Final Medicare Physician Fee Schedule Rule Displeases Doc Groups

It “does not go far enough” to address the last two decades of payment cuts, they say

https://www.medpagetoday.com/publichealthpolicy/medicare/118333

Physician groups were generally dissatisfied with the final 2026 Medicare Physician Fee Schedule rule released late last week by the Centers for Medicare & Medicaid Services (CMS).

“Decades of repeated Medicare cuts and rising costs have created an unsustainable situation that is pushing practices, many of whom are small businesses, to the brink of closure and threatening patients’ access to care,” William Harvey, MD, MSc, president of the American College of Rheumatology, said in a statement. “This final rule from CMS does not go far enough to address the 33% decline in reimbursement physicians have faced since 2001. Congress can no longer ignore the damage these chronic underpayments are causing.”

“While we appreciate the modest payment increase finalized by CMS for 2026, this temporary relief does not address the fundamental structural problems plaguing Medicare physician reimbursement,” Jerry Penso, MD, MBA, president and CEO of the American Medical Group Association (AMGA), said in a statement. “The conversion factor increase, driven by a one-time congressional intervention, provides a short-term reprieve, but the underlying erosion of physician payment continues to threaten access to care and the viability of high-value, team-based medicine.”

The new fee schedule gives doctors treating Medicare patients a 3.77% pay bump if they participate in alternative payment models (APMs), and a 3.26% increase for those not participating in APMs. The bulk of those percentages comes from a 2.5% 1-year increase Congress passed in its “One Big Beautiful Bill” in July, as well as a 0.49% adjustment CMS said was necessary to account for proposed changes in work relative value units (RVUs) for certain services. Without those additions, the conversion factor increases would be 0.75% for physicians participating in APMs and 0.25% for those not participating in them.

ATA Action, an advocacy group for telemedicine providers, said in a statement that although it was encouraged by the agency’s inclusion of provisions that expand telemedicine coverage and streamline processes related to it, “we have ongoing concerns that the issue of provider location and home address reporting has not yet been fully resolved, a change that could significantly impact providers across the country when the current flexibility expires on December 31.”

On the other hand, said ATA Action executive director Kyle Zebley, “CMS did finalize an important provision that was not included in the proposed rule that we advocated for, which permanently allows teaching physicians to supervise residents virtually, when the patient, resident, and supervising clinician are in separate locations, in all teaching settings.”

In contrast to the specialists’ groups, the primary care groups sounded more upbeat. The American Academy of Family Physicians (AAFP) said in a statement that it was “pleased by several provisions in the 2026 Medicare Physician Fee Schedule that strengthen the healthcare system and prioritize primary care.”

The provisions cited by AAFP include broadening the use of the G2211 add-on code, which will make it more feasible for doctors to provide care at home, and the introduction of optional add-on codes to support behavioral health integration services.

Unlike the AMGA, the AAFP was positive about the overall payment increases of 3.77% and 3.26%, depending on whether or not the physician is in an APM. “These updates reflect CMS’ commitment to supporting primary care,” the organization said. “However, most of the increases for 2026 are temporary adjustments … which will expire at the end of 2026. To sustain this progress, we urge Congress to take action to prevent another payment cliff, which would leave practices struggling to keep pace with inflation despite the promising direction set by CMS.”

The final rule also included a new “efficiency adjustment” — a 2.5% cut for clinical services that are not time-based — to reflect its opposition to the American Medical Association’s (AMA) longstanding method for recommending physician reimbursement rates using RVUs that are partly based on the amount of time it takes to provide a particular service.

“Research has demonstrated that the time assumptions built into the valuation of many [Physician Fee Schedule] services are … very likely overinflated,” CMS said in a fact sheet about the final rule. The AMA said the efficiency adjustment would reduce payment for 7,000 physician services, amounting to some 95% of all those provided by physicians.

The efficiency adjustment received mixed reviews. “Physicians are already stretched thin by increasingly complex patients and the escalating costs of running a practice,” Qihui “Jim” Zhai, MD, president of the College of American Pathologists, said in a statement. “These reductions to physician work ignore the realities of modern medicine, including rising patient complexity and evolving technologies that demand more from physicians, not less. A one-size-fits-all policy is unfairly targeting pathologists and other specialists.”

The American College of Emergency Physicians also expressed unhappiness. “Unfortunately, the efficiency adjustment for non-time-based services as finalized is a flawed and overly broad policy that fails to differentiate between services that can achieve further efficiencies and those that cannot, as well as those that have already been re-evaluated through existing processes recently,” the group said in a statement, adding that under the new schedule, “independent groups, especially smaller practices, will see shrinking reimbursement while costs remain the same — contracts become financially unsustainable, consolidation accelerates … and emergency department coverage and timely patient access to lifesaving care are put at risk.”

But the American College of Physicians (ACP) disagreed. “ACP is glad to see that the fee schedule finalized the introduction of an efficiency adjustment that will help account for how clinical practices and resource utilization patterns evolve and better align payments with those changes,” ACP President Jason Goldman, MD, said in a statement. He added that the ACP “appreciates CMS’s decision to exclude evaluation and management (E/M) services from the efficiency adjustment. The work associated with E/M services has become increasingly complex and intensive due to the need for comprehensive, person-centered, and relationship-based care.”

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Aren’t politicians suppose to work in the best interest of their constituents ? The Senate has basically shut the federal government down. 

Apparently there is some 2-3 million federal works that are expected to work and not being paid. Of course the 535 members of Congress continue to get paid while the government is “shut down”.

This Saturday, it is claimed that 42 million people who get food stamps – which is now on a EBT debit card -their EBT cards will not be “re-charged” with the $$ that is due the first of the month.   39% of those EBT $$ is for feeding KIDS.  The House has already signed a bill that would provide $$$ to keep the government open for 60-90 days while the Senate works out their problems.

It is claimed it is all over some supplemental $$ for Obamacare premiums, and without it .. some families – 20 million people- will see a $1,200 to $1,800 increase in their annual premiums.

Just out of curiosity, I checked what our Medicare B & Supplement premiums have changed over the last 5 yrs and those premiums for the two of us has went up abt $4,600 over the last 5 yrs. That is affecting 63 million people on Medicare A&B. That is a 55% INCREASE in FIVE YEARS.

The increases in SS $$ over that same time frame is 23% that would be for the average couple would be $7,300. So the increase in Medicare Part B & supplement would have taken 63% of a couple’s SS overall increase. Remember overall COLA ( Cost of Living Adjustment) during the 2020-2024 was abt 20%.

A couple having a $500,000 retirement “nest egg” would have lost $100,000 buying power of the money in their retirement nest egg.

I saw one <D> Senator on TV saying that with the <R> have the White House, majority in the House & Senate, that depriving federal employees of their paychecks – and expecting them to work and depriving 42 million people (39% kids) going  without the ability to purchase food/nutrition. Is the only lever that the <D> have to get the Senate to agree to spend a couple of TRILLION DOLLARS more than we have and would be added to our already 37 trillion national debt.

It is reported that the Senate – which needs a 60% vote in order to keep all of these benefits flowing – has voted THIRTEEN TIMES NO!.

All it would take is 8 <D> to vote to re-open the Federal government.

“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey, VP, Pharmacist

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The True Story of Morphine Milligram Equivalents (MME)

https://www.acsh.org/news/2022/03/01/true-story-morphine-milligram-equivalents-mme-16154

By Chuck Dinerstein, MD, MBA — March 1, 2022

Image courtesy of qimono on Pixabay

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Notice that this article doesn’t talk about people who are on Medicare and/or Medicare disability. The average retired couple gets ~ 37,000.00/yr in social security. I went back and looked at what we paid for Medicare Part B & Part B supplement and since 2020. The premiums have only increased $5,300/yr. THREE to FOUR times what they are talking about the AVERAGE FAMILY will have their premiums increased, without tax credits. Keep in mind that nearly 50% of families don’t pay any federal taxes.

The youngest Baby Boomer will not turn 65 y/o and be eligible for Medicare until 2029. Is it just me or does it seem that once you are unfortunately disabled or retired…. you are pretty much on your own to survive. Of course, if you can’t get proper medical care, you will fall off the list of getting back all the money you paid into the SS system?

The cost of inaction is high

https://www.medpagetoday.com/opinion/prescriptionsforabrokensystem/117991

In the U.S., no politically driven healthcare crisis ever really ends. It just mutates.

Case in point: the current debate over extending enhanced Affordable Care Act (ACA) health insurance tax credits, which will expire at the end of 2025 if Congress does not act. Most (but not all  ) Republicans want to end

these subsidies, while most Democrats want to keep them. This is a primary factor in why the federal government shut down on October 1.

If the GOP gets its way, ACA health insurance coverage for tens of millions of Americans will become more expensive. For households earning between $28,000 and $55,000 per year, their annual premiums would rise by anywhere from $1,200 to $1,800

A Brief History of ACA Premium Support

Originally, ACA premium tax credits were designed to help low- and middle-income Americans afford insurance through the ACA marketplace. People earning between 100% and 400%

of the federal poverty level (FPL) would pay no more than a set percentage of their income toward premiums. The federal government would cover the rest.

Then came the COVID-19 pandemic. To prevent a coverage collapse, Congress approved and President Joe Biden signed into law the American Rescue Plan Act

in 2021, which temporarily boosted those credits and eliminated the upper income cap. Suddenly, more Americans, especially self-employed individuals, gig workers, and middle-income families, could afford coverage.

The Inflation Reduction Act (IRA) of 2022 extended enhanced credits through 2025.

Enrollment exploded to record highs: according to the Kaiser Family Foundation (KFF), after the introduction of the enhanced premium tax credits, the number of people enrolled in the ACA marketplace more than doubled from about 11 million people to more than 24.3 million this year

Unless Congress acts before December 31, the enhanced credits will disappear. At that point, only Americans from households with incomes between 100% and 400% of the FPL will generally qualify

for ACA premium tax credits.

Policy Whiplash Harms Care

For 15 years, the ACA has been a political football. You may recall that this current stalemate is not the first time

Congress shut down the federal government over ACA policy. And during Trump’s first term, the administration dramatically cut the federal role in administering the ACA. The Biden administration reversed many of those policies and enhanced tax credits. Ironically, more than 80%

of people who now benefit from the enhanced tax credits live in states won by Trump in 2024.

Now, as the political pendulum swings back, Americans are once again left wondering: Will I still be able to afford insurance next year?

That kind of uncertainty erodes faith in government, and in healthcare itself. It is difficult to plan for preventive care or manage chronic conditions when your ability to afford coverage depends on who wins the next election.

Unfortunately, we’re already getting a taste of the likely consequences: as ACA plans post rates for 2026 that account for the potential loss of enhanced subsidies, some Americans may assume they can’t afford health insurance and not sign up

.The Financial Shock Ahead

According to the Peterson Foundation, more than 300 ACA marketplace insurers submit rate filings with regulators from each state every year. While ACA marketplace premiums have increased over the past several years, 2026 is expected to be the biggest increase in premiums since 2018 — even if the tax credits remain in place. (In 2025, premiums increased a median rate of 7%

.) Take those subsidies away, and the financial burden will be catastrophic for those who depend on the ACA for insurance.

Failure to extend the enhanced credits combined with planned insurance premium hikes could lead to ACA marketplace premium increases of more than double

! Self-employed adults, small-business owners, and small-business employees (nearly half

of those on the ACA) — the very people least likely to have employer-based coverage — will be hit hardest with higher rates.

And then there are the Americans who will lose coverage.

The Urban Institute estimates that without enhanced credits, the number of uninsured people will increase by about 4.8 million

. In contrast, if Congress permanently extends the tax credits, an additional 3.6 million people

would have health insurance by 2030.

The Domino Effect

Every American with ACA marketplace coverage will feel the pain if Congress does not act.

When individuals drop coverage, consequences ripple across the system. Hospitals see spikes in uncompensated care. Clinics treat more patients who delay preventive visits until conditions worsen, raising overall healthcare spending (and, of course, leading to worse health outcomes). Insurers raise premiums for everyone else to offset losses. The uninsured get sicker, and the insured pay more.

For Americans and their healthcare providers, this scenario could not be unfolding at a worse time. States are still untangling the chaos from Medicaid redeterminations, which have already pushed 27 million people

off Medicaid rolls since 2023. Many of those individuals were supposed to transition to ACA coverage. Now, just after they have lost Medicaid, they could lose affordable marketplace options too.

Inflation, labor shortages, and rising hospital costs only magnify the pressure. If ACA enhanced credits lapse, the entire healthcare ecosystem will suffer. The uninsured rate, which fell to a record low of 7.2%

in 2023, will climb again. Rural hospitals, which are already closing at alarming rates, will face more uncompensated care and risk bankruptcy. Small businesses and gig workers will face impossible choices between paying premiums or paying rent.

The pain will not be evenly distributed. The largest coverage losses will occur in non-Medicaid-expansion states     , mostly in the south and Midwest. These regions are the ones suffering from highest rates of hospital closures, physician shortages, and poor healthcare system performance

. The result is a deeper divide between the insured and the uninsured, and an even more fractured healthcare system.

Fixing healthcare in America does not require a massive overhaul or new bureaucracy. It requires predictability. Congress should make the enhanced premium tax credits permanent and provide long-term stability for the ACA marketplaces. That one move would stabilize insurance markets, reduce churn, and give patients, providers, and insurers the certainty they need to plan for the future.

The ACA has never been perfect. But when funded, supported, and left to function without constant sabotage, it works. Republicans must accept that fact.

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FDA sent warning letters to six companies selling compounded retatrutide

https://www.medpagetoday.com/popmedicine/cultureclinic/117942

The FDA has warned six online companies for selling compounded retatrutide, an unlicensed weight-loss drug that has gained traction among social media influencers.

Five

U.S. firms and one in Germany received similarly worded letters in September

for selling products labeled as retatrutide, a compound developed by Eli Lilly that is still in clinical testing, without FDA authorization.

The agency said

the companies violated federal law by marketing the unapproved drug and misbranding products that require medical supervision but lacked adequate directions for safe public use. The compound does not qualify for compounding exemptions.

“Retatrutide is an investigational molecule that is legally available only to participants in Lilly’s clinical trials,” a company spokesperson told MedPage Today in an email. “Anyone purporting to sell retatrutide for human use is breaking the law, and no one should consider taking anything claiming to be retatrutide outside of a Lilly-sponsored clinical trial.”

The warnings come amid surging online interest in retatrutide. An investigation by the Guardian

found fitness influencers and sellers on platforms such as WhatsApp and Telegram driving demand for the compound, which they promote for its purported fat-burning properties.

“The GLP-1 boom has sort of taken over social media,” Daniel Rosen, MD, a bariatric surgeon in New York City with a large Instagram following

, told MedPage Today. “You have this idea of people treating themselves. You have a boom of new players on the scene looking to cash in.”

“So all of a sudden, you have pharmacies marketing directly to patients. You have coaches or content creators who are moving into the space of wellness and having brand deals with laboratories that are producing these drugs for experimental uses — but that’s wink-wink in terms of, the package says ‘not for human consumption,'” Rosen added. “That’s the kind of stuff that you’ll see.”

Retatrutide, a triple-hormone receptor agonist, targets glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1), and glucagon receptors. Phase II data

have shown strong results: participants receiving the highest dose lost an average of nearly a quarter of their body weight within a year, and all in that group lost at least 5%.

“The issue is, that’s phase II,” Stuart Weinerman, MD, an endocrinologist at Northwell Health in Great Neck, New York, told MedPage Today. “No one should use drugs that are not yet proven to be safe and effective until they are out on the market, FDA approved. We don’t know the final data. There can be surprises in phase III trials that did not show up in the preliminary data.”

Still, those early results have fueled viral interest. The Guardian cited several TikTok users promoting the drug, including one who offered a discount code and others who invited users to message privately for purchasing advice.

“I am concerned about influencers promoting this medication before FDA approval,” Noor Khan, MD, a bariatric medicine specialist at the University of Pittsburgh Medical Center, told MedPage Today in an email. “This can lead to use of counterfeit or contaminated medications and can lead to adverse health outcomes, especially if patients are not being monitored for appropriate use. These are powerful medications and need to be used responsibly.”

The viral buzz surrounding retatrutide has led curious patients to question their physicians about it.

Weinerman said the barrage of inquiries he has fielded reflects “a very broad range of opinions partly seeded by nonsense on social media,” from questions about cost and availability to distrust of drugmakers.

Rosen warned that physicians who prescribe medicine without FDA approval are “exposing yourself to liability.”

“From a safe-practice standpoint, it’s better to wait and know all the data and be able to present that to patients to make informed decisions,” Rosen added. “I think it’s better to lose market share on the Reddit craze and be conservative from that perspective. That’s how I’m approaching it.”

Patients who buy retatrutide online, experts said, have no assurance of what’s in the vial: it could be counterfeit, incorrectly dosed, or simply the wrong drug for their needs.

“They may not be appropriate candidates for this medication because of their other health issues, and lack of medical oversight can lead to serious adverse outcomes,” Khan said.

The FDA letters require written responses within 15 working days. As of mid-October, however, the agency’s website showed no record of any replies. Five of the six companies continued to sell retatrutide, with prices ranging from $99.99 for a single 10-mL vial to $1,025 for a 3-month supply.

“It could be cheap,” Weinerman cautioned, “but it still could be poison.”

MedPage Today contacted the FDA, the six companies for comment but did not receive responses by press time.

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