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Physicians need to be paid better for taking care of chronically ill patients, and they should also be relieved of onerous paperwork burdens such as prior authorizations, senators and witnesses agreed Thursday at a .

"Medicare Physician Fee Schedule payments have declined by more than 25% over the past two decades, as clinicians continue to face skyrocketing costs for overhead, equipment, supplies, and staffing needs," said Sen. Mike Crapo (R-Idaho), the committee's ranking member. "The colossal gap between stagnant fees and steep inflation poses a dire threat to long-term patient access."

"For many specialists recent regulatory changes have further intensified these issues, as new billing codes and valuation shifts have triggered drastic cuts under the program's budget neutrality rules," he continued. Because of those rules, "a payment bump for primary care prompts payment reductions for entirely unrelated procedures and services."

"Nine years ago, Congress took concerted action to repeal the draconian sustainable growth rate system, which had threatened cascades of dramatic cuts," Crapo said. "In enacting the Medicare Access and CHIP Reauthorization Act (MACRA), policymakers sought to stabilize the fee schedule and incentivize value-based care. In practice, these reforms have largely failed. The Merit-based Incentive Payment System (MIPS) aimed to establish an accessible on-ramp to participation in quality-driven alternative payment models, or APMs. Instead, this system has buried clinicians in dozens of hours of paperwork each year."

A Fragmented System

The fragmentation of care under the Medicare program is also problematic, said hearing witness Amol Navathe, MD, PhD, professor of health policy and medicine at the University of Pennsylvania, in Philadelphia. "Medicare beneficiaries with chronic conditions see more than five physicians concurrently," he said. "My colleague Matt Press [Matthew Press, MD, MSc, medical director of Penn Medicine's Primary Care Service Line] found that over just 3 months, with other clinicians and the patient to actively coordinate care for just one important clinical condition."

"With good intentions, CMS [the Centers for Medicare & Medicaid Services] has attempted to [help by] adding more billing codes," said Navathe, who was speaking for himself. "But reducing the important work of clinicians to a list of codes is a fraught task. The result is an administratively complex system of ticky-tack codes that are underused because the cost of billing them is itself unprofitable."

"Addressing fragmentation will require a new way of care, which in turn will require substantial changes to physician payment," Navathe added. "Simply adding more dollars to the current system won't be enough. Physician groups need to be able to invest in new capabilities, use technologies like telehealth when safe, efficient, and effective, and staff practices differently." He advised starting with paying primary care physicians a set monthly fee, in addition to their fee-for-service payments, to compensate them for care coordination and other tasks.

Committee chair Sen. Ron Wyden (D-Ore.) was especially floored by Navathe's comment about the 50 interactions. "We have had some jaw-dropping testimony around here over the years, but to hear that one patient [required] 50 interactions ... That was really extraordinary," Wyden said.

Sen. Marsha Blackburn (R-Tenn.) asked about the usefulness of the MIPS program, which requires physicians to choose from a list of quality measures that they need to report on. "The experience that my colleagues and I have had under MIPS has been one that, frankly, hasn't been that effective," said Navathe. "It's unclear that the measures that we're reporting on are actually in keeping with what beneficiaries really care about. And I think that's a fundamental disconnect."

MIPS's "choose your own adventure" approach makes it very hard to collect a standardized data set, he said. "I think it's very challenging to improve MIPS by making marginal changes to it. I think most likely we need to reimagine it completely and potentially replace it."

Prior Authorization Issues

The hassles caused by prior authorization rules also came under discussion. Sen. Sheldon Whitehouse (D-R.I.) said he and some colleagues were working on a bill that would require Medicare Advantage plans, which are run by private insurers, to get upfront approval from CMS before requiring prior authorization from a provider for a particular procedure. "We've been focusing on applying that to providers that are under a value-based model and have shown that they succeeded" in lowering their costs and qualifying for a payment bonus, he said.

"Presumably, they have no interest in running up bills that would raise their costs and diminish their payment at the end of the day," Whitehouse said. "It doesn't make sense to apply a prior authorization to a provider who has successfully engaged in an at-risk value-based practice. And so we're looking at trying to get rid of that, or make them at least come in first to CMS and say, 'You've got to authorize me requiring prior authorization.'"

Steven Furr, MD, president of the American Academy of Family Physicians, said that although he doesn't have a problem with prior authorization for more expensive procedures and treatments, he does have a problem "when it comes to basic drugs and basic things we need to do. Just to give you a perfect example, if I have a patient with acute [pain in the] abdomen, it's easier to send them to the emergency room -- because they don't have to get a prior authorization there to do a CT scan -- than to do it in my office because it would take me a day or two to get the prior authorization for it," Furr said.

That's just one example of how "prior authorizations, which are meant to control costs, in many ways actually increase costs," he continued. In another instance, "sometimes the best drug might be a more expensive drug that is better for the patient, because it might lower their cardiovascular risk along with taking care of their diabetes or hypertension. So there are all kinds of issues with prior authorization that keep us from providing the best care that we can, and actually drive up costs."

Concerns About the RUC

Medicare's Resource-Based Relative Value Scale Update Committee (RUC), a group of physicians convened by the American Medical Association to develop reimbursement codes along with their "relative values" for use in the Medicare Physician Fee Schedule, also came in for its share of criticism. At the hearing, Sen. Elizabeth Warren (D-Mass.) referred to the RUC as "a secretive committee run by the American Medical Association [that] has played an outsized role in recommending the relative value of physician services, and it has overwhelmingly recommended that specialty services are worth a whole lot more than primary care."

She asked Navathe why that might be true. "The methodology that the committee uses heavily values inputs like time, differentiated skill, and intensity, and these are easier to estimate for concrete things like doing a surgical procedure, more so than a cognitive activity like diagnosing a patient effectively," Navathe said. In response to another question from Warren, he said the committee has an "overrepresentation" of specialists compared with primary care doctors.

Warren said she "strongly agreed" with a recommendation by some medical groups, including the National Academy of Medicine and the , to change the committee structure so that primary care is adequately paid.

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