What does the Republican Party's resounding win in the midterm elections mean for radiology? The tidal wave of change was profound: As of press time, the Republicans had won seven Democrat-held Senate seats, giving the party at least a 52 to 46 seat advantage in the Senate. The Republicans could add two more seats in still undecided Alaska and Louisiana.
In the House of Representatives, Republicans added at least 13 seats, for a majority of 244 to 174, and are poised to add more, with 16 House seats still undecided. Republicans have not controlled both houses of Congress since 2006.
The Radiology Business Management Association (RBMA) and its legislative affairs advisors have followed developments in Washington closely on behalf of RBMA's more than 2,400 members who focus on the business of radiology. While politics is a dynamic and often surprising field, RBMA believes the following developments are now more likely because of the election outcome.
SGR bill developments
One of the more immediate tasks facing the 114th Congress next year will be to once again tackle the flawed sustainable growth rate (SGR) formula for calculating Medicare physician payments. The current SGR patch that prevents significant cuts to Medicare payments to physicians expires on March 31, 2015.
The election results will bring more than Republican control of the Senate; the results also mean there will be new Republican chairmen of the Senate Finance and House Ways and Means committees. These are two of the key committees -- along with the House Energy and Commerce Committee -- with jurisdiction over Medicare and the SGR.
While it is unlikely that there will be a complete rewrite of the current SGR reform proposal, both Sen. Orrin Hatch (R-UT), who is in line to become the new chairman of the Senate Finance Committee, and Rep. Paul Ryan (R-WI), who is likely to become the next chairman of the House Ways and Means Committee, will look to put their stamp on any SGR reform proposal.
Both support comprehensive reform of the SGR, and both are likely to try to include major Medicare reforms as part of any proposals to pay for SGR reform. With Republican control of the Senate, there is an increased likelihood that SGR reform could move forward as part of a reconciliation bill that includes other major Medicare reforms. Passage of a reconciliation bill only requires 51 votes in the Senate, so it is an appealing route for Republicans.
Closing the in-office ancillary services exemption to self-referral
Because Republicans generally oppose government restrictions on markets, their majority in both houses of Congress makes the argument for ending self-referral for advanced medical imaging a more difficult one to win. Although the potential cost savings to Medicare of ending self-referral for advanced imaging, radiation oncology, and other services might be a way to pay for other healthcare policy changes (e.g., SGR repeal), to date, Congress, aside from champions like Rep. Jackie Speier (D-CA), has shown little appetite to act in what is often viewed as a fight between medical specialties.
RBMA, a member of the Alliance for Integrity in Medicare (AIM) coalition, will continue to advocate for closing the in-office ancillary services exception.
Affordable Care Act changes
While Republicans look to control 52 to possibly 54 Senate seats, they must still overcome likely Democratic efforts in the Senate to filibuster Republican legislation to repeal and/or degrade the Affordable Care Act (ACA). It takes 60 votes in the Senate to overcome a filibuster, and even if Republicans can persuade a half-dozen Democrats to vote with them, they will still face a Democratic president with the power to veto legislation he does not like and who is deeply invested in protecting ACA, as it is his signature piece of legislation.
Republicans, mostly for political reasons, are likely to continue to call for an outright repeal of ACA. RBMA legislative experts predict that repeal efforts are unlikely to succeed, and that once the political posturing subsides, there will be efforts to make smaller fixes to ACA, which could include repeal of the medical device tax, relief for small employers, and delays of some parts of the law.
Lame duck session
Although Congress adjourned in late September with many important issues unresolved, we don't foresee significant action on healthcare in the lame duck session slated to begin on November 12, 2014. With Republicans looking forward to having control of both houses of Congress after January, they will be reluctant to tackle anything beyond issues that absolutely must be accomplished before the end of the year. These may include the following:
- The Marketplace Fairness Act to allow states to collect sales tax on Internet retailers
- Tax extenders for the roughly 60 tax provisions -- individual, business, and energy -- that have expired this year and need to be either renewed or made permanent for taxes not to increase
- An omnibus bill funding the government for 2015, and related to that, the roughly $600 billion fiscal year 2015 National Defense Authorization Act
- Reauthorization of Terrorism Risk Insurance Act
In addition, Congress must extend the authority for the U.S. to continue to arm and train Syrian rebels. Attaching healthcare provisions to any of these "must do" bills will be extremely difficult.
Action moves to CMS
With Republicans in control -- but without the mandate for action that comes from a strong majority -- RBMA anticipates that in 2015, much of the action may instead move from Capitol Hill to Maryland, where the U.S. Centers for Medicare and Medicaid Services (CMS) is located.
Congress has required that CMS furnish the data it used to justify the multiple procedure payment reduction (MPPR) on the professional component of imaging. When that information is released, it may provide an opportunity to get CMS to rescind the policy because of flaws in the data, or to seek a legislative fix to remove this cut to imaging reimbursement.
In addition, CMS is expected to issue a decision on whether or not Medicare will cover low-dose CT screening for lung cancer. If the agency decides against covering the test, there is strong data to take to legislators to support a law that would require Medicare to cover the test, as it does for other screening tests with a B or higher rating from the U.S. Preventive Services Task Force (USPSTF).
Finally, the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare payment policy, continues to recommend that Medicare move to a single payment regardless of whether a test or procedure is performed in a hospital outpatient setting or a freestanding medical center. CMS has pushed back against site-neutral payment systems because of the many practical concerns in implementing such a policy, but the potential savings are significant. While a bill just to implement site-neutral payment is unlikely to pass, this idea could come up as a pay-for in other healthcare bills.
RBMA encourages radiology business professionals to follow these issues closely and wishes to thank the firm of Roberti + White for its contributions to this analysis.
Mike Mabry is executive director of RBMA, and Richard White is managing partner of Roberti + White.
