spending caps for 2 years, increasing defense and nondefense spending. It then reimposes those caps (known as sequestration), which largely pay for the package, said the CBO.

According to an analysis by Politico, the 2-year extension of some Medicare policies — including physician fee cuts — will provide about $38 billion in offsets.

Under the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians were due to receive a 0.5% fee increase in 2018 and 2019. But the 2014 Protecting Access to Medicare Act (PAMA) — which is reviewing misvalued codes — has essentially overridden the MACRA update. Physician organizations had asked Congress to restore the 0.5% MACRA cut. The fee cut will remain at 0.5% in 2018 and will be reduced to 0.25% in FY19.

The continuation of PAMA-related cuts is "contrary to Congress' intent under the Medicare Access and CHIP Reauthorization Act to ensure positive and stable payments to doctors as they transition to new delivery models," said American College of Physicians President Jack Ende, MD, in a statement. "ACP calls on Congress to enact permanent relief from the PAMA cuts."

The budget package did include a new Medicare payment, which will begin in 2021, for a telemedicine neurologic consult for patients who present to hospitals or mobile stroke units. The bill incorporates the Furthering Access to Stroke Telemedicine Act of 2017 (HR 1148), which was introduced by Rep. Morgan Griffith (R-VA) and Rep. Joyce Beatty (D-OH).

The bill also expands coverage of telemedicine services offered by Medicare Advantage Plans and Accountable Care Organizations.

In addition, members of the House succeeded in adding a technical correction to the Merit-Based Incentive Payment System. That was welcome news to the American Society of Clinical Oncology. "This move will ensure that quality payment adjustments under the program are applied only to fee schedule services, ensuring fairness and that patients with cancer can continue to have access to high-quality care," said ASCO President Bruce E. Johnson, MD, FASCO, in a statement. ASCO strongly advocated for the change, he said.

The package also includes the following:

  • A restoration of funding for federally supported community health centers, many of which had begun laying off staff. The program lost its funding in September. The clinics, which mostly serve low-income Americans, would get $7 billion over the next 2 years.

  • An additional 4-year extension of the Children's Health Insurance Program (CHIP), which had received a 6-year extension in the continuing resolution that was approved in January.

  • $6 billion for the opioid epidemic, which will go toward state grants, public prevention programs, and law enforcement.

  • Elimination of Medicare's Independent Payment Advisory Board.

  • $500 million over the next 2 years for the National Health Service Corps, and an additional $363 million over the 2 years for the Teaching Health Center Graduate Medical Education program.

  • A permanent repeal of Medicare's coverage limit on physical therapy, speech-language pathology, and outpatient treatment.

  • A 5-year extension of the Maternal, Infant, and Early Childhood Home Visiting Program, which helps guide low-income, at-risk mothers in parenting.

  • Closing of the Medicare Part D "doughnut hole" 1 year early, in 2019. When enrollees hit the doughnut hole ($3750 in 2018), they must pay the full cost of medications until they reach $5000 in out-of-pocket payments. The Affordable Care Act required closure in 2020.

  • $300 million for the Special Diabetes Program for type 1 diabetes, and $300 million for the Special Diabetes Program for Indians.

  • A reversal of some of the planned cuts to the ACA's Prevention and Public Health Fund. It adds $100 million in funding in FY19, bringing it to a total of $900 million, but it proposes cutting $1.35 billion overall from FY22 to FY27.

  • Allow physician assistants to serve as the attending physician to hospice patients and perform other functions consistent with their scope of practice through the Medicare Patient Access to Hospice Act (HR 1284), which was included in the package.

  • $5.8 billion for the Child Care Development Block Grant program.

  • $4 billion to rebuild veterans' hospitals and clinics.

  • $2 billion for research at the National Institutes of Health.

  • $90 billion in disaster relief, including $23.5 billion for the Federal Emergency Management Agency's disaster relief fund, $28 billion for community development block grants, $2 billion to help Puerto Rico rebuild its electric grid, and $5 billion for the island's Medicaid program.

The Endocrine Society praised the renewal of the Special Diabetes Program, which was created in 1997. The Endocrine Society noted that the renewal allows the National Institute of Diabetes and Digestive and Kidney Diseases to issue research grants to fund type 1 diabetes research, and funds type 1 diabetes research as well as education and prevention programs for Alaska Natives and American Indians. "The renewal of the Special Diabetes Program is key in continuing groundbreaking diabetes research and ensuring the most vulnerable patients with diabetes have access to prevention and education programs," said Robert Lash, MD, the society's chief professional and clinical officer, in a statement.

Dr Ende said the ACP is pleased that the agreement extended the CHIP reauthorization and that it reauthorized funding for 2 years for the National Health Service Corps, the Teaching Health Center Graduate Medical Education program, and community health centers, "all of which provide valuable resources for vulnerable communities across the nation and help train the next generation of primary care physicians.'

Michaal Munger, MD, president of the American Academy of Family Physicians (AAFP), also applauded the CHIP and community health center funding. "Not only will continuation of CHIP ensure uninterrupted care for children with serious health challenges, but it enables parents to take their children in for necessary preventive care," he said in a statement.

Funding of the National Health Service Corps and the Teaching Health Center Graduate Medical Education programs are especially important to family medicine, said Dr Munger and Mark A. Baker, DO, president of the American Osteopathic Association. "Reauthorizing these programs will support the training of the next generation of primary care physicians in underserved areas and provide access to essential preventive health services and care for families across America," said Dr Baker in a statement emailed to Medscape Medical News.

The AAFP has urged more permanent funding for teaching health centers (THCs). Because family medicine residencies — which make up the majority of THCs — run for 3 years, "Graduating medical students must be assured they can complete their residency training at the program to which they've matched," said Dr Munger. "Two-year funding for THCs will discourage newly graduated medical students from choosing this option," he said.

The ACP and the AAFP said they are pleased with the inclusion of the CHRONIC Care Act and other provisions to address chronic illness. The bill, said Dr Ende, "extends the Independence at Home Medical Practice Demonstration Program, which provides a home-based primary care benefit to high-need Medicare beneficiaries with multiple chronic conditions [and] allows Medicare Advantage plans to offer a wider array of targeted supplemental benefits to chronically ill enrollees."

Correction: This article and its headline have been updated to clarify that the new deal results in a Medicare cut to physicians in 2019, not a reduction in the planned cut, as originally stated.

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