BOC Secretary John J. McGraw, MD, interviews his Congressional representative

Before his election to Congress, Rep. Phil Roe (R-Tenn.) practiced as an obstetrician-gynecologist. He is currently the cochair of the GOP House Doctors’ Caucus, a group of almost 20 physicians serving in Congress. Recently he spoke with John J. McGraw, MD, secretary of the AAOS Board of Councilors. The two covered several topics, including the future of the Independent Payment Advisory Board (IPAB), the in-office ancillary service (IOAS) exemption, and the sustainable growth rate formula (SGR).

Dr. McGraw: You have been the champion of repealing the IPAB, along with Allyson Schwartz, your Democratic colleague from Pennsylvania. What will happen if this board is appointed and takes action to cut where it needs to or thinks it needs to in the areas of Medicare, Medicaid, and Tri-care?

Rep. Roe: The IPAB was not in the original healthcare bill passed by the House. I personally believe that this was a very bad idea.

What this Board does is set spending targets for Medicare, because we know that clearly the nation is on an unsustainable course with Medicare spending. The president has the authority to appoint 15 bureaucrats.

Something I didn’t realize until very recently is that even if the president chooses not to place anyone’s name in nomination, all of that power and decision-making goes to one person—Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS). Then one person, not a board of 15 people, will make those decisions.

An article in The New England Journal of Medicine (June 2011) demonstrated that, if the IPAB had been in place, provider payment cuts would have been triggered in 21 of the last 25 years. This is essentially the SGR issue on steroids! It would be possible—but very difficult—to get 60 senators to agree to override these cuts.

We have more than 120 bipartisan cosponsors for HR 351 (The Protecting Seniors Access to Medicare Act) in the House. We must put pressure on the Senate to take action. I am working to get this bill out of Committee as a clean bill—not linked to other legislation—sometime this year.

Dr. McGraw: One issue that is of interest to the AAOS is the possible expansion of the Stark Laws. The Senate, along with the Government Accountability Office, has studied this issue and believes that $110 billion annually may be saved by prohibiting physicians from owning in-office ancillary services such as advanced imaging and physical therapy.

That concerns us because we care about the quality of these services and we think that, as orthopaedic surgeons, we can better ensure quality if we have an interest in how these services are rendered. We have also put a great financial investment into these services and believe the convenience for our own patients would be greatly jeopardized if this exception were to be prohibited.

From your perspective, what do you think the chances are that this expansion of the Stark Laws may come up?

Rep. Roe: It certainly could, but at least Pete Stark was defeated in the 2012 elections. As a practicing physician who has had an imaging center in my practice, now sold to a hospital, I did not see the costs go down for patients. As a patient, I used the imaging center in my cardiologist’s office and it was much easier for me to get that service.

If the specialty societies write the meaningful use criteria, why would it matter, so long as the quality standard is there, where the imaging takes place? If it can be done in a cheaper, more convenient environment and the quality can be documented, I see no reason in the world why doing an MRI or imaging test cannot be done right there in the office.

I can’t imagine anyone doing a better ultrasound at a patient’s bedside than me, because I have done thousands of them and I know the patient’s clinical symptoms. That’s what I want for my family. Ultimately, I don’t know what the outcome of this fight will be.

Dr. McGraw: It’s possible that the SGR issue may get resolved in this Congress. What are your thoughts on the likelihood of this happening?

Rep. Roe: I think for the first time in 15 years or so there is a chance to repeal and reform this failed system. Because Medicare growth rates were down, the Congressional Budget Office rescored the fix for this, going from around $280 billion to around $138 billion. That is still a lot of money, but it is half of what it was, so I think we have a real chance.

The first hearing in 4 years has been held on this issue and the champions of repeal include Rep. Michael Burgess, a fellow obstetrician from Texas; Rep. Charles Boustany; and Rep. Tom Price on the House Ways and Means Committee. We have great representation on the doctor side where this issue is concerned.

There will still be fee-for-service; that’s not going to disappear completely. In counties with only one or two doctors, you can’t have an Accountable Care Organization, so I believe fee-for-service medicine will still have a place. However, we will move to pay for quality and outcomes. I think we have a strong shot at getting it out of the House.

Dr. McGraw: What do you think will be the impact of sequestration? We do have to cut our budget in some form with almost $17 trillion in debt, but how do you see this affecting the house of medicine?

Rep. Roe: These cuts are going to happen. The reason it is important to have this discussion is that we must look at the entirety of the budget, not just part of the budget. The country spends $300 billion a month and we are asking to cut $8 billion a month; that should not be that hard to do.

If you look at this lengthy healthcare law, the two entities that we did not ask anything about were the patients and the doctors, what do they want. Instead, we had the bureaucracies and the government, the insurance companies, pharmaceuticals, and all these other people involved—everyone but the two people that really have to navigate through this: the doctor sitting in the examining room and the patient trying to take care of his or her ailment.

I cannot tell you how much respect I have for the American healthcare system but I am concerned when I go speak to medical schools about encouraging these young people. It is fun to get someone coming into your office who cannot walk and see them walk out the door, which is a lot of gratification you cannot put a dollar sign on. I really hope we do not ruin that passion in physicians; I look forward to continuing to work with orthopaedics.

Download and hear the entire interview at www.aaosnow.org (click on “AAOS Now podcasts” in the left navigation bar)