It looks like there’s another fight brewing on the hill. Unfortunately, rather than a battle where the Republicans are leveraging their numerical superiority over the Democrats, it seems that it will once again be an internecine scrap between warring factions inside the GOP. At issue is a proposed plan to solve, once and for all, the perpetual “Doc Fix” problem with Medicare. A solution is allegedly in the offing which would eliminate the Sustainable Growth Rate (SGR) formula which was supposed to reduce Medicare costs but keeps getting cut down when Congress passes a doc fix to increase payments to doctors.

The need to fix this issue is something that both sides can agree on, but as usual it’s the “how” where things fall apart. This year, however, according to both Politico and the Daily Caller, the Speaker of the House has come up with a plan that will address the situation over the long term. The looming problem is that he allegedly got Nancy Pelosi and the Democrats to buy into it before getting his own conservatives to sign off.

In a rare display of bipartisanship, House leaders are actively pursuing a deal to permanently change the way Medicare pays doctors and to extend a children’s health program for two years.

The estimated $200 billion package could be introduced as soon as this week by House committees responsible for health care policy. Both Speaker John Boehner (R-Ohio) and Democratic Leader Nancy Pelosi (D-Calif.) are personally involved to the point that Pelosi reached out to Senate Minority Leader Harry Reid (D-Nev.), and Boehner has spoken to Senate Majority Leader Mitch McConnell in recent days.

Major hurdles remain, but the politics are intriguing given the very partisan character of the House. Both Boehner and Pelosi appear willing to take some risks to solve what has been a thorn in both parties’ sides for years. And unlike the Homeland Security debate this winter, the speaker is being bolder about building a bipartisan coalition to defuse a crisis — rather than waiting until it has engulfed him in the final hours.

“Willing to take some risks” is one way to put it. National Journal has a slightly different description, though.

The House’s hard-core conservatives have gotten used to losing at the end of a long legislative fight. But for the first time in the 114th Congress, Speaker John Boehner is cutting them loose from the get go.

That is a noted strategy shift for Boehner, who on several recent occasions—including last month’s Homeland Security Department funding standoff—has only gone to Pelosi as a last resort and, instead, relied on 218 Republicans to pass right-leaning bills. Now he is not bothering to try to appease the most vocal hard-liners in his party, members who—Boehner’s allies have argued—were never going to come around to his side anyway.

It seems that Paul Ryan is on board too. So here are the details which already have Heritage (among others) up in arms. The deal will cost $200B over ten years and only a third of it is paid for. On the plus side, the “paid for” part comes from reforms to Medicare which push some of the costs back to hospitals and other service providers… something Republicans have been asking for every year. The “Doc Fix” goes away because the threatened 20% cut to reimbursements is no longer on the table. The Democrats don’t get a tax increase out of it, but it includes a two-year reauthorization of the Children’s Health Insurance Program.

The Speaker is making the argument that the downstream benefits to Republican priorities will more than make up for the unfunded price tag on this deal. Perhaps it will. But if this is an initiative which will rely on heavy Democrat support plus whatever establishment GOP votes can be found, it’s going to be yet another shock to the system for House conservatives who are already restless after the DHS funding negotiations. Get out the popcorn because this is probably going to be very interesting.