By Jane M. Orient, M.D.
Nine times in the past eight years, Congress has, at the last second, delayed the automatic cuts in doctors’ Medicare fees that it decreed some 13 years ago to prevent Medicare spending from outpacing other consumer expenditures.
The AMA threatens that doctors, especially primary care doctors, will stop accepting Medicare patients if the cuts go through. Congress cites the impending bankruptcy of the program.
Every time cuts are postponed, the next scheduled cut gets deeper. It’s like a balloon mortgage payment in reverse.
And the controversy gives columnists another occasion to rail against those greedy overpaid doctors, unwilling to assume a bit of shared sacrifice despite the economic downturn.
As Steven Pearlstein writes in The Washington Post, Congress and the President should not accede to these “un-Hippocratic ransoms.” So what if Medicare physician fees haven’t quite kept up with the costs of running the office? What he calls a “modest gap” has been “more than offset” by physicians’ working harder.
What’s a little 21 percent pay cut to someone who already makes much more than the average patient does? Of course, Mr. Pearlstein doesn’t seem to recognize that when overhead is 50 percent or more, a 21 percent cut in revenue means a cut of 42 percent or more in the physician’s actual pay. And if one is losing $23 per patient visit, it is impossible to “make it up on volume.”
Unlike the AMA, the Association of American Physicians and Surgeons (AAPS) has repeatedly said: Let the cuts go through. But don’t cut off benefits to seniors who see the doctors of their choice.
Both Congress and the AMA appear to be in deep denial about several basic facts:
First, Medicare is insolvent. Expenditures will be cut because the government doesn’t have any money.
Second, the access problem is not caused by the “sustained growth rate” (SGR) formula, but by price controls. If doctors can’t collect enough to keep their doors open, they close, like any other business.
Third, physicians could make more money while charging less, if it were not for the costs of filing claims and complying with Medicare rules.
Fourth, more doctors would do primary care if they could charge a fair price—that the patient was willing to pay—and organize their work in the most efficient way. If they could charge $100 for one long enough visit, instead of churning five patients through frantic $20 visits to bring in $100 without being accused of “upcoding,” doctors would find primary care much more attractive.
We are warned that more doctors will “opt out” if the cuts go through, as up to 200 Texas doctors are already doing each year. Exactly. We need more opted-out physicians to take care of seniors who can’t find a physician willing to work under Medicare’s constraints and threats—or who want a non-government physician.
Congress, however, punishes seniors who choose such a doctor by denying them any reimbursement at all for services they receive from opted-out doctors— or that are ordered by such doctors, even if performed by Medicare providers.
While Pearlstein might be shocked to hear it, doctors opt out of Medicare not because they want more money—many stay in just because they fear a serious drop in income—but because they want to be able to do their job. They want to be able to order what a patient needs, not what a Medicare bureaucrat decides he may have.
Congress apparently intends to cut costs by simply not paying them. Then, if doctors see fewer patients, there are fewer bills for tests or procedures. The government not only saves the $15 it might have paid the doctor, but hundreds or thousands of dollars on tests or drugs.
Fixing the SGR may top the AMA’s agenda. But for seniors, the problem is draconian cuts in care. These can be averted only by restoring patients’ freedom to choose an independent doctor, not by a slight easing of their captive doctor’s shackles.
Jane M. Orient, M.D., Executive Director of Association of American Physicians and Surgeons, has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at www.drjaneorient.com.
Dear Dr. Orient,
Thank you very much for your most eloquent and concise presentation of the “Big Picture”.
Unfortunately, the parties that control this tragic situation do not suffer from the consequences of their short sighted vision. If, members of Congress and the President were in the same predicament as the physicians and patients under that same duress, they would agree with you in a heart beat !
Why don’t you invite Mr. Pearlstein to visit these physicians who dropped out of Medicare and encourage him to apply his investigative skills to enlighten the Public, Congress and the President of their foolish, irresponsible and hypocritical conduct, as the US Healthcare is like the Titanic hit by an iceberg.
The truth is very far off from the simplistic and utterly inaccurate perception entertained by a well orchestrated propaganda machine painting the physician as the alleged villain.
Hence, it is the duty and responsibility of journalists, such as Mr. Pearlstein, to educate the Public instead of conducting themselves as blindfolded activists, when in fact they should be forward thinking individuals or at least objective observers.
These are very challenging times for the House of Medicine but we must approach these issues the same way we conduct a history and physical for our patients, using SOAP !
For those who are not familiar with this acronym, the ” S ” stands for Subjective symptoms, the ” O ” stands for Objective symptoms, the ” A ” stands for Assessment and the ” P ” stands for Plan.
Without a correct diagnosis there is no possible cure for the disease.
” Elementary, my dear Dr. Watson “, as Sherlock Holmes would say, the brainchild of a physician, Sir Arthur Conan Doyle. Reducing the hemorrhage by clamping a capillary will not stop the bleeding from the carotid artery.
Let us not forget to apply a significant dose of common sense, otherwise we are all doomed.
I applaud your courage to speak up and stand tall facing this Tsunami.
Respectfully submitted,
Gil Mileikowsky MD
As an anesthesiologists, I currently get reimbursed for taking care of patients with Medicare and Medicaid Govt insurance less than 25 cents on the dollar compared to patients with private/commercial insurance, and this is without the 21 percent cut. These patients are commonly much sicker and complex than nonmedicare and nonmedicaid patients. So I basically get “taken to the cleaners “, patient after patient, day after day , month after month, and year after year by the federal government every time I care for these patients!!!… It’s absolutely absurd…the Govt reimburses me for my care 50% in absolute dollars and 20% in inflationary dollars compared to what I got reimbursed 20 years ago!!!… This would be like the Govt forcing Ford Motors to accept $2000.00 for a $10,000.00 car, day after day… They couldn’t stay in business for a week … It’s absolutely crazy!!!… An unlike a primary care physician who can put up a sign at their office that they’re not accepting Medicare or Medicaid patients(opting out), I don’t have that option!!!! All my patient’s are at a hospital or medical facility that they’ve already been admitted to for their surgery or procedure before I care for them …..and the hospital requires that I accept medicare and Medicaid patients to have privileges to provide care for any patients at the hospital or medical facility… additionally with the passage of Obama healthcare “reform” the number and reimbursement for care to physicians for Medicare and Medicaid patients will go from absolutely terrible to worse and at the same time the reimbursement for care of privately insured patients will become much worse through the “exchanges” … and will eventually after a relative short transition period be the same as the terrible Medicare and Medicaid reimbursement for care by physicians !!!!! The Govt and Obama administration has made it clear that they will not listen to or negotiate anything reasonable, so the only option will be for anesthesiologists and other physcians to stop taking care of nonemergency patients until the absurd reimbursement and Govt control of patients and patients is stopped and reversed!!!!!!…
Addendum..The last sentence should be that the Govt has made it “absolutely” clear they won’t listen or negotiate anything reasonable with physicians …and that the absurd reimbursement and control of patients and “physicians” has to be stopped and reversed and become appropriate and reasonable!!!!…
When the problems resulting from government control of anything begin to reach critical mass, you can always expect government to demonize those they have been controlling. Government is never the problem, and they will always have another (worse) solution. Ayn Rand had it well described in “Atlas Shrugged.” It is time for us all to not play their game.
Be prepared for enforced acceptance of any and all government plans disguised as beneficent passage of “any willing provider” legislation. The catch will be the passage of “any willing provider” for HMO acceptance will come with the enforced acceptance of ALL government plans. The only way to blunt this and all other heavy handed intrusions which the AMA is willing to accommodate, is to simply walk away from the profession for a while. Painful as it may be, it is the only solution. When government sees resolute action they can not co-opt (such as has been the case with the AMA) then they back down very quickly. It is very much like the way terrorists are successfully handled; but we have not learned that lesson either. In the case of medicine, the practices that MUST grasp at each dollar, no matter what the cost, will continue on until they perish from overwork and overhead. Those who can plan an extended downsize in their practice will return to a bountiful source of willing patients willing to pay a fair price for good care.
One of the best overviews I’ve ever read on the current situation and the need for 180-degree ethical and economic-minded turnabout by doctors, members of Congress and patients! I’m giving the piece wider coverage by including it in our email CCHC Health Care Newsletter. Thank you Jane!
Dr. Orient, thank you again for your PASSIONATE CLARITY.
Of course, as we all know, since “their” real goal is power, requiring “them” to destroy free markets and American medicine, no dose of irrefutable logic and common sense will influence “them.”
But essays like yours continue to awaken the sleeping…
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Forget the 21% cut looming on the horizon, we’ve already taken a massive hit to our pockets via the RACs. Has anyone else factored in the time and expense associated with responding to the countless requests for documentation? The physicians in my practice do about a 50/50 split between outpatient and inpatient care and resultantly, Medicare hits us with these requests on average 100 times per month. Adding injury to insult, the reviewers are LPNs. Who knew you needed to go to medical school to make critical care evaluations?
This has to stop. This administration will whittle down primary care to nothing if left unchecked. Anyone else looking to work on a cruise ship?
July 7, 2010 and we still have not been paid for dates of service from June 1 to current. Although Congress instructed Palmetto to release the funds, they’re still being held. When we call our “support” line, we’re told “it’s in the hopper” but can’t tell us when the funds will be released.
Is anyone else expriencing this debacle?