Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep122: Policy uncertainty in 2026, with Anders Gilberg of MGMA
Transcript
- 0:00 So stay tuned. There's a lot of interesting things going on in healthcare, a lot of technology programs that the administration is moving forward with, and this, this HHS has shown itself to be very independent in its thinking and in many ways controversial. So stay tuned. I think it's going to be an interesting year in 2026 0:22 you off the chart, a business of medicine podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today before we get started, just a quick note, physician's practice will be hosting a practice Academy event on March 19. The new practice management track is a virtual learning experience designed for physicians and practice administrators who want to build stronger, more efficient and more resilient practices. It focuses on practical, real world strategies that you can apply right away from optimizing operations to adapting to an evolving healthcare landscape. You can register today by clicking the link in the show notes or by going to registration.physicianspractice.com that said in today's episode. Keith Reynolds, the managing editor of physicians practice, sat down with Anders Gilbert, the Senior Vice President of Government Affairs at the Medical Group Management Association, or MGMA. They're talking about how recent policy changes are showing up in practices, including the fallout from expiring ACA subsidies, and what coverage gaps can mean for patient access and practice finances. Anders also shares what MGMA is watching on Capitol Hill in 2026 and how practices are trying to adjust as policy decisions continue to shift so Anders, thank you, as always, for joining us, and now let's get into the episode. 1:41 How you doing today? Anders, great, Keith, how are you doing? 1:44 I can't complain too much. It's a nice, chilly day out here in Ohio. Lots of snow. Gotta, gotta love the snow coming out east. So, yeah, it's gonna be cold this weekend for anybody who's wondering, we are talking on January 22 right before the big polar vortex hits us all, so let's get right into it. Honors when Washington punts on funding for the last minute at the last minute, what's the first thing that breaks down for medical groups? Is it staffing cash flow or patient access? 2:15 Well, what you're referring to, I think, is the aftermath of when the government shut down in the fall, and we're coming up against another deadline here soon. Yep, that's January 30, right? That's correct, absolutely. And what had happened then? I don't think we're going to have the same issues this time. I don't think the government's going to shut down, but it was a real problem, and we medical groups and physician practices have been dealing with this for a while, ever since the end of 2024 when a lot of the things that are important to them, like the ability to provide telehealth or to move their practice into an alternative payment model, a lot of these, what We call healthcare extenders, were delayed. So in the fall, we had a situation where telehealth flexibilities in Medicare that allowed physician practices to provide telehealth at all, really, in Medicare, they expired. And while the government was shut down, they were reinstated. But it really caused a lot of problems in terms of, again, the ability for practices to have care continuity with their patients. A lot of their telehealth appointments got canceled, and they had to bring the patients in physically, and then created situations with transportation and reimbursement and all kinds of things. So it can be really disruptive for medical practices that they have to change midstream, only to then three weeks later, reinstate all of these different policies to allow their patients to then get telehealth within the practice. That's just one example. There were a number of other examples. So it can be really disruptive when Congress either can't agree on something or delays implementation of something, 4:07 alright, so you mentioned the telehealth, you know, extensions. They've extended it a couple times, you know, if they keep extending it, but they don't make it permanent. You know, is that really progress? Are we just sort of, you know, keeping practices in limbo. 4:21 I think there has been some concern with telehealth. It really took off during covid. And I think everybody acknowledges it's really beneficial for beneficiaries. And I don't think that's the problem necessarily. There's been some apprehension like, Would it be more fraud? Could it introduce more fraud in the system? Could it increase volumes in terms of Medicare patients getting excessive amounts of care, would it cost the system more? And I think all of those items haven't really borne out. And to that end, there's more of an appetite now to extend it. At the end of this month, we have an appropriate. Variations bill that is being considered by both the House and Senate over the next week or so. And this one's interesting insofar as it includes an extension, but it includes an extension of through 2027 which is a lot better than a short term extension that we had been experiencing last year would be like three or four months until the next budget continuing resolution kicked in. So that's something that I think is very positive, that Congress is starting to look more long term. So stay tuned. We have to make sure that this bill passes, but it will need to be passed by the end of the month to keep the government 5:39 running again. All right, so staying on telehealth, you know? What are some rules that you if you could, you know, if you were, we'll say God Emperor Anders of the US. You know, what are some telehealth rules that you'd lock in permanently if you could? And you know why? 5:59 Yeah, so before covid, telehealth wasn't even covered outside of rural areas by Medicare, and I think a lot of people don't even remember that, so it's very limited. In addition, when a patient had a need for telehealth in a rural area, let's say that they had to get in touch with a specialist in a different city, a sub specialist for a rare disease. What would ultimately happen is they'd have to go to an originating site, and it would it would be a HIPAA secured originating site. So they'd literally have to go into a physician's office or another originating site to go then speak on telehealth to another physician. So there are two major things that I think the flexibilities have introduced. One is the basic coverage outside of rural areas, which is absolutely critical, because, you know, so much the country is outside of rural areas. It's critically important in rural areas, and to that end, in a rural area as an example, there's no longer going to be at least if the flexibilities are extended a requirement to provide the care in an originating site, and so that allows flexibility for patients in all parts of the country to receive care in their home. So in my mind, those are the two major, major pieces of it that the extension beyond the rural areas into all parts of the country, as well as allowing patients to receive this care in their home. 7:29 You guys are, you know, always pushing for the the 1.0 work. You know, gpci floor or Gypsy, as you I heard it pronounced In plain terms. You know what happens to rural practices if you know, if they just will not adopt that. 7:46 So for years now, and I can't even remember when it started, Congress averts what's called the lapse of the Gypsy floor on the work RVU. And what does that really mean? It means that physicians providing care in rural areas they are there's a calculation that goes into how much should their cost, their work, be valued by Medicare? And the baseline is 1.0 but some localities in this country are below 1.0 and some are above 1.0 an example of locality above 1.0 might be downtown Los Angeles. So in the past, though, given the support for rural care and the need to provide access to patients in rural areas and the proliferation of important members of Congress in these rural areas, the expiration of this 1.0 floor has always been passed. And ultimately, what it means is that physician work in those rural areas will be valued at the baseline as opposed to below the baseline. And it's a dollars and cents issue. I mean, it may be slightly less expensive to provide care in a rural area, but it's also there are a lot of other costs that rural physicians incur in rural areas that doesn't necessarily make their work any less valuable than their peers in other parts of the country, the training is the same, their expertise is the same. So there's a real strong effort every year to avert this. We would say, why don't you just kind of, you know, let's just acknowledge the fact that this workflow has never been followed for many years, and let's permanently raise the floor for those rural physicians around the country. But again, that's on the table for the funding bill at the end of the month, and so that would go through the end of this year. Importantly, last year again, it was kind of limping along through what we call continuing resolution. So again, it expired at the end of September last year, and it caused billing problems for those physicians in rural areas who were paid just a little bit less, but also then a lot of those bills had to be rebuilt and administrative. Basically was a big hassle. So we're pleased to see at least Congress looking a little bit longer term, but we would say, let's just permanently deal with that issue. All right. 10:09 So, you know, for practices with, you know, labs in office, you know, what do the next PA, ma related cuts mean in real life? Are we talking fewer tests, longer turnaround or sending patients, you know, just completely out 10:22 of house. Yeah, it was a long history. But without getting into the long history of what we call PAMA, was the legislation that enacted certain new ways to value physician lab services, and not just physician lab services, but lab services outside of medical practices as well. So the same thing for large laboratories that you all might be familiar with would be included in in under the scope of Pama, but for a physician practice, what we want to is to be able to provide a full range of services for our patients. To have it if you have an elderly patient who needs a lab test, so they don't have to go home, get transportation back to the practice or to another lab. We want to be able to provide that at the end of the month again. So there's a lot happening at the end of this month, some of the cuts that were scheduled to occur as a result of the way some of these lab tests were valued based on data that was accumulated by the Medicare program, that cuts would occur in the range of 15% for our members who have these physician owned labs, reimbursement is always already relatively low for laboratory services. And you know, we don't have the same economies of scale. We're not doing 1000s and 1000s and 1000s of these services, like a big reference laboratory would do. So it's important that we don't obviously cut physician laboratory services at 15% at the end of the month. Also, there's a new bill that we support using another acronym called the Results Act, which would not only create a more sustainable payment system for laboratories, but also reform the data collection methodology that caused the cuts in the first place. That's not on the table at the end of the month, just the delay of the cuts is on the table. Which is good, but we also support passing this Results Act, which would be a little more fundamental in the reform of that aspect of Medicare. 12:21 Yeah, and you guys put out a or, well, you put out a letter to Congress earlier this month about that, right? All right, sorry, I was just 12:30 gonna say, the reason we did that, and it's good news, is that the Energy and Commerce Committee in the House of Representatives was looking at a number of healthcare bills, and that is one of them. So hopefully there was some help on their eyes, and they moved that bill. 12:44 All right, cool, cool, all right. So like you're pushing Congress to restore Advanced APM incentives and ease the QP thresholds are groups actually leaving value based care models, because the math is, you know, just not working anymore. 12:59 One of the problems of medical practice that's largely into fee for service. And you know is, how do you transition from fee for service into value based care, where you're getting paid for everything you do in fee for service, but in many cases, in value based care, the incentives are to do higher quality, potentially lower volume service, amount of services do less but at a higher quality. And so the incentives are sometimes don't work with one another. And so many practices have needed a little bit of subsidy in order to carry through as they adopt value based care arrangements, and in this case, Advanced Alternative Payment Models under the Medicare program. So in the past, there were these APM bonuses that call them bonuses, but really what it is is some additional money based on your fee for service billings under Medicare that would help you then subsidize your move towards value based care, whereas your fee for service billing might go down, but then move you, move you into value based care, hopefully provide higher quality at a lower cost, but not necessarily have that immediate hit on your revenue. And then in the end, you'd be able to share in some of the savings based on the nature of the value based care arrangement or APM you're in. So we felt it was very important. Unfortunately, last year, at the end of 2024 it was in the legislation that ultimately did not pass. And we have not had this for medical practices and physician practices in 2025 so the bill that would then fund the government at the end of this month would reinstate it at about 3.1% in terms of that incentive payment. And I think it's really, really helpful for our practices that want to move into value based care, but can't take that initial financial hit, and then this offers them an opportunity or a cushion. You. 15:06 Keith, 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. 15:58 Minute the big the big issue with you know, closing the government down last year was the ACA subsidies, those expired earlier this year. What? How does that translate, you know, for practices, you know, are we seeing more cancelations, more bad debt, more uncompensated care, like, you know, what's the actual fallout of that? 16:20 Well, we're in January, so I think it's hard to say yet, in retrospect, what the Fallout was. But for medical practices that have a payer mix that would include those products that those insurance products that their patients have, that are on the exchanges, what it means is, if a patient could not renew that product because their premium doubled or tripled because of the expiration of the premium tax credits that medical practices have had to think of innovative ways to help their patients, to provide payment plans, to give them discounts for cash paying arrangements, and to provide a number of accommodations as they get used to understanding what exactly the circumstances are with the new coverage that that patient has, or if it's expired, to accommodate the fact that They may be a uncompensated care situation. Certainly, you know, it's of concern in different parts of the country. It affects different specialties and different types of care in different ways. You know, we might have situations in which patients are no longer going in for primary care visits, and that can then can cause situations in which, you know, problems that are relatively managed then become acute, and then they end up in the hospital. So it's not good for our healthcare system to have these shocks to the system. And I think people can decide what their position is on the subsidies and whatnot, but anytime you remove care or coverage of care from 4 million people, that can cause major problems for medical practices. So we've been telling them to, you know, do their best and offer them solutions like that I mentioned also, but they need, they need to protect their own bottom line. So, for example, eligibility verifications to make sure that they understand what the insurance coverage their patients, even if it's existing patient, what their insurance coverage is now that they may have let that lapse at the end of last year. So it's a problem, but it's not necessarily as big of a problem as we might see, which is a two for one situation with the Medicaid cuts that will kick in closer into 2027 with the implementation of state work requirements, the predictions there would be like over 10, 10 million people uninsured. And so the combination the two is quite a lot. And I know the nation's medical groups are doing the best they can to help their patients, and so I'm happy to come back and kind of tell you what they're experiencing here. But, you know, it's only the 22nd of January, and this is kind of new for them, and we're hoping that with the tools that we provided them, they're able to manage it. 19:13 Yeah, it feels like it's already, you know, should be June by now. It's just things won't slow down. So actually, going back a little bit, you know, the one big, beautiful bill, Act gave more flexibilities as to what, you know, patients could pay for when it comes to DPC or concierge care with HSA dollars. Is that a sign, you know, from what you're hearing on the hill, is that a sign that, you know, that Congress is more interested in giving, you know, a little bit more preference to these sort of models over the traditional, you know, independent practice. 19:48 Well, I think they just need to be careful, because not every patient can be in direct primary care. And not that we don't have a lot of members of ours that may be in those type of. Arrangements. But you generally have to have the resources to do that. And oftentimes we find the patients with the most chronic conditions the most needs, are not likely to be the ones in those arrangements. I think the administration has shown through its technology policies, and it's some of its value based care arrangements, the direction of their centers for Medicare and Medicaid Innovation, that they do want to have more consumer direction, directed care. And so this is very much in line with that. But I think, you know, it's yet to really manifest itself in a big way, and this may have incremental effects that you know may be beneficial, but for a lot of patients with multiple chronic conditions on the major programs like Medicare or Medicaid, you Know their their needs are pretty heavy in terms of the amount of care that they need. And, you know, primary care is absolutely critical. But then there's the also, the aspects of, if patient has a situation where they're hospitalized and needs additional care in a hospital setting or acute care setting, you know, do they have the coverage as well, to complement the direct primary care arrangement that they might have with their family physician or internal medicine doctor. 21:27 Alrighty, I think that's all the questions I've got for you today. Anders, I would love to open the floor though. You know what did you guys always have your fingers in a ton of different pies? You know what's what's going on with y'all? 21:39 Well, I think, like right now in terms of MGMA government affairs, what we do at the beginning of each year we issue our advocacy agenda. It's not significantly different than in prior years, but we've adapted it to the what we obviously see with this administration. We tried to take a proactive approach with our advocacy in Washington, but also we have to react to what's coming down the pike in terms of regulations. So we see some things on the horizon that we're watching very carefully, potentially, for example, interestingly enough, a Biden year rule that this administration still keeps talking about related to cybersecurity, and our concerns being that they could be extremely high dollar spent, from an unfunded mandate perspective, on medical groups, if they finalize what was proposed under the Biden administration. So stay tuned. There's a lot of interesting things going on in healthcare, a lot of technology programs that the administration is moving forward with, and this, this HHS has shown itself to be very independent in its thinking and in many ways controversial. So we're there to help support medical practices, and we appreciate this opportunity to just chat with you. So stay tuned. I think it's going to be an interesting year in 2026 22:55 Well, That's putting it mildly, I'm sure. All right, Anders, it's always a pleasure to talk to you, and we'll definitely have you back as soon as possible. So thank you so much anytime Keith once again, 23:15 that was Anders Gilberg, Senior Vice President of Government Affairs at the Medical Group Management Association, or MGMA, speaking with Keith Reynolds, managing editor of physicians practice. 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, and don't forget physicians practice will be hosting its practice Academy event on March 19, featuring a new practice management track with practical, actionable education for physicians and practice administrators. You can register today by clicking the link in the show notes or by going to registration.physicianspractice.com as always, be sure to check back on Monday and Thursday mornings for the latest conversations with 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'd like the best stories that medical economics and physicians practice published deliver. 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 also Montrell. Medical economics and physicians practice are both members of the mjh Life Sciences family. Thank you. You.