Medicare Physician Payment Updates and the
Sustainable Growth Rate (SGR) System
Jim Hahn
Analyst in Health Care Financing
November 6, 2009
Congressional Research Service
7-5700
www.crs.gov
R40907
CRS Report for Congress
P
repared for Members and Committees of Congress
Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System
Summary
Each year since 2002, the statutory method for determining the annual updates to the Medicare
physician fee schedule, known as the sustainable growth rate (SGR) system, has resulted in a
reduction in the reimbursement rates (or a “negative update”). With the exception of 2002, when
a 4.8% decrease was applied, Congress has passed a series of bills to override the reductions.
However, these actions have required almost yearly attention from the Congress.
The SGR system was established because of the concern that the Medicare fee schedule itself
would not adequately constrain overall increases in spending for physicians’ services. While the
fee schedule limits the amount that Medicare will pay for each service, there are no limits on the
volume or mix of services. The SGR system was intended to serve as a restraint on aggregate
spending. If expenditures over a period are less than the cumulative spending target for the
period, the update is increased. However, if spending exceeds the cumulative spending target over
a certain period, the update for a future year is reduced, with the goal to bring spending back
in line with the target.
In the first few years of the SGR system, the actual expenditures did not exceed the targets and
the updates to the physician were close to the Medicare economic index (MEI, a price index of
inputs required to produce physician services) in the first two years (2.3% in 1998 and 1999,
compared with a MEI of 2.2% in 1998 and 2.3% in 1999). For the next two years, in 2000 and
2001, the actual physician fee schedule update was more than twice the MEI for those years
(5.5% update vs. MEI of 2.4% in 2000, 5.0% update vs. MEI of 2.1% in 2001). However,
beginning in 2002, the actual expenditure exceeded allowed targets and the discrepancy has
grown with each year, resulting in a series of ever-larger cuts under the formula.
Some criticisms of the SGR system point to purported flaws in the technical details behind the
formula, while others have just expressed general displeasure with the resultant outcome.
Although several modifications have been proposed to replace the SGR system, no proposal has
garnered unanimity of support and almost all proposals would be expensive to implement
compared against the current baseline, which necessarily assumes that significant cuts to the fee
schedule will occur.
Legislative activity in the current session of Congress includes S. 1776 and H.R. 3961. S. 1776
would have (1) set the update to the conversion factor at 0% for 2010 and in subsequent years,
and (2) sunset the SGR system immediately. On October 21, 2009, the cloture motion to proceed
to the bill was not invoked by the Senate by a vote of 47-53. The key feature of H.R. 3961 is that
it would create two categories of physician services (evaluation, management, and preventive
services in one category with all other physician services in the other), each with its own separate
target growth rate and conversion factor update. CBO has estimated that implementing the bill
would increase direct spending by about $210 billion over the 2010-2019 period.
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Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System
Contents
Introduction ................................................................................................................................ 1
Background on the Medicare Fee Schedule ................................................................................. 1
Updates and the Sustainable Growth Rate (SGR) System ...................................................... 1
Conversion Factor Calculation .............................................................................................. 2
Sustainable Growth Rate (SGR) ...................................................................................... 2
Update Adjustment Factor............................................................................................... 3
Historical Updates and Legislative Overrides .............................................................................. 3
Analysis and Criticisms of SGR System ...................................................................................... 6
Potential Modifications and Alternatives ..................................................................................... 7
Recent Legislative Activity ......................................................................................................... 9
H.R. 3162 (110th Congress) ................................................................................................... 9
Summary ........................................................................................................................ 9
Brief Analysis ............................................................................................................... 10
S. 1776 (111th Congress) ..................................................................................................... 11
Summary ...................................................................................................................... 11
Brief Analysis ............................................................................................................... 11
H.R. 3961 (111th Congress) ................................................................................................. 11
Summary ...................................................................................................................... 11
Brief Analysis ............................................................................................................... 12
Figures
Figure 1. Difference Between Cumulative Allowed and Actual Expenditures for
Physician Services Under the SGR System............................................................................... 4
Figure 2. Formula Updates, Actual Updates, and the Medicare Economic Index .......................... 9
Tables
Table 1. Summary of Updates and Legislative Activity................................................................ 5
Contacts
Author Contact Information ...................................................................................................... 12
Congressional Research Service
Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System
Introduction
Each year since 2002, the statutory method for determining the annual updates to the Medicare
physician fee schedule, known as the sustainable growth rate (SGR) system, has resulted in a
reduction in the reimbursement rates (or a “negative update”).1 With the exception of 2002, when
a 4.8% decrease was applied, Congress has passed a series of bills to override the reductions.
However, these actions have required almost yearly attention from the Congress. This report
provides a background on the Medicare fee schedule, the SGR system and the annual updates,
and discusses recent proposals to address this issue.
Background on the Medicare Fee Schedule
Medicare payments for Part B services2 provided by physicians and certain non-physician
practitioners are made on the basis of a fee schedule.3 For each of the over 7,000 tasks and
services for which physicians bill Medicare, the Center for Medicare and Medicaid Services
(CMS) assigns relative values that reflect physician work (i.e., time, skill, and intensity it takes to
provide the service), practice expenses, and malpractice costs.4 The adjusted relative values are
then multiplied by a conversion factor to derive the actual payment amount in dollars. Medicare
pays providers the lesser of the actual charge for the service or the allowed amount under the fee
schedule.
Updates and the Sustainable Growth Rate (SGR) System
The SGR system was established because of the concern that the Medicare fee schedule itself
would not adequately constrain overall increases in spending for physicians’ services. While the
fee schedule limits the amount that Medicare will pay for each service, there are no limits on the
volume or mix of services. The SGR system was intended to serve as a restraint on aggregate
spending. While the SGR targets are not limits on expenditures, they represent a “sustainable”
trajectory for cumulative spending on Medicare physician services from April 1996 forward. The
annual fee schedule update thus reflects the success or failure in meeting the goal. If expenditures
over a period are less than the cumulative spending target for the period, the update is increased.
However, if spending exceeds the cumulative spending target over a certain period, the update for
a future year is reduced, with the goal to bring spending back in line with the target.
1 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance And Federal Supplementary Medical
Insurance Trust Funds, p. 22. http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2009.pdf
2 For detail on fee-for-service Medicare and other Medicare background information, see CRS Report R40425,
Medicare Primer, coordinated by Hinda Chaikind.
3 Social Security Act, Sec. 1848. [42 U.S.C. 1395w–4]. In some instances, special rules apply to the calculation of
Medicare fees for some services including anesthesia, radiology, and nuclear medicine.
4 The determination of the relative value units affects all payments under the fee schedule. Refinements in existing
values and establishment of values for new services have been included in the annual fee schedule updates. This
refinement and update process is based in part on recommendations made by the American Medical Association’s
Specialty Society Relative Value Update Committee (RUC) which receives input from approximately 100 specialty
societies. The law requires a review every five years.
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Expenditure targets have been a factor in the calculation of Medicare physician payment updates
since the current fee schedule was first implemented in 1992. Originally, two and then three
conversion factors were used for different categories of services (surgical, primary care, and other
nonsurgical services). However, under the Medicare Volume Performance Standard (MVPS)
method, targets were set (and typically exceeded) each year; there was no cumulative goal and no
significant consequence to exceeding the expenditure target. The current SGR method for
calculating annual updates was created partly in response to the shortcomings of the prior
method.
The Balanced Budget Act of 1997 (BBA97, P.L. 105-33) replaced the MVPS with the SGR, with
the objective of creating a sustainable growth path for Part B expenditures. First, BBA 97 added a
cumulative spending criteria that resulted in actual consequences for failing to meet expenditure
targets; beginning with April 1, 1996 as the starting point, actual program expenditures are
compared to growth targets to determine annual updates. Second, BBA 97 introduced the rate of
growth in the per capita amount of the gross domestic product (GDP) into the SGR calculation
and also provided for the use of a single conversion factor instead of three.5 By tying the
expenditure targets to the growth in GDP per capita, this system attempted to hold Medicare
physician expenditures to a level that would not consume an ever-increasing share of national
income.
Since the conversion factor applies to all services, the update to the conversion factor is the key
component for determining how reimbursements change from year to year.
Conversion Factor Calculation
The annual update to the conversion factor calculation is based on (1) the Medicare Economic
Index (MEI), which measures the weighted average annual price changes in the inputs needed to
produce physician services,6 (2) the Update Adjustment Factor (UAF), used to equate actual and
target (allowed ) expenditures, and (3) allowed expenditures, equal to the actual expenditures
updated by the SGR.
Sustainable Growth Rate (SGR)
The SGR sets both the cumulative and allowed expenditures under the UAF formula and consists
of the following components:
• the estimated percentage changes in physicians fees,
• the estimated percentage changes in the number of fee-for-service beneficiaries,
• the estimated percentage growth in real gross domestic product (GDP) per capita
(10-year moving average), and
• the estimated percentage changes resulting from changes in laws and regulations.
5 The Balanced Budget Refinement Act of 1999 (BBRA 99, P.L. P.L. 106-113) incorporated an adjustment for the prior
year into the UAF update calculation; it also moved from a fiscal year to a calendar year system.
6 For more information on the components used to calculate the MEI and quarterly historical data, see
http://www.cms.hhs.gov/MedicareProgramRatesStats/downloads/mktbskt-economic-index.pdf
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Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System
One important implication of the way this formula was constructed is that sustainable growth in
Medicare physician expenditures should be equivalent to the rate of growth in the economy (i.e.,
the growth in GDP per capita). In addition, the formula implies that increases in managed care
enrollment relative to fee-for-service Medicare would result in a slightly lower SGR.
Update Adjustment Factor
The update adjustment sets the conversion factor at a level so that projected spending for the year
will meet allowed spending by the end of the year. The adjustment factor is the sum of (1) the
prior year adjustment component; and (2) the cumulative adjustment component. Use of both the
prior year adjustment component and the cumulative adjustment component allows any deviation
between cumulative actual expenditures and cumulative allowed expenditures to be corrected
over several years rather than a single year. As originally established, the adjustment factor can
not be less than minus 7% or more than plus 3%. Thus, despite calculations which would have led
to larger reductions, the UAF adjustment has been minus 7% for the last several years. The caps
on the adjustment limit the annual reduction or increase. Thus, the gap between cumulative actual
spending and cumulative allowed spending grows larger each year and is exacerbated whenever
Congress overrides the reductions, since the targets are never modified under current law.
Historical Updates and Legislative Overrides
Under the update formula, if actual expenditures do not exceed target expenditures, the update
would be positive and payments would increase for all services. In the first few years of the SGR
system, the actual expenditures did not exceed the targets. (See Figure 1.) As a consequence, the
updates to the physician fee schedule were close to the MEI in the first two years (2.3% in 1998
and 1999, compared with MEI of 2.2% in 1998 and 2.3% in 1999).7 For the next two years, in
2000 and 2001, the actual physician fee schedule update was more than twice the MEI for those
years (5.5% update vs. MEI of 2.4% in 2000, 5.0% update vs. MEI of 2.1% in 2001). However,
beginning in 2002, the actual expenditure exceeded allowed targets and the discrepancy has
grown with each year.
7 See Table 6, Actual Past Medicare Economic Index Increases and Physician Updates for 1992−2009, and Estimated
Values for 2010, in CMS publication, “Estimated Sustainable Growth Rate and Conversion Factor, for Medicare
Payments to Physicians in 2010.”
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Figure 1. Difference Between Cumulative Allowed and Actual Expenditures for
Physician Services Under the SGR System
1996-2008
$10.00
$0.00
6
199
($10.00)
($20.00)
($
s
n ($30.00)
illio
)b
($40.00)
($50.00)
($60.00)
($70.00)
Source: CRS figure from CMS data contained in “Estimated Sustainable Growth Rate and Conversion Factor,
for Medicare Payments to Physicians in 2010.” Available at http://www.cms.hhs.gov/SustainableGRatesConFact/
Downloads/sgr2010p.pdf
Notes: This graph shows the difference between cumulative al owed expenditures and actual expenditures for
physician services. The 2008 figures for both al owed and actual expenditures are CMS estimates.
As a consequence of exceeding the target, the formula dictated a reduction in the fee schedule in
2002. Although reductions have been called for every year since, Congress has passed legislation
that has overridden the cuts each year since. (See Table 1.)
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Table 1. Summary of Updates and Legislative Activity
2002-2009
Year Formula
update
Actual
update Legislation
Notes
2002
−4.8%
−4.8%
2003
−4.4%
1.4% Consolidated The update was 1.7% but was
Appropriations
effective on March 1, 2003 so
Resolution of 2003
the average update for the year
(CAR)
was 1.4%.
2004
−4.5% 1.5%
Medicare
Modernization Act
of 2003 (MMA, P.L.
108-173)
2005
−3.3%
1.5% MMA
2006
−4.4%
0.2% Deficit
Reduction
Although the DRA froze the
Act of 2005 (DRA,
conversion factor update,
P.L. 109-171)
refinements to the RVUs
resulted in a 0.2% update for
the year.
2007
−5.0%
0% Tax
Relief
and
Health Care Act of
2006 (TRHCA, P.L.
109-432)
Jan-Jun 2008
−10.1% 0.5%
Medicare,
Medicaid,
Physicians who voluntarily
and SCHIP
reported on certain quality
Extension Act of
measures during July 1, 2007-
2007 (MMSEA, P.L.
December 31, 2007, were
110-173)
eligible for a bonus payment of
1.5% in 2008 per TRHCA.
Jul-Dec 2008
−10.6% reduction
0% (0.5% from Medicare
See above.
from June 2008 level
2007 level)
Improvement for
Patients and
Providers Act of
2008 (MIPPA, P.L.
110-275)
2009 1.1%
MIPPA
Physicians
who
voluntarily
reported on certain quality
measures during 2008 were
eligible for a bonus payment of
1.5% in 2009 per MMSEA.
Source: 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance And Federal
Supplementary Medical Insurance Trust Funds, p. 22. http://www.cms.hhs.gov/ReportsTrustFunds/downloads/
tr2009.pdf, and CMS, Estimated Sustainable Growth Rate and Conversion Factor, for Medicare Payments to
Physicians in 2010, http://www.cms.hhs.gov/SustainableGRatesConFact/Downloads/sgr2010p.pdf
In addition to overriding the payment reductions, Congress has also included provisions in several
of the laws to increase Medicare physician payments in other ways. For example, the Congress
has altered the geographic adjustment factor for physician work, one component used in making
regional adjustments to payments under the physician fee schedule. MMA set a floor on the work
geographic adjustment index at 1.0 for 2004-2006, thereby slightly increasing the payment
amounts in some areas. TRHCA extended this provision through 2007, MMSEA extended it
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through June 30, 2008, and MIPPA extends it through December 2009. In addition, beginning
January 1,2009, MIPPA also raised the work geographic adjustment in Alaska to 1.5.
Some of the bills also modified the cap on the conversion factor, which has led to the current
situation where the consequence of not overriding the reduction would lead to cuts in excess of
the 7% cap. TRHCA specified that the override of the reduction that would have been
implemented under the statutory formula was to be treated as if it did not occur. Therefore, the
starting base for the 2008 calculation was 5% below the actual 2007 conversion factor. MMSEA
overrode the reduction for the first six months of 2008 and provided for a 0.5% increase for that
period. However, the legislation again specified that the override of the statutory formula was to
be treated as if it did not occur. MIPPA again specified that the override of the statutory formula
was to be treated as if it did not occur. As a result, CMS estimates that a reduction of 21.2% will
be necessary in 2010 unless Congress acts again to override the current situation.8
Analysis and Criticisms of SGR System
The experience in recent years has been that the volume and the intensity of physician services
provided to Medicare beneficiaries are growing at more than double the rate allowed under the
SGR system.9 Payment reductions as called for under the update formula have required almost
annual interventions by Congress and the SGR system has been criticized (and defended) amid
calls for its repeal. While some of the criticisms of the SGR system point to purported flaws in
the technical details behind the formula, others have just expressed general displeasure with the
outcome.
One commonly asserted criticism is that the SGR system treats all services and physicians equally
in the calculation of the annual payment update to the detriment of physicians who are “unduly”
penalized. The expenditure target is a nationwide aggregate and the annual updates are applied
uniformly; there is no direct link between individual behavior and the subsequent update. Thus,
actions might be individually rational (physicians provide and bill for additional services and
collect greater reimbursement) yet collectively detrimental (the annual update is reduced).10 An
individual physician who controls or reduces volume does not see a resulting increase in
payments.
Others point out that there is no ability to distinguish between appropriate volume increases (for
instance, due to changes in disease conditions that increase demand) and inappropriate volume
increases (for instance, when tests or procedures are provided that are not necessary).
8 CMS press release, “CMS Announces Payment, Policy Changes For Physicians Services To Medicare Beneficiaries
In 2010,” October 30, 2009. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3539&intNumPerPage=
10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&
chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
9 U.S. Government Accountability Office (GAO), Medicare Physician Payments: Trends in Utilization, Spending and
Fees Prompt Consideration of Alternative Payment Approaches, testimony of Bruce Steinwald before House Energy
and Commerce Committee, July 25, 2006.
10 Often referred to as the tragedy of the commons: while it may be individually rational for each herder to let livestock
graze on the common field (to preserve his own), the collective consequence of many such individual decisions is that
the common fields are overgrazed and all herders suffer from the degradation or depletion of the common good.
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Additionally, the targets may not be not adequately modified to reflect scientific and
technological innovations or site-of-service shifts, and providers have often stated that actual
increases in practice costs exceed those allowed under the system. The impact of legislative and
regulatory changes also may not be fully reflected in the SGR calculation.
The inclusion of some items and services in the expenditure targets has also been called into
question. Specifically, physicians have argued that Part B drug spending should be excluded from
the calculation since physicians have no control or influence on the price of these drugs, although
CMS is preparing to addressed this in its implementation of the 2010 proposed rule changes.
Potential Modifications and Alternatives
Although a number of modifications to the SGR system have been proposed, there is no
consensus around a long-run alternative. In addition, any permanent change would likely be quite
costly because the Congressional Budget Office (CBO) baseline must assume that a reduction in
the conversion factor will occur for the next several years as required under current law. In
addition to the impact on federal outlays, any change in the update formula will also have
implications for beneficiaries; because Part B beneficiary premiums must cover 25% of Part B
program costs, any overall increase in spending results in a proportional increase in premiums.11
Suggested modifications have ranged from modifying the current formula to replacing the
formula and linking updates to payment adequacy and/or quality measures. While a change in the
formula would require legislation, some observers have suggested that there are things CMS
could do administratively to ease the impact of the current formula. Proponents argue that these
changes, such as removing Part B drugs from the calculation, could somewhat moderate the
negative updates that are predicted.
The Medicare Modernization Act of 2003 (MMA) required that GAO study “the appropriateness
of the sustainable growth rate formula” and “the stability and predictability of such updates and
rate and alternatives.”12 In a 2005 report, the GAO categorized options for alternatives around
two themes: (1) proposals that end the use of spending targets and separate fee updates from
explicit efforts to moderate spending growth; and (2) proposals that retain spending targets but
modify the current SGR system to address perceived shortcomings.13 The first approach
emphasizes stable fee updates, while the second automatically adjusts fee updates if spending
growth deviates from a predetermined target. GAO stated that “the choice between the two
approaches may hinge on whether primary consideration should be given to stable fee increases
or to the need for fiscal discipline within the Medicare program.” The second approach would end
targets as an explicit measure for moderating spending growth. Updates would be based on cost
increases with the possibility of specifically addressing high volume service categories such as
medical imaging.
The Deficit Reduction Act of 2005 (DRA) required MedPAC to submit a report to Congress on
mechanisms that could be used to replace the SGR system, including “such recommendations on
11 For details on Medicare Part B premiums see CRS Report R40082, Medicare: Part B Premiums, by Jim Hahn.
12 P.L. 108-173, Section 953(a).
13 U.S. Government Accountability Office, Medicare Physician Payments: Concerns about Spending Target System
Prompt Interest in Considering Reforms, GAO-05-85, October 8, 2004.
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alternative mechanisms to replace the sustainable growth rate system as the Medicare Payment
Advisory Commission determines appropriate.”14 In its March 2007 report, MedPAC described
two possible paths: one path would eliminate the SGR and emphasize the development and
adoption of approaches for improving incentives for physicians and other providers to furnish
lower cost and higher quality care, while the second path would add a new system of expenditure
targets in addition to these approaches.15 However, MedPAC did not make any recommendations
in favor of any single alternative to the SGR, citing “significant disagreement … within the
Commission about the utility of expenditure targets” and stating that the complexity of the issues
made it difficult to recommend any option with confidence. MedPAC did stress in the report that
“a major investment should be made in Medicare’s capability to develop, implement, and refine
payment systems to reward quality and efficient use of resources while improving payment
equity.” Examples cited by MedPAC include pay-for-performance programs for quality,
improving payment accuracy, and bundling payments to reduce overutilization.
MedPAC has also recommended updating payments for physicians’ services based on the
estimated change in input prices for the coming year less an adjustment for savings attributable to
increased productivity. Specifically, input prices would be measured using the MEI (without
regard to the CMS adjustment for productivity increases). The recommended productivity
adjustment would be that used across all provider services.16
In March 2008, CBO issued cost estimates for a variety of approaches for dealing with the
physician payment issue.17 Proposals with modest costs assumed a freeze for the second half of
2008 (as opposed to a 10.6% reduction), with reductions in future years to hold future rates at
current law levels. More costly alternatives would freeze or increase payments over the 10-year
budget window. For example, increasing payments by the MEI each year through 2018 would
increase federal spending by $288.1 billion for the FY2008-2018 period. Coupling this with a
provision excluding this change from beneficiary premium calculations (“premium hold-
harmless”) would increase federal spending by $364.3 billion over the same period.
Figure 2 shows that in each year since 2002, the MEI has been greater than the update as
determined under the SGR formula and the actual update that physicians have received as a result
of congressional intervention.
14 P.L. 109-171, Section 5104(c).
15 Medicare Payment Advisory Commission, Assessing Alternatives to the Sustainable Growth Rate System, March
2007.
16 MedPAC, Report to the Congress, Medicare Payment Policy, March 2008.
17 http://www.cbo.gov/ftpdocs/90xx/doc9055/03-14-SGR_Options.pdf
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Figure 2. Formula Updates, Actual Updates, and the Medicare Economic Index
2000-2009
8.0
5.55.5
6.0
4.84.8
4.0
3.0
3.1
2.9
2.8
2.6
2.4
2.1
2.1
1.8
1.6
2.0
1.4
1.5
1.5
1.1
0.5
0.2
0.0
0.0
e
ng
ha
-2.0
C
%
-3.3
-4.0
-4.4
-4.5
-4.4
-4.8-4.8
-5.0
-6.0
-8.0
-10.0
-10.1
-10.6
-12.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Formula update
Actual update
MEI
Source: 2009 Annual Report of the Boards of Trustees of the Federal Hospital Insurance And Federal
Supplementary Medical Insurance Trust Funds, p. 22. http://www.cms.hhs.gov/ReportsTrustFunds/downloads/
tr2009.pdf, and CMS, Estimated Sustainable Growth Rate and Conversion Factor, for Medicare
Payments to Physicians in 2010, http://www.cms.hhs.gov/SustainableGRatesConFact/Downloads/
sgr2010p.pdf
Notes: MMSEA included a six-month override of the SGR update (−10.1%) for the first half of 2008. MIPPA
provided for an 18-month override of the SGR update that would have taken effect on July 1, 2008 (−10.6%) that
included the second half of 2008 and al of 2009. See also Table 1.
Recent Legislative Activity
H.R. 3162 (110th Congress)
Summary
The Children’s Health and Medicare Protection Act of 2007 (CHAMP, H.R. 3162) was introduced
on July 24, 2007. Section 301 of Title III would have modified the SGR system by eliminating
the single conversion factor currently applied to all physician services and would have established
separate target growth rates and conversion factors for each of six newly created service
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categories.18 The six categories of physician services would have been the following: evaluation
and management services for primary care and for preventive services; other evaluation and
management services; imaging services and diagnostic tests; major procedures; anesthesia
services; and minor procedures and other services.
The provision would have replaced the single SGR computation with separate target growth rates
for each of the service categories created above. Beginning with 2008, the target growth rate for
each service category would have been computed and applied separately using the same method
for computing the sustainable growth rate under current law except that (1) “physicians’ services”
would refer to the physicians’ services included in the appropriate service category, (2) the
estimate of the annual average percentage growth in real gross domestic product per capita for the
applicable period would have been increased by 0.03, and (3) a national coverage determination
would be treated as a change in regulation and thus incorporated into the Secretary’s estimate of
the percentage change in expenditures for all physicians’ services in the fiscal year (compared
with the previous fiscal year) resulting from changes in law and regulations.
Beginning with 2008, the conversion factors would be computed and updated separately for each
service category. In 2008, the conversion factors would have been based on the single 2007
conversion factor multiplied by the appropriate update for the category (see below). In subsequent
years, the conversion factor for each category would have been based on the conversion factor for
the service category adjusted by the appropriate update. The provision would have established a
floor for updates so that the conversion factors for each service category would be no less than
0.5% for 2008 and 2009.
The Committee on Ways and Means amended and reported the bill on Aug. 1, 2007 and the
House passed the bill the same day by a vote of 225 − 204.19 The bill was never taken up by the
Senate.
Brief Analysis
The approach to modifying the SGR as proposed in H.R. 3162 attempted to address, among other
things, the criticism that the current update calculation penalized (or rewarded) all physicians
identically regardless of the individual’s or the specialty’s contribution towards meeting or
exceeding the aggregate expenditure target. Thus, even though imaging services have grown
faster than other types of physician services (including evaluation and management services,
tests, major procedures, and other procedures) the resulting impact on the annual update factor
applies to all services across all specialties. However, others have countered that this delineation
may not be appropriate and the CHAMP approach went too far. For example, some of the
increase in imaging services may have allowed for the earlier detection of disease conditions such
as cancer, which may have produced savings for other services and specialties (e.g., nuclear
medicine and oncology services).
18 This summary and discussion includes only the proposed modifications to the Medicare physician update
methodology in the CHAMP Act relevant to the ongoing discussions regarding proposed solutions. For complete
details, please see CRS Report RL34122, H.R. 3162: Provisions in the Children’s Health and Medicare Protection Act
of 2007, Provisions in the Children’s Health and Medicare Protection Act of 2007.
19 http://clerk.house.gov/cgi-bin/vote.asp?year=2007&rollnumber=787
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Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System
S. 1776 (111th Congress)
Summary
On October 13, 2009, Senator Stabenow (and 4 co-sponsors) introduced S. 1776, the Medicare
Physician Fairness Act of 2009, which would have (1) set the update to the conversion factor at 0
for 2010 and in subsequent years, and (2) sunset the SGR system immediately. On October 21,
2009, the cloture motion to proceed to the bill was not invoked by the Senate by a vote of 47 −
53.20
Brief Analysis
Setting the update to the conversion factor at 0 would have effectively frozen the Medicare
physician fee schedule at 2009 levels in perpetuity, barring other changes. No replacement to the
SGR method for determining annual updates was proposed as a substitute. The periodic review of
RVUs and the subsequent reallocation of weights would still have affected the relative
reimbursements across services, however, because such adjustments are implemented in a budget
neutral manner, the physician reimbursements would not have increased overall as a result of this
bill.
H.R. 3961 (111th Congress)
Summary
H.R. 3961, the Medicare Physician Payment Reform Act of 2009 was introduced on October 20,
2009. The proposals in this bill share some of the same approaches and objectives as Section 301
of the CHAMP Act, but also differ significantly in a few important ways. First, rather than
creating six different categories of physician services, the bill would create two categories of
service beginning in 2011, each with its own separate target growth rate and conversion factor
update. The two categories of service would be (1) evaluation, management, and preventive
services, and (2) all other services. Second, the year 2009 would be established as the new
baseline year for calculating expenditure targets (rather than 1996 under current law) for each of
the two categories of services. Third, only physician services would be included in the calculation
of actual and target growth expenditures; services provided incident to the physician visit (such as
laboratory services), would not be included. Fourth, during the transition to the calculations
required for the new method of calculating targets and updates, the 2010 update would be the
percentage increase in the Medicare economic index (MEI). In its final rule for 2010 Medicare
physician payments, CMS specified that the MEI will be 1.2%.21
20 http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00325
21 The MEI measures the weighted-average annual price change for various inputs needed to produce physicians’
services. The calculation of the 2010 MEI is given in Table 33 of the final 2010 Medicare physician payment rule
issued by CMS. http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf.
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Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System
Brief Analysis
The impact of this bill would be felt not only by physicians but also by other parts of the
Medicare program, the Department of Defense TRICARE program, and beneficiaries under
Medicare Part B. CBO estimates that enacting H.R. 3961 would increase direct spending by about
$210 billion over the 2010-2019 period.22 Not only would physician reimbursements under the
Medicare physician fee schedule increase, but expenditures under the Medicare Advantage (MA)
program would increase because per beneficiary spending for fee-for-service beneficiaries would
increase as a result of the bill, raising the “benchmarks” that Medicare uses to determine the
capitation payments for beneficiaries enrolled in Medicare Advantage plans. TRICARE
expenditures would rise because its physician reimbursements are based on Medicare’s physician
fee schedule. Furthermore, since Medicare Part B beneficiary premiums are required to cover
25% of total Part B expenditures, the increases in physician reimbursements as a result of
changing the update calculation would put pressure on future Part B premiums to rise.
The proposed modification might reduce the likelihood that future expenditures exceed the target
expenditures, since the growth rates would be more generous under this bill than under current
law, but this might lead to an increase in the total expenditures of the Medicare Part B program.
While the SGR has been heavily criticized, a fundamental assumption was that tying physician
expenditure growth to the rate of growth in GDP per capita could lead to a sustainable growth
path. By allowing the two categories to grow at GDP per capita plus 1% or 2%, this bill would
appear to allow for a situation where physician expenditures grow and consume a greater
percentage of the national income.
Author Contact Information
Jim Hahn
Analyst in Health Care Financing
jhahn@crs.loc.gov, 7-4914
22 CBO Cost Estimate, “H.R. 3961 − Medicare Physician Payment Reform Act of 2009,” November 4, 2009
http://www.cbo.gov/ftpdocs/107xx/doc10704/hr3961.pdf
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