Anders Gilberg of MGMA on the looming government shutdown

Physicians Practice
You know, Medicare cuts are always top of mind. What's the latest, and how is MGMA pushing back?

Anders Gilberg
Well, Medicare cuts have taken on kind of a new degree of sophistication because it's not just annual cuts. This year, we actually, as part of our advocacy efforts working with other organizations, were able to get a two and a half percent increase in the One Big Beautiful Bill Act, and that's a two and a half percent increase for next year. But CMS, in the proposed Physician Medicare Fee Schedule for 2026, is proposing some more specific adjustments to work RVUs and practice expense RVUs.

Ultimately, what that means is they're proposing a shift from a lot of codes that are more specialty-driven, more procedural-driven, to office visits and other E/M-type codes. So even though there is an increase next year in the conversion factor for Medicare, some specialists could easily see a cut if those rules are finalized. We've pushed back on it mostly because of the arbitrary nature of what they're doing. It's not really grounded in a lot of evidence and data, but it’s something that your listeners and readers should be aware of, because if they're in certain specialties that are procedure-heavy, then they could potentially have Medicare cuts that they're not even aware of to individual codes.

Physicians Practice
So it seems every time we chat, we're talking about administrative burden, paperwork, all that sort of stuff. It seemed like last time we chatted, there was a bit more of an appetite to touch on things that have been taboo in the past when it comes to healthcare. What’s the appetite for doing something about the burden?

Anders Gilberg
Well, administrative burden is the number one issue for our members, and it kind of manifests itself in things like prior authorization reform. I will say in the first Trump administration, there was a concerted effort—something called “Patients Over Paperwork”—that we were part of and worked with the administration on.

This administration has been a little more chaotic in terms of their approach, and even though a lot of what they're doing is in a deregulatory kind of framework, they haven't really focused their efforts yet on very specific initiatives to reduce the paperwork burden. I think as things progress with this administration, we’ll be able to do more.

There have been some announcements with payers about reducing prior authorization burden, only to be followed up the next day or two by a demonstration project to introduce more prior authorization in traditional Medicare, which is really unprecedented. So we are going to be working with the administration and continuing to push to reduce the red tape.

There’s certainly at least an executive order in place with the President that for every regulation issued, a number of regulations must be removed at the same time to reduce the overall burden of regulations in this country. So within that framework, I think we can work on the healthcare burden for our members and physicians around the country.

Physicians Practice
All right, so it seems, Anders, every time we chat, you know, we talk about what you want to do, what you're trying to do—let's talk about what you've done. What's the biggest advocacy win that stands out over, let’s say, the past year or two?

Anders Gilberg
Well, I think a lot of these advocacy wins are a little more subtle. Back to prior authorization—we’ve had legislation pending in Congress to address the burden of prior authorization, to make sure that health insurers, especially Medicare Advantage plans where we see a lot of abuse, are transparent in their activities and in what procedures or other types of codes are subject to prior authorization.

We often see a situation where there are certain codes that require prior authorization, but those authorizations are approved 95-plus percent of the time. So why even have it in the first place? It just creates burden and hassle. So even though legislation hasn't passed yet, over the last year or two we've been working with the administration and the prior administration, and the implementation is now about to begin of actual regulations to deal with prior authorization in federal programs—especially in Medicare Advantage and Medicaid as well.

I think that's a real positive. It started with a meeting between MGMA, some other key associations, and the head of Medicare and the U.S. Surgeon General about three years ago. True to their word, those regulations were proposed and finalized, and now, starting next year, we're going to be implementing those. So I’m really proud of that advocacy, and I think we're going to get something out of it finally on prior authorization. At the same time, we're going to continue to pursue additional legislative proposals in Congress. I just think it's been difficult, no matter what topic you're working on, to get proposals through this Congress and the prior Congress, which have not really produced a lot of legislative work.

Physicians Practice
Okay, so what's the biggest policy issue—what’s most urgent right now?

Anders Gilberg
Well, the most urgent is that we are two days away from a government shutdown, and although my hope is that it won’t last or even occur, there are some key provisions that expire at the end of September. Chief among them are telehealth flexibilities that medical groups have enjoyed since COVID.

Prior to COVID, in Medicare, medical practices and patients didn’t even have a benefit for telehealth unless they were in a rural area and had to go to an originating site—they couldn’t even do it in their home. During COVID, those rules were loosened up, but that all expires along with the budget continuing resolution that is bringing us to the brink of shutting down the government.

That is a key issue we want to have renewed. In addition, rural providers—rural physicians who treat Medicare patients—have a benefit under the work RVU, something called the geographic price index, or GPCI. They have a 1.0 floor, and that 1.0 floor is going to expire in two days as well. If that expires, their payments will be significantly impacted negatively.

Those are two issues within two days that we’re watching, and we’re really strongly advocating—hopefully—that this government shutdown will not occur, and those issues will be part of a continuing resolution so we can continue to provide care in rural areas with telehealth, as well as pay physicians appropriately.

Physicians Practice
All right, so it seems that everybody wants to have their voice heard—it’s taking multiple forms in the country right now—but what's the best way that practice leaders can make their voices heard more effectively with lawmakers?

Anders Gilberg
Well, I think relationships are really important. Oftentimes, it's the relationships back in the district. If you can invite a member of Congress to come see your practice firsthand, I think that is one really important way to build relationships and then be a resource for the local office of a member of Congress or state legislator.

At MGMA, we even have a grassroots center, so our members can go on and input their ZIP code. Automatically, we have a number of key issues we're focused on—from physician payment, telehealth, and alternative payment model incentives—and they can get an immediately pre-populated letter, which they can edit and tailor to their needs. Then it's sent based on their ZIP code to their members of Congress and senators in the United States Congress.

So we have a number of vehicles for folks to get involved, but oftentimes it's just the good old relationships back in the district that really do the trick.

Physicians Practice
All right, so we're heading into 2026. What's the one policy change that practices should be preparing for?

Anders Gilberg
Well, we don't know exactly what's going to occur with the final Physician Fee Schedule—those rules will be pending, and we’ll know about those in November. However, another key element that's also part of this shutdown debate at the moment is the expiration of the Affordable Care Act subsidies for patients who have insurance that they purchase on the exchange and receive a tax credit to help pay for.

Those expire at the end of 2025. According to the Congressional Budget Office, if Congress doesn't renew them, four million patients could be uninsured. Then we’d have a situation where the burden on practices to verify insurance, help patients understand their insurance, and hopefully not deter them from getting preventive care or coming in to see their physician before they get really sick and end up in the hospital would increase significantly.

So we're advocating for the continuation of those Affordable Care Act tax credits. That, coupled with some of the provisions in the One Big Beautiful Bill Act—which don’t take effect until more of 2027 but are related to Medicaid—could affect 10 million beneficiaries who might lose their coverage.

We have a lot of work next year to try to have Congress revisit that, perhaps before the midterm elections. But if Congress doesn't act this year on the subsidies, we could have millions of individuals uninsured or losing coverage at the beginning of next year. So that’s a critical advocacy issue that we will continue to work on.