0:00
The bottom line is, there were a number of things that were important to medical practices that were delayed a couple months. So we're going to be right back in on this, and we're starting fresh lobbying on those issues. Again.

0:18
Welcome to off the chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the assistant editor in medical economics, and I'd like to thank you for joining us today in today's episode physicians practice editor Keith Reynolds speaks with Anders Gilbert, Senior Vice President of Government Affairs at the Medical Group Management Association, or MGMA, through conversation. Forms just as the federal government reopens after a historic shutdown, which is a welcome development, but also a temporary one. The deal extends key health care policies only through January 30, so practices may find themselves back in limbo in only a matter of weeks. ACA tax credits still expire at the end of the year. Telehealth only extended through January, and some practices now have to redo Medicare claims that were underpaid during the shutdown. Anders explains what the temporary deal actually means for medical groups and why the 2026 Medicare Physician Fee Schedule may end up affecting practices even more than the shutdown itself. Anders, thank you, as always, for joining us, and now let's get into the episode.

1:22
You Hey there, folks. We're here with Anders Gilbert, Senior Vice President of Government Affairs for MGMA. How you doing today? Honors, good Kate. How are you? I can't complain at all, and if I did, no one would listen. So let's dig right in. We are talking on Thursday, November 13, the government is reopening after a an epic, historic length closure.

1:49
So tell me a little bit about the deal that that got this, all this all rolling again.

1:55
Okay. Well, again, we're focused more on the health care aspects of the deal and well, while it is good to have the government reopened, clearly, there were multiple pieces of the the associated healthcare policy issues that caused the most drama around the deal. So first of all, it was the ACA subsidy issue, which didn't get resolved again, the advanced premium tax credits expire at the end of the year, and those individuals that buy insurance on the exchanges has been reported multiple, multiple forums, could see their premiums go up two times, three times, four times, five times. And so it's still a sticky political issue out there a lot of Republican states, you know, like the largest growth in those the use of those tax credits is down in Texas and Florida, for example. So we'll see if that gets resolved. The the Senate Democratic leader, Thune, Senator Thune, he promised some kind of vote on that, but frankly, the House made no such promise. So we will see what happens on that issue. I think if you're managing a medical practice, or you're dealing with the business of the medical practice, that's important. Obviously, if you have a large payer mix of patients that buy insurance on the exchange, you don't want a bunch of uninsured patients if they decide to drop it on January one, given the premium increase. But you know, things that will be important is just do a lot of eligibility verifications and checks to make sure that you understand where patients are at the beginning of the year. I think most physician offices would would be doing that the beginning of the year anyway. So stay tuned. I think there'll be more on this. It's still a very politicized issue. The other issues that were important to us had short term extensions in the agreed upon spending package, but only to January 30. So things like extending telehealth flexibilities and Medicare, you know, again, Medicare flexibilities were only instituted to cover telehealth outside of rural areas during covid. And so again, we're limping along. That's retroactive. And so now with like claims. You know, if you have claims and and doctors offices saw patients over the last month of October, they can go and submit those claims, and they would be covered. But this all expires at the end of January again, so we're going to be right back on that issue. Also the geographic areas, the gypsies, the geographic price indices in many states are below what's called the 1.0 work floor. So what they how they value physician work, essentially, big states like North Carolina or Indiana, the entire state is below that floor. So unfortunately, in October, all Medicare claims in for medical practices in those states were paid at slightly lower amount. And if you build a patient now, we have a situation. Situation where all those claims are going to get reprocessed, and practices might have to go back and Bill patients for these very nominal amounts, and so it's kind of a mess. Anytime there's reprocessing, it can kind of be a mess, but stay tuned on that. We'll get more information about that coming coming out soon. There was one issue, if you're like a health policy wonk that kind of has been looming out there also, but this agreement struck the pay go requirements that were triggered in the one big, beautiful Bill act. And basically no one's talking about it yet, but they might, but it eliminated $3.4 trillion from the pay go requirements, and so pretty much put three and a half trillion dollars on the debt, and it's in the appendix of this. Well, the why I would bring this up is that if, if Congress didn't do that, there would be, across the board, 4% cuts in Medicare starting on January one. So the bottom line is, there were a number of things that were important to medical practices that were delayed a couple months. So we're gonna be right back in on this, and we're starting fresh lobbying on those issues again.

6:13
All right, so, you know, the government's reopened. You know, what is the immediate impact, though, that this is gonna have on practices?

6:20
Well, the immediate impact, I mean, I live in Washington, I drove in this morning. Traffic was still pretty light, so I'm not sure it's technically open yet, but people will start coming to work here soon, right? But again, the immediate effect on practices will simply be derivatives of what I just talked about. So that reprocessing issue, we're going to have to look for guidance on how CMS wants to reprocess Medicare claims in those in those states and and then again, the telehealth coverage. So, you know, it's, it's an isolated, very thin, you know, slice of issues, but very important, depending on specialty and practice style, just to remind people, usually at the end of each year, we have some huge problem with Medicare cuts and physician practices. And we can talk more about the physician fee schedule, which also also came out during the shutdown, but there was a two and a half percent increase in to mitigate reduct like the overall reductions to the conversion factor, that was part of the one big, beautiful Bill act, and that was for the entirety of 2026 so at least there was a floor put in on an issue that typically we have to deal with at the end of the year. So it's off the table,

7:36
all right. So,

7:38
you know, looking back now on the shutdown as it is very fresh history. As you said, it's, you know, not necessarily fully open yet, you know what sort of like, what's been the worst impact that you guys have had reported to you at MGMA, like, what were practices feeling?

7:54
I think again, it depends on the practice and the payer mix and how much Medicare they have, if they were doing a lot of telehealth, and then all of a sudden that telehealth wasn't covered in October, on October 1, you know, for some practices, it was really dramatic. They had to, like, reschedule patients, bring them into the office. These are elderly patients, you know, might not have transportation. So there were real problems in October, depending on what the practice did. But if you're like a surgical practice, and you're providing care in a state above that floor, that geographic floor, and you're not doing telehealth, you're doing procedures in the hospital, probably not a whole lot of impact. So we'll see about that for those affected practices. But again, you know it's highly dependent on, like, how much, how many Medicare patients you have? Do you provide telehealth? Where are you located? Things like that. But some people wouldn't even know that there was a difference here, and some practices were dramatically affected. All right,

9:02
so you mentioned the physician fee schedule, you know, that came out during the closure. You know, does the reopening, you know, does that change the implementation timeline at all, or, or any other timelines on, you know, rule making that's been going on or paused, or any sort of that sort of thing.

9:21
It doesn't directly affect the implementation of the fee schedule. I was a little surprised. Actually, the fee schedule came out Friday night, Halloween, at like 515 in the evening, and it had all the bells and whistles, 2500 pages, all the fact sheets and press releases came out, so there were people working in the government over at CMS at the time. There are dramatic effects depending on variables relative to like specialty and whatnot, in the fee schedule, and we can talk about that, but not really related directly to the shutdown. And. In fact, the implementation the fee schedule, might have more of an impact on medical groups than the actual shutdown did at this point.

10:06
All right. Well, tell me about it. What sort of impacts is that?

10:11
Yeah, so again, as I said, there's a two and a half percent increase baked in to the conversion factor, which is the multiplier that helps physicians come to $1 figure for what they get paid in Medicare, and that, plus some like additional, what we call budget neutrality adjustments that actually resulted in increases over three and a half percent or over 3% let's say, depending on if you are participating in Advanced Alternative Payment Model, or if you're not so slightly more, if you are in an APM, little bit less, but both are above 3% additions to the conversion factor, that's good. But if you're in a specialty, there are two major provisions that were implemented that MGMA we were concerned about and the many, many, many specialties were concerned about. One was an efficiency adjustment to work RV use, which was a two and a half percent cut across the board, but for especially affected codes, like procedure codes, not codes that would use, like time as a factor in the in the coding element of it. And so, like offices, it's probably would be improved by what they CMS did, but procedures would probably hit it's highly dependent on, you know, a number of variables. But like oncology practices certainly were hit pretty hard by that certain specialties. So my I would encourage everybody you know, like MGMA has a fee schedule analysis. If you're not a member of mg May, which I would encourage you to be. But if you're not, you could probably get some information on the CMS website about the impact by different specialty. There are fact sheets on the website. So there's the work RVU piece, and then there's the practice expense RVU piece, again, CMS shifting stuff around there on the RV use there the relative value units. And in that case, a lot of specialties that have physicians who work in hospital facility settings could see very dramatic decreases. So even if they got a three and a half percent increase on the conversion factor, some specialties could see 10% cut overall if, for example, they were an independent practice. But did the you know, predominantly, most of their care in a facility setting, and the hospital gets a facility payment. The practice gets a lower physician reimbursement because they don't have the overhead cost and what they you know, because they're providing it at that facility that care those type of codes, a lot of specialists were hit pretty hard, depending on where you practice the most. And you know, I would say, like, if you're an employed hospital, like if you're employed by a hospital, a practice owned by a hospital, it's probably not a huge factor, in some cases on the practice expense side, because, you know you're, you're getting a salary anyway, but for those practices that are like billing Medicare, not employed physicians, yeah, again, definitely check and see you know what your codes look like for the next year. Alright?

13:37
So let's, let's get into the nuts and bolts politics of this thing, so, as you said, you know, Thune, you know, promised to vote in December. Didn't promise on, you know, which way that vote would go. The house has not made any recommendations. The President is saying whatever he's saying at that given moment. You know, this shutdown and reopen cycle. It at least from sitting here in Ohio, seems like this is probably going to be a thing going forward, not to be overly millennial about it, but, you know, it's going to be a thing. What is that? That sort of instability of, you know, federal policy, like, how will that affect medical groups, you know, and how can they prepare for, you know, the possibility of these disruptions going forward?

14:28
Well, the shutdown again, is like that's related to the budget. And in the past, we have these health we call healthcare extenders here in Washington. So it could be this gypsy floor, the 1.0 work floor. It could be telehealth coverage. You know, frankly, we're advocating for permanent a permanent floor, a permanent health care coverage. You know, there's some lab cuts to physician owned and other types of labor clinical laboratories in Medicare that need to be resolved. Like all these little issues, there's lots of hospital issues that we don't focus on, but the hospitals do, and typically. They not always. Those issues are dealt with as part of like budget bills, and they're typically at the end of the year, and then the extensions are full year last year. You know what's like to answer your question created just a mess because there was a bill in December of last of this year, or right last year to fund the government this year. And, you know, we had Elon Musk and tweeting about it, and Donald Trump tweeting about it, and that got slimmed down from, like, 1000 pages to 200 pages and stripped out all kinds of very important healthcare, healthcare policy issues. I'll give you an example of one. You know, like, we have a lot of medical practices that perform services and are part of advanced APMs, and there was an incentive payment to participate in APMs as part of that that got scrubbed out in December, and we'd love to see that back in and so, again, the fact that these extenders are linked to the budget is a real problem, to your point. And so what happened this year was the December bill of 2024, got us to March. March got us to the end of September. The government shut down. We're now retroactively dealing with all of these extenders and billing in October. And then we all we were able to do, all the Congress was able to do is get an extension on many of these issues, including the budget, through the end of July, January. So what is that like? Two months, two and a half months, if we're lucky, right back at this so it's less about the government shutting down. I mean, that's a problem in and of itself, but it's really the association of these extenders, important things like payments to physicians who work in rural areas and provide telehealth services. That's the problem, and that kind of stuff. You know, the instability that that creates, the fact that you can't, you know, plan business, make business decisions into the new year. You also have workflows and whatnot, like, telemedicine is a whole different workflow than inpatient care. And you know, there are you're paying for vendors to provide that service. You know, it's not just, we're all sitting here on, like, iPads and stuff like you, you have an elderly population, sometimes not as technologically savvy, and you're trying to, like, it's just a different workflow, getting them signed up, get them signed in, all of that. And so you know the fact that that, like, it's like a light switch with Congress, when it shuts down like that, just turns off and then turns back on and then turns off. It just makes running a medical practice really hard. Again, very dependent on what you do and where you do it. But again, for those practices that do a lot of telehealth that might be located in an area that has a geographic adjustment below 1.0 on that work, RVU total mess, and they're gonna have to deal with reprocessing all of October and half of November. Now, of all claims, every single claim in Medicare.

18:11
Hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack, an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh, lifesciences.com with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute.

18:59
What do you see, in 2026, you know, we, we've, you know, I feel like I've talked to you about telehealth, flexibilities, you know, 1000 times. You know, what do you see happening with that next year?

19:13
Well, my hope would be that Congress actually does some work on the core issues here and there are bills out there that are bipartisan, like, this is not a partisan issue. That's the irony of it. There's legislation that we support that would extend telehealth flexibilities for two years and then allowed there to be some studies about addressing some of the concerns with telehealth. Like not everybody thinks telehealth is a panacea. It could be subject to fraud. There are privacy concerns. You know, we also don't. Our lawmakers don't want volume and Medicare to increase unnecessarily because of telehealth, so they want it to be done, right? So a two year extension and study some of the issues to prevent. Fraud and privacy issues and things like that. That would be a prudent approach. We would support that. So in the next year, that's what we'd want. We also, you know, why do we have to, like, fix this work floor in rural areas every year? We should just fix, just permanent, if you're going to bypass that every year, just permanently implement a floor of 1.0 there are other major issues too that are highly bipartisan, like prior authorization reform don't have a cost to it that we would love to see resolved at the end of this year, perhaps before the January 30 deadline, and again, that has a majority of members of Congress on both sides of the aisle in both houses, doesn't cost anything like the unfortunate experience of this year and last year is that the Congress has been the least productive Congress in history. And at the it's two different sessions, but 2024 in the beginning of the this current session, starting in 2025 going through next year. And so our hope is, and our desire, and like our what we're working toward is to work with Congress to, like, do some things that will help medical practices, help physicians, and they're not even partisan issues. They're not caught up and things like we just experienced with the shutdown, and get things done. But the lowest, I think it was off my top of my head, that last, last Congress had the lowest number of bills passed ever, like, ever, so then you get something done, and I think, like, that's one issue and then, importantly, things like these, ACA tax credits. It's an election year, next year. And again, it's hard for me to believe that, especially some of the Republicans that didn't vote for it in this go around because of the associate, you know, they didn't vote for it because it was associated with that shutdown and whatnot. Okay, that's a principle that they had, but I think in an election year, especially given a lot of the drama that's gone on now with the shutdown, there will be acute interest from their own constituents about why didn't my health insurance double or triple this year. And again, like I said, a lot of those districts that had a lot of use of this tax credit from the ACA over the last five years or so, you know, when the implementation of that occurred, this additional up to, like, over, in some cases, 400% of the federal policy level. Those are Republican districts, and so I think the Republicans are going to have to figure out a way to mitigate the effect of that when their constituents lose their health care coverage or have to pay twice the amount for an exchange product. So I think something will be done on that. I don't have a crystal ball exactly how that's going to go.

22:59
That used to be, you had to keep the constituents happy. Yeah, who knows anymore? All right, so let's, let's then turn to FTC action. Let's talk non compete agreements. So that was big, big news. I believe it was last year, maybe even the year before that. You know, the FTC was coming out against these non compete agreements. There were, you know, practices obviously a bit concerned about that, because that, you know, raises the leverage for individual physicians. The Trump administration Part Two comes in, and there's some funniness about it, a lot of, we'll say, discussion of how that wasn't going to happen. But we're also hearing that there's some quiet, some quiet meetings happening that aren't necessarily getting a lot of play in the media at this point. Now, what are you what are you hearing about this non compete ban? Is that? Is that still alive, or is it dead in the water

24:02
well, a lot of what happened under the Biden administration got withdrawn in the in the Trump administration. So that's obvious. I don't have anything concrete to report with this administration on the implementation of a ban on non competes. One of the things, obviously, there's a lot of a patchwork of state laws. For example, like California, they're banned. I will say, for an organization like MGMA, it's very highly dependent. So we represent medical groups, and I hear a lot of different things from our members on non competes and both sides, most physicians don't want to be subject to a non compete if they're employed by a hospital, that kind of thing. But we also represent medical practices, let's say if they subsidize a physician to move to their community and. Work in their practice, and, you know, have some type of measure of non compete in their contract of a new physician. Maybe have that physician eventually become an owner of an independent practice. Then, you know, there might be a concern about that physician, if they work for a year, and then took a bunch of the patients and opened up shop across town. So I don't think it's as cut and dry. It's just an individual physician issue for an organization like ours, and we look at it in a pretty balanced approach. And so we will be looking to see what the administration does, if anything on this the one thing about the Trump administration from experience, because we did four years back, you know, 2017 but the Trump Administration uses a lot of, like requests for information and like studying different issues, like like this, like non compete, use of non competes. And so we'll see, you know, typically we would submit something on that, provide some thoughts on that. But again, with this issue, it's one thing if you're a individual physician, and it's another thing, though, if you're an independent medical practice, like you may not want, and the hospitals can use a non compete and, you know, and you can't and like, there's all kinds of like market aberrations that occur. So we will look at it very closely and see what the administration does. But sometimes that you get a lot of noise around these, like requests for information, and then nothing happens. And respectfully, there was a lot of that in the in the first term of the Trump administration, where we responded to so many requests for information only to that issue just kind of like disappeared.

26:46
It seems that the the Trump Part One and Part Two, the by word is sort of it's not a problem until it is sort of deal. So Okay, last question, you know, again, look into your crystal ball. You know, do whatever you got to do. What's on the horizon for policy next year?

27:08
Yeah, so unfortunately, we're going to be in this short term situation in January. So the first 30 days, we're gonna have a little sprint there. And it's an election year. So like, my hope would be and like, what we will be advocating for, again, is permanent legislation to address a number of issues. Like I said to your previous question, there was a temporary two and a half percent increase to the conversion factor put into place for next year, but we're going to be back to square one on that in 2027 and we will be advocating for physician payment reform next year. My hope is we can do it this year. But finally, prior authorization reform, there are some exciting things, because even though legislation on prior authorization has languished in Congress. The administration is going to be implementing Biden era regulations to start to implement some regulatory framework around prior authorization with, I think the key implementation date would be January in 2027 that would allow medical practices to using their EHR. Physicians using EHR to have a standardized way of in a more transparent manner, transmitting prior authorizations getting shorter turnaround times that would affect Medicare Advantage plans, you know, different kinds of federal plans that are subject to that. That's pretty exciting, because even if we don't get the legislation, there are some things that we will be working on in the regulatory space next year. But again, like we need physician payment reform. I think there needs to be a re like the whole idea of value based care. There needs to be a policy refocusing effort on that. One of the concerns I have about what I've seen out of this administration so far is that, you know, their efforts to deal with value based care aren't really about value based care as much as this wiser model, which is a demonstration project out of the Centers for Medicare, Medicaid, Kate innovation to address overspending in traditional Medicare by implementing prior authorization. So the irony is like, you know, Administrator Oz, on one hand, has been kind of jawboning insurance companies about reducing the burden on of prior authorization, on on physicians, but at the same time, they're implementing a plan to expand prior authorization and traditional Medicare, which doesn't really have traditional Medicare, that's the best part of traditional Medicare, and so prior authorization, I think, will be front and center next year. So as I look at in my crystal. Ball. Hopefully we can get an approach looking at physician payment reform, long term, actually doing something so we don't have to limp along, actually dealing with telemedicine, extension, long term, dealing with prior authorization, which is the number one administrative burden for medical practices and doctors every time I go anywhere, number one. So there are issues to be dealt with, and hopefully the impetus in an election year will allow some of that to get done. The alternative is just everything gets bogged down in politics and nothing gets done. I hope that's not the case, but this Congress has not shown to me yet a real desire to work on health care policy, so we will see

30:41
Well, hope springs eternal, which I feel like is how every one of our interviews end.

30:48
But I appreciate your optimism. Keith, well, you know, you

30:50
got to find the silver lining. Brother, it's the only thing that keeps us going. It's, you know, we are physicians practice. We're all about actionable tips, and, you know, trying to keep everybody functioning so alrighty. Anders, thank you so much for for coming out and chatting with us. It's always a pleasure.

31:10
Thank you. Thank you, Kate.

31:22
Once again, that Reynolds, editor of physicians practice, and Anders Gilbert, Senior Vice President of Government Affairs at MGMA. My name is Austin Luttrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with healthcare experts sharing strategy. Experts, sharing strategies, stories and solutions for your practice, you can find us by searching off the chart wherever you get your podcasts. Also, if you like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine. Podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Luttrell. Medical economics and physicians practice are both members of the MGH Life Sciences family. Thank you.