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  • Medicare cuts 2021

    Posted by Melenas on October 30, 2020 at 1:24 pm

    Did anyone attend the ACR town hall meeting about Medicare payment cuts to radiologist? 
     
    As I understand it, it is going to likely happen unless there is a budget freeze. And it mainly stems from primary care doctors getting more of the Medicare money at the expense of radiologist. If Medicare moves, most likely the private insurance probably would follow. Right?
     
    If your group is private and you do your own billing, you could have 10% cut across the board in salary. If you were making 500k, that would mean 450k now. If you are employed by a hospital or part of RAD PARTNERs since you are guaranteed a base salary, it doesnt really impact you. Am I correct? The owner of the practice (Rad partners or the hospital) gets dinged. They might pass it on to you but still they are obligated for the contract year. And the 10% cut could be even more. 
     
    Is this likely to force more private practices to sell out and join RP or become employed by hospitals?  Why work that hard to get a few extra thousands a year when you can leave all the business/QA/running to someone else. Lifestyle over money. 

    tdetlie_105 replied 3 years, 7 months ago 26 Members · 67 Replies
  • 67 Replies
  • g.giancaspro_108

    Member
    October 30, 2020 at 1:32 pm

    .

    • jtpollock

      Member
      October 30, 2020 at 2:43 pm

      Insurers [u][b]will[/b][/u] follow, but there’s usually a ~year lag so they can update their fee schedules/systems. If your contract specifically states you get reimbursed X% of Medicare, there’s usually a month lag. 
       
      And I’ve said it before, the cut is most likely higher that 10%. That’s the average number they give, but if you dig into the numbers I’ll bet it’ll be a 5% cut to extraneous exams and a 15% cut to high volume exams. So revenue decline is usually steeper than the average number they publish. I don’t know this for sure, but that’s how they operate, but ‘ll have to wait for Medicare’s fee schedule. 
       
      to because I’m sure 

      • suman

        Member
        October 30, 2020 at 3:36 pm

        If you were making 500k you won’t be making 450k. You will be making 200k. Public option is coming, everyone will sign up. Look up salaries in France and multiply that by 1.2 – 1.4 to get the new normal here.

        • erasmopa

          Member
          October 30, 2020 at 3:47 pm

          Avocado is much smarter than the rest of us but…for 200k salary European docs also get free medical school and college education, free health care, their kids go to college for cheap or free. In other words it is not an apples to apples comparison at all. Not saying it is impossible that what Avocado is saying will come to pass, but if it does there will be a mass exodus and brain drain from US medicine. I would neither practice in nor receive my care in that crap system. Id rather move to Europe and make 200k there where the 200k would go twice as far.

          • suman

            Member
            October 30, 2020 at 3:48 pm

            Yeah we gonna have free med school too. Common sense change.

            In France you won’t get 200k btw. That’s why I said multiply by 1.2 – 1.4 to adjust for CoL (same for other professions like engineers).

            • erasmopa

              Member
              October 30, 2020 at 4:00 pm

              Sign me up! Turn this country into Europe. I will retire at 45, my kids will go to college for free, and I will get my healthcare for free. I will just have to supervise the healthcare of myself and my family since it will be coming from providers like Avocado that do not understand what theyre doing.

              • jennycullmann

                Member
                October 30, 2020 at 6:13 pm

                He never answered the timeline, as far as I know (maybe I have to check that thread again). It was an IF Biden propostion
                 
                which isn’t going to happen. Try again, avo

                • ljohnson_509

                  Member
                  October 30, 2020 at 6:28 pm

                  People will still think were rich making 200k. No one cares we gotta pay for school, health, etc.

                  • erasmopa

                    Member
                    October 30, 2020 at 6:44 pm

                    Lets say hypothetically the goal in this country was to pay US doctors 1.2-1.4 times what the French equivalent is paid. If one made the rational decision that pay should be correlated to hours worked and productivity, wouldnt US doctors still end up being paid 2-3x as much?

                    I once worked with a French rad who moved to the States. Once he got here and realized what he had signed up for, he couldnt move back fast enough. A French rad is not expected to read 120-150 cases per day with 30-50 being Ct or mri. That is no slight on European rads. I also doubt they provide 24-7 reads with instantaneous turn around times for even non-emergency cases.

                    I am not saying our culture is right and theirs is lazy. Just pointing out that there is a huge cultural difference. My French is pretty good. Quite confident I could move to France and replace 2-3 rads and not feel overworked.

                  • alpomeroglu_229

                    Member
                    October 30, 2020 at 6:52 pm

                    One thing that I learned from the webinar was that the proposed 11% cut includes both the technical and professional components. If your practice bills for just the professional component, the cut will be less (I forget the exact percentage). 

                    Another interesting point was that it was Trump who started this whole revised E&M reimbursement shift. I got the impression from the panelists that a Biden win would be more likely to stop this legislature, though I may be reading more into it than intended. 

                    • cytek1

                      Member
                      October 30, 2020 at 9:04 pm

                      10% to revenue, not income. Your costs, what little they are, remain fixed. But the end result will be more than a 10% hit to income. Really sucks for providers that do any sort of high volume lower profit margin work.

                    • tdetlie_105

                      Member
                      October 31, 2020 at 4:25 am

                      Quote from Valerian

                      10% to revenue, not income. Your costs, what little they are, remain fixed. But the end result will be more than a 10% hit to income. Really sucks for providers that do any sort of high volume lower profit margin work.

                       
                      Thanks for the redirection on the other thread, I erroneously relied on the “similar thread” option w/o checking dates but funny/not funny how history repeats itself.  

                    • tdetlie_105

                      Member
                      October 31, 2020 at 4:36 am

                      Quote from jejudo

                      One thing that I learned from the webinar was that the proposed 11% cut includes both the technical and professional components. If your practice bills for just the professional component, the cut will be less (I forget the exact percentage). 

                      Another interesting point was that it was Trump who started this whole revised E&M reimbursement shift. I got the impression from the panelists that a Biden win would be more likely to stop this legislature, though I may be reading more into it than intended. 

                       
                      I had some similar take-aways.  Logically one would think stopping these cuts would nicely fit in with a Covid relief bill and is a no-brainer.  I wasn’t sure what the % was regarding the tech fee, but cuts will be less if one’s group relies on pro fee only.  In the past it seems that CMS final ruling typically is not as severe as proposed ruling but who knows.  Overall I’m cautiously optimistic that something will be done either this year or next year particularly if the 2nd wave is bad but who knows given that we are relying on politicians.  I didn’t get a strong sense of whether a Trump or Biden win would make a difference but was not paying close attention 

                    • jennycullmann

                      Member
                      October 31, 2020 at 9:21 am

                      I generally think that we’ll last at least until the end of this decade with reasonable streams. While that may suck for trainees, it is probably the worst case scenario and for those of us currently working won’t change all that much. We’ll have bigger fish to fry in the last half of this decade, anyway.

                    • jtpollock

                      Member
                      October 31, 2020 at 10:35 am

                      CMS finalizes rule requiring insurers to disclose negotiated rates for radiology, other shoppable services

                      Transparent prices will be bad if not worse than a “10%” cut. You know someone will create a website where you can look up the cheapest imaging service a la GoodRx. This will drive prices down further.

                    • suman

                      Member
                      October 31, 2020 at 6:01 pm

                      Oh no not the evil transparent pricing! Quick, call the ACR lobbyists.

                    • Melenas

                      Member
                      October 31, 2020 at 9:11 pm

                      Is avacado a spy? He seems so anti radiology.

                    • suman

                      Member
                      October 31, 2020 at 9:34 pm

                      How naive does one have to be to think that depriving hospitals of unethical cash flows won’t drag the physician pay down as well? It’s all one big beast, sucking blood out of the USA.

                      Public option is coming, people. No more professional fees. Grab your W-2 and stay complacent.

                    • Unknown Member

                      Deleted User
                      October 31, 2020 at 9:58 pm

                      [link=https://www.cbpp.org/blog/medicare-in-the-2021-trump-budget]https://www.cbpp.org/blog…-the-2021-trump-budget[/link]

                    • Patrick

                      Member
                      October 31, 2020 at 10:31 pm

                      Medicare pricing is amazingly transparent.  Go the website and search the associated CPT code.  Voila.
                       

                    • Dr_Cocciolillo

                      Member
                      October 31, 2020 at 11:12 pm

                      Guacamole is a troll who confuses the younger rads. A nurse or some other mid level. A tech.
                      Someone who lives in envy of what he doesnt have and cant achieve as a physician

                    • Melenas

                      Member
                      November 1, 2020 at 2:45 am

                      Sounds like it. Or he’s Bernie himself.  

                      Quote from wisdom

                      Guacamole is a troll who confuses the younger rads. A nurse or some other mid level. A tech.
                      Someone who lives in envy of what he doesnt have and cant achieve as a physician

                    • gustavobarraza_207

                      Member
                      November 1, 2020 at 9:25 am

                      “”One thing that I learned from the webinar was that the proposed 11% cut includes both the technical and professional components. If your practice bills for just the professional component, the cut will be less (I forget the exact percentage). “”

                      This is totally INCORRECT:

                      See link below. The proposed cut is WORSE for professional component. Looking at MRI technical cut is 8%, professional cut is 12% !!!

                      [link=https://info.hapusa.com/blog-0/medicare-proposed-major-cut-in-radiology-reimbursement-for-2021]https://info.hapusa.com/b…reimbursement-for-2021[/link]

                    • ljohnson_509

                      Member
                      November 1, 2020 at 9:32 am

                      We thought itd be AI that puts the last nail in the coffin… The cuts will continue. Then AI will come mixed in with extenders doing some of our work.

                    • clickpenguin_460

                      Member
                      November 1, 2020 at 10:06 am

                      There’s a tipping point at which the cuts are high enough that the added time/labor is no longer worth it and it would be better to just go the other direction.
                       
                      For example, perhaps we should all just cut our hours to 40/week, stop scanning patients after 4 pm and not do night or weekend coverage.  
                       
                      I would take a guess that we’d all take a big financial hit but have a hugely improved quality of life and then it would take about 6 months for a healthcare system revolt that shifts money back to us.
                       
                      This will never happen of course, but just a fantastical musing similar to a strike/civil disobedience move.  

                    • erasmopa

                      Member
                      November 1, 2020 at 10:20 am

                      I agree about the tipping point, and I dont think its so crazy. These cuts are going to cause specialists like GI to cut back on their own procedure volume and guess what they will order in its place? More radiology exams. There will come a point at which trainees and med students will turn away from radiology, retirements will increase, and more rads will decide the money isnt worth the overnights and the weekends. There will not be the manpower to read all of the cases. At that point either hospitals will have to subsidize the radiology department, the cuts will need to be reversed or it will become the norm for studies to sit on lists unread for days or weeks.

                    • ljohnson_509

                      Member
                      November 1, 2020 at 10:29 am

                      Theres no tipping point. The young radiologists have enormous loans and limited skills outside radiology. The older rads who have made poor choices and expensive lifestyles have no where to go either. Theyll work themselves to death to keep their salaries.

                    • Melenas

                      Member
                      November 1, 2020 at 10:35 am

                      What is the likely salary structure for the newbies? Do you think most places will still offer the ‘typical starting salary’ and put a clause in there that is is conditional on the market? or will most places start to decrease offer by 10 to 15% in anticipation of the eventual drop in payment? 

                    • Melenas

                      Member
                      November 1, 2020 at 10:39 am

                      Quote from Drrad123

                      Theres no tipping point. The young radiologists have enormous loans and limited skills outside radiology. The older rads who have made poor choices and expensive lifestyles have no where to go either. Theyll work themselves to death to keep their salaries.

                      That’s the problem isn’t it. The currently working radiologist do not have a unique set of skills that only they can do. New rads hungry for money, or even foreign graduates who are willing to work for money can fill the spots if the current working rads aren’t willing to work for less money. WE just do not have the power. 
                       
                      It is sort of like in the research field. Post doctoral fellows get crap pay, so many American graduates don’t go into research. But guess what? plenty of Chinese, Indian, country X students are more than willing to fill in those spots. I wonder if that will be the trend. 
                       
                      If the established American Rads aren’t willing to work for less, it will gradually shift to others. Maybe relax the requirements to be able to interpret studies, not require stringent vesting for those who might read the studies. 

                    • Dr_Cocciolillo

                      Member
                      November 1, 2020 at 10:58 am

                      I think we have more trolls on here and non-radiologist than genuine radiologist posting , just saying bullshit.

                      If you believe it, it may happen.

                      Will have to see what the cuts, if any, come around and how that changes the structure.

                    • reuven

                      Member
                      November 1, 2020 at 3:12 pm

                      Quote from wisdom

                      I think we have more trolls on here and non-radiologist than genuine radiologist posting , just saying ****.

                      If you believe it, it may happen.

                      Will have to see what the cuts, if any, come around and how that changes the structure.

                      I completely agree and great advice!

                    • jennycullmann

                      Member
                      November 2, 2020 at 6:22 am

                      Quote from wisdom

                      I think we have more trolls on here and non-radiologist than genuine radiologist posting , just saying ****.

                      If you believe it, it may happen.

                      Will have to see what the cuts, if any, come around and how that changes the structure.

                       
                      This will happen, but again, use the 2-3x rule — it takes two or three times the claimed time period before actually happening. IF it’s a decent analysis/idea in the first place. I still say we have zero to worry about until at least 2025

                    • clickpenguin_460

                      Member
                      November 20, 2020 at 2:40 pm

                      dontcutdocs.com

                    • y.rajshekar

                      Member
                      November 26, 2020 at 9:27 pm

                      How often radiologists get paid significantly more than professional component? I can see it happening in groups that own imaging equipment or having negotiated good contract.

                    • clickpenguin_460

                      Member
                      November 27, 2020 at 10:05 am

                      We might get an assist from more public-facing, sympathy-gathering specialties.
                       
                      [link=https://www.courier-journal.com/story/opinion/2020/11/23/front-line-doctors-clinicians-cant-afford-pay-cut-from-washington/3773390001/]https://www.courier-journ…washington/3773390001/[/link]

                    • Unknown Member

                      Deleted User
                      December 1, 2020 at 9:15 pm

                      According to this article, the fee schedule was finalized without changes to the budget neutrality requirements.  Is that the end of the story for 11% cuts?
                       
                      [link=https://www.fiercehealthcare.com/practices/cms-finalizes-physician-fee-schedule-including-controversial-updates-to-e-m-visits]https://www.fiercehealthc…-updates-to-e-m-visits[/link]

                    • cieminsjohn

                      Member
                      December 2, 2020 at 1:38 pm

                      I think its up to senate? to make a change at this point….

                    • Patrick

                      Member
                      December 2, 2020 at 2:23 pm

                      I left emails and called my 2 senators today.

                    • Unknown Member

                      Deleted User
                      December 2, 2020 at 3:05 pm

                      I did that. They just responded with form letters saying this issue is important to them. They didnt say if theyre actually going to do anything though.

                    • m.j_433

                      Member
                      December 2, 2020 at 3:25 pm

                      I received a somewhat real response from one of our senators. It contained a line about how he understands provider payments can have a significant impact on patient access to care and he will keep my thoughts in mind…

                    • tdetlie_105

                      Member
                      December 2, 2020 at 5:15 pm

                      Quote from n.rad

                      I received a somewhat real response from one of our senators. It contained a line about how he understands provider payments can have a[b] significant impact on patient access to care[/b] and he will keep my thoughts in mind…

                       
                      Hopefully I am wrong but that seems to be the largely ineffective strategy that the ACR/our lobby uses for each proposed CMS cut and at best it usually just slightly mitigates the proposed cuts (with the exception of this current one).  Maybe some groups are stressed enough that a 10% cut would put them under but that would simply allow some larger corporate group or mega-group to take over their contracts.
                       
                      Also it is my understanding that the potential bills are only a 2 year delay of cuts anyway.  Rads will simply work harder/read faster as they always have.  Groups will stop hiring and lengthen/do away with partnership tracks etc.  It is quite disheartening to think how impotent our lobby and how little control we have over our compensation but there’s no reason to belief that CMS cuts won’t continue to target us until we are single payor.  Ezekiel Emanuel must be elated.

                    • Unknown Member

                      Deleted User
                      December 2, 2020 at 5:42 pm

                      Its probably good we are in the same boat as some heavy hitters like cardiac surgery, EM and anesthesia. Maybe their lobbies are more effective.

                    • tdetlie_105

                      Member
                      December 2, 2020 at 6:10 pm

                      Quote from 2BRads

                      Its probably good we are in the same boat as some heavy hitters like cardiac surgery, EM and anesthesia. Maybe their lobbies are more effective.

                       
                       
                      That is a good point, and is a significant difference than prior cuts.  Hopefully this helps us out.
                       
                      I understand that this whole E/M issue is not new but it is truly mind-boggling how fields like EM, anesthesia, critical care, and IR were/are literally on the front lines, face-to-face against Covid and yet CMS thinks this is appropriate timing. [8|]

                    • radiologistkahraman_799

                      Member
                      December 2, 2020 at 6:21 pm

                      I don’t understand how the fee schedule has to be “net neutral”, yet literally everything else in the gov’t is like, “Ahh, f*ck it, spend it”?  Seriously, we are 27T in debt… but WE are the ones who have to keep our sh*t in line?  

                    • tdetlie_105

                      Member
                      December 3, 2020 at 5:59 pm

                      Quote from TurboEcho

                      I don’t understand how the fee schedule has to be “net neutral”, yet literally everything else in the gov’t is like, “Ahh, f*ck it, spend it”?  Seriously, we are 27T in debt… but WE are the ones who have to keep our sh*t in line?  

                       
                      Yeah pretty ridiculous.  Think that this is a sliver of the pie that they can control so they do…while driving to work I was thinking about our nation’s debt and was wondering at what point/time will it directly affect Americans day to day, seems like an abstract # right now

                    • ariesanurhani_334

                      Member
                      December 3, 2020 at 6:26 pm

                      Cut other places that waste federal money

                    • Unknown Member

                      Deleted User
                      December 3, 2020 at 7:27 pm

                      Income, wealth, happiness are so relative. There was a time when physicians had a tremendous amount of power and prestige. I personally find it interesting that the power and prestige was lost when physicians unfortunately agreed to be controlled by government (medicaid, medicare) and controlled by insurance companies (in-network agreements). Physicians were clearly taken advantage of by smarter business minds. Physicians didn’t understand their value in the system and are now considered the evil greedy capitalists. They are the enemy and are the focus of the largest cuts in the medical revenue pie even though they are the smallest sliver of the pie. Radiologists can’t understand how PE firms convince radiologists to sell their souls. It’s pretty simple. Doctors have little business smarts. If doctors had business sense and unity, they would control the medical revenue pie. Philanthropy has its merits. I have become much more philanthropic as I am properly reimbursed for my hard work. Not participating in government or in network scams.

                    • Unknown Member

                      Deleted User
                      December 4, 2020 at 9:19 am

                      Quote from IR_CONSULT

                      Income, wealth, happiness are so relative. There was a time when physicians had a tremendous amount of power and prestige. I personally find it interesting that the power and prestige was lost when physicians unfortunately agreed to be controlled by government (medicaid, medicare) and controlled by insurance companies (in-network agreements). Physicians were clearly taken advantage of by smarter business minds. Physicians didn’t understand their value in the system and are now considered the evil greedy capitalists. They are the enemy and are the focus of the largest cuts in the medical revenue pie even though they are the smallest sliver of the pie. Radiologists can’t understand how PE firms convince radiologists to sell their souls. It’s pretty simple. Doctors have little business smarts. If doctors had business sense and unity, they would control the medical revenue pie. Philanthropy has its merits. I have become much more philanthropic as I am properly reimbursed for my hard work. Not participating in government or in network scams.

                      What services do you provide out of insurance or government networks?

                    • i2906

                      Member
                      December 4, 2020 at 7:16 pm

                      and everything is getting more expensive

                    • suman

                      Member
                      December 4, 2020 at 9:05 pm

                      So are folks are already getting comms from management about upcoming pay cuts due to these CMS changes?

                    • tdetlie_105

                      Member
                      December 5, 2020 at 7:51 pm

                      Quote from avocado

                      So are folks are already getting comms from management about upcoming pay cuts due to these CMS changes?

                       
                      what do you mean precisely? From hospital admin? 

                    • Unknown Member

                      Deleted User
                      December 5, 2020 at 8:25 pm

                      Billing co sent an estimate based on past payor mix.

                    • abbaspour.1j

                      Member
                      December 5, 2020 at 8:33 pm

                      [attachment=0]

                    • tdetlie_105

                      Member
                      December 6, 2020 at 2:09 pm

                      Graphs like that are ridiculous but physicians won’t get any sympathy from the public etc given our compensation

                    • kayla.meyer_144

                      Member
                      December 6, 2020 at 2:14 pm

                      The increase in administrators is a direct result of complaints that medicine needs to be run more like business than public health. 
                       
                      So who do you call when you need to run for-profit businesses? Physicians? I don’t think so. Physicians are employees of the people controlling the revenue.

                    • tdetlie_105

                      Member
                      December 7, 2020 at 6:04 am

                      Quote from 2BRads

                      Its probably good we are in the same boat as some heavy hitters like cardiac surgery, EM and anesthesia. Maybe their lobbies are more effective.

                       
                      The more I read about the current state of medicare (insolvency 2024), the less confident I am that these cuts are getting delayed.  I am not quite sure what the concrete ramifications of insolvency are (sorta like the US having >20 Trillion in debt), but it does not sound or look good on paper politically. New administration will have to attempt to do something about this.  Not quite sure what that will look since providers are unhappy about cuts, costs keep rising, and demand for services will keep rising.  Also hard to see the large private insurers, large HC systems, and pharm quietly relinquish their piece of the pie.
                       

                    • russellm

                      Member
                      December 7, 2020 at 8:07 am

                      Who do you think will be making a final decision on these proposed medicare cuts? Will the Trump administration be deciding before they go out or will they wait for the Biden folks to come in and decide?

                    • janecreeve_520

                      Member
                      December 7, 2020 at 8:33 am

                      [link=https://www.govtrack.us/congress/bills/116/hr8702]https://www.govtrack.us/congress/bills/116/hr8702[/link]
                       
                      “prognosis” – according to Skopos lab – AI 
                      1% chance of passage
                       
                      no idea how meaningful 83 cosponsors is

                    • suman

                      Member
                      December 7, 2020 at 9:06 am

                      It’s not getting reversed.

                    • tdetlie_105

                      Member
                      December 7, 2020 at 10:32 am

                      More good news: Apparently Pelosi is adding a surprise medical bills fix that will give an additional 30% cut to hospital based physicians (rads, ER, anesthesia).  This is separate and on top of the 10% cut. 

                    • russellm

                      Member
                      December 7, 2020 at 10:42 am

                      Is that real? Could you please post the link?

                    • tdetlie_105

                      Member
                      December 7, 2020 at 11:22 am

                      Quote from Raddoc

                      Is that real? Could you please post the link?

                       
                      I unfortunately do not have a link. This was just emailed to me from a friend of a friend that is part of one of the larger corporate outfits who massed email all of their rads.  Hoping that we get some emails/links to contact our representatives from the ACR later today.

                    • cieminsjohn

                      Member
                      December 7, 2020 at 1:27 pm

                      [link=https://twitter.com/EdGainesIII/status/1335667166344073216?s=20]https://twitter.com/EdGai…35667166344073216?s=20[/link]

                    • suman

                      Member
                      December 7, 2020 at 1:48 pm

                      Quote from Nibbler

                      [link=https://twitter.com/EdGainesIII/status/1335667166344073216?s=20]https://twitter.com/EdGai…35667166344073216?s=20[/link]

                      I like how he tags the whole swamp in this Tweet #4: [link=https://twitter.com/EdGainesIII/status/1335670636665073664]https://twitter.com/EdGai…us/1335670636665073664[/link]

                      Really convenient.

                    • tdetlie_105

                      Member
                      December 7, 2020 at 1:52 pm

                      Quote from Nibbler

                      [link=https://twitter.com/EdGainesIII/status/1335667166344073216?s=20]https://twitter.com/EdGai…35667166344073216?s=20[/link]

                      thanks

                    • Unknown Member

                      Deleted User
                      December 14, 2020 at 10:34 pm

                      Is it this?  Where is it in here?  [link=https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/No%20Surprises%20Act%20FINAL%2012-11-20.pdf]https://energycommerce.ho…20FINAL%2012-11-20.pdf[/link]

                    • tdetlie_105

                      Member
                      December 15, 2020 at 10:18 am

                      Quote from ztune

                      Is it this?  Where is it in here?  [link=https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/No%20Surprises%20Act%20FINAL%2012-11-20.pdf]https://energycommerce.ho…20FINAL%2012-11-20.pdf[/link]

                       
                      I don’t know.  Latest I’ve seen from ACR is optimism on new language for SMB, apparently largely bc of congressmen Richard Neal from Mass, who for whatever reason, opposed the version that favored insurers. Also optimism for delaying the 10% CMS cuts due to both house and senate support.  Obviously everything is far from a done deal.