TMA Moment in Time: SGR Repeal Texas Medicine April 2023


For 13 long years, three little letters plagued physicians taking care of the nation’s Medicare patients: SGR. Those letters may be out of physicians’ vocabulary now, but they nevertheless represent the mountains that can, in fact, be moved when the Texas Medical Association is steadfast and relentless in its advocacy.

Abilene otolaryngologist Austin King, MD, was TMA president in 2015 when Congress finally repealed the SGR – the flawed Sustainable Growth Rate formula Medicare had used since 1997 to calculate physician payments. He doesn’t mince words when describing what he characterized as “incomprehensible,” “disastrous,” and “a problem for years.”

The threat of double-digit pay cuts year after year had the nation’s physicians in agreement: SGR had to go. Though designed to sustain Medicare with lower costs, the “disastrous” result Dr. King referenced began as a 4.4% physician pay cut in 2003, snowballed to 10% by 2008, and then skyrocketed to 24% by 2014 – costing the federal government $153.7 billion in “patches” each time Congress suspended the cuts, according to the Congressional Budget Office.

Such deep cuts would have proved fatal to independent practices oriented around Medicare patients, Dr. King says.

Federal lawmakers “knew that [cuts] would cause further access problems for Medicare patients because it was already difficult for them to get into some types of specialists, like internists,” he said. “So, they would kick the can down the road.”

By 2015, lawmakers saw the proverbial writing on the walls of physician practices declaring they were unable to accept new Medicare patients – and SGR took its last gasp.

By 2003, TMA had already experienced a huge state advocacy win with a full court press for medical liability reform. The SGR repeal became a testament to the efficacy of TMA’s advocacy on the national stage.

“TMA is really a significant player on the national basis as well as the state basis, which is unusual for a state medical society,” Dr. King said.

If some of the complaints from the SGR era still sound familiar, it’s not without reason. Although not a one-and-done fix for the Medicare physician payment problems that have persisted, the SGR victory was nonetheless a critical success for physicians and patients, and created a playbook for future Medicare reforms as TMA once again turbocharges its advocacy on the issue.

TMA Board Trustee Joseph Valenti, MD, chaired TMA’s Council on Socioeconomics during the SGR repeal and now serves on The Physicians Foundation’s Board of Directors.

“If we were able to get rid of the SGR and get [its replacement] MACRA, then we can change MACRA,” he said, referring to the Medicare Access and CHIP Reauthorization Act of 2015.

Texas leadership

Indeed, SGR repeal was a national fight, and TMA remained at the forefront thanks to its physician champions and the legislative relationships it cultivated over the years.

TMA’s own Medicare Meltdown campaign spanned several TMA presidencies as year after year, Congress allowed SGR to wreak its havoc, with physicians’ practice viability hanging in the balance until the 11th hour. Lawmakers would eventually and repeatedly step in and take emergency action – sometimes retroactively – to defer the scheduled cuts, all the while buying short-term relief but eschewing a long-term solution.

Press conferences, Capitol Hill visits, posters, fact sheets, media interviews, phone calls, videos – TMA mustered all of its resources to get the meltdown message across:

“We need to remind Congress that this ongoing crisis ... doesn’t affect just physicians but also millions of seniors, people with disabilities, and military families,” TMA’s president, Susan Rudd Bailey, MD, warned in 2010 as physicians then faced a more than 20% pay cut. “Each time Congress plays this game of chicken, the cut to physicians grows deeper, and fear among our patients and physicians increases.”

By 2015, TMA’s years-long task of educating federal lawmakers and their staff about what was at stake had paid off.

“It was a huge push,” Dr. King said.

Congress ultimately realized repealing the SGR – which the American Medical Association estimated would cost $141 billion – was cheaper than maintaining it, with the added benefit of preserving patients’ access to care.

Medicine found a champion in Texas’ own U.S. Rep. Michael Burgess, MD, an obstetrician-gynecologist from Lewisville who had staked his congressional career on eliminating the SGR and ultimately authored its replacement, MACRA.

His bill gained broad bipartisan support in the House, including from then-Speaker John Boehner (R-Ohio) and then-Minority Leader Rep. Nancy Pelosi (D-California). Texas’ own Sen. John Cornyn, then majority whip, carried the flag in the Senate, averting a key amendment threat. President Barack Obama signed MACRA into law on April 16, 2015.

Dr. King recalls getting updates along the way from Representative Burgess, a longtime TMA member, and from Senator Cornyn, with whom he attended college at Trinity University in San Antonio.

“Medicine really owes a large debt to Michael Burgess and John Cornyn because they’re the ones who pulled [MACRA] through,” he said.

The result: “We are clearing up our books, and that should have happened a long time ago,” Representative Burgess told Texas Medicine at the time. “Will it ever be necessary to come back and do something else? Well, at least the starting point won’t be having to repeal SGR.”

A jumping-off point

In fact, MACRA shifted Medicare physician payment from fee-for-service to value-based care, charting a whole new path that for many physicians is still unsteady.

Dr. Valenti celebrated SGR repeal as Council on Socioeconomics chair. But in the years since, MACRA’s limitations have revealed themselves, informing TMA’s continued advocacy in the realm of Medicare physician payment reform, he says.

“We’re constantly working to make it less obtrusive for physicians,” he said, pointing to victories along the way.

For instance, the Centers for Medicare & Medicaid Services’ two recently adopted quality measures – proposed by The Physicians Foundation and supported by TMA – recognize the impact of nonmedical factors on patients’ health outcomes and help compensate physicians for addressing them. (See “Closing the Loop: Payers Address Social Drivers of Health,” May 2022 Texas Medicine, pages 22-25.)

TMA has set its sights on reforming the Medicare physician payment system, citing successive cuts, rising inflation, and pandemic strain. Late last year, Texas physicians sent nearly 2,000 messages to their federal representatives protesting a scheduled 4.5% Medicare pay cut, which Congress partially and temporarily averted.

Yet again, TMA’s efforts have drawn national attention.

AMA President Jack Resneck Jr., MD, lauded TMA and the Texas Delegation to the AMA for their leadership on national health care issues like Medicare pay, prior authorization reform, and physician wellness. (See “Strength in Numbers,” March 2023 Texas Medicine, pages 24-27.) “It is a powerful and respected group,” he said of the delegation during a keynote speech at TMA’s Winter Conference in Austin on Jan. 29.

Dr. Resneck said Medicare physician payment reform was also a top priority for AMA.

“Blocking the cuts is not good enough,” he said. “We cannot wait for this any longer.”

Dr. Valenti believes this is good for the cause, and TMA’s precedent for success has him optimistic. 

Last Updated On

April 09, 2024

Originally Published On

March 30, 2023

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Leadership | Medicare | Practice Viability

Emma Freer

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Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

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Amy Lynn Sorrel

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Amy Sorrel

Amy Lynn Sorrel has covered health care policy for nearly 20 years. She got her start in Chicago after earning her master’s degree in journalism from Northwestern University and went on to cover health care as an award-winning writer for the American Medical Association, and as an associate editor and managing editor at TMA. Amy is also passionate about health in general as a cancer survivor, avid athlete, traveler, and cook. She grew up in California and now lives in Austin with her Aggie husband and daughter.

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