The Enemy of Better: Worse

Posted by Brian F. Sweeney, Jr.

Posted: October 31, 2009 - 7:49 pm

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A half a dozen Medicare patients a week that have no primary care physician come through my office. Some of them come from Emergency Department referrals. Some are patients that used to have a physician that dropped them when they turned 65. Some of them are bouncing around from sub specialist to sub specialist piecing together care.

Contrary to public belief most primary care physicians in town do have Medicare patients. Many offices will not take new Medicare but will keep patients when they become Medicare beneficiaries. There are also a few clinics that still will take on Medicare patients although it often overwhelms them.

Medicare simply does not reimburse well enough to allow for most clinics to open their doors wide. A primary care practice with only Medicare patients would be teetering on bankruptcy.

It is easy to look at a number and think a physician is being paid adequately. Most people writing nasty letters to the paper forget that money does more than pay the doctor. It pays for the office staff, rent, utilities, supplies, insurance, accountants, lawyers, and the rest of what is needed to run a practice.

The writers of such letters also have likely never worked for free in their life. They certainly have never paid to work either which is what it comes down to with medicine and Medicare in Alaska at times.

There are procedures done in hospitals, offices, and surgery centers where the use of one piece of disposable equipment immediately puts the facility in the red if the patient has Medicare. One of the ways the current bill wants to pay for the new plan is to tax medical devices and make this situation worse. That is only one of the many taxes in the bill not being counted in the cost to the system as a whole.

Medicare is now implementing private auditors to decide if a "T" did not get crossed and demand money back with penalties for a service that has already been rendered. It is at the point now where they can extrapolate that number across an entire practice and multiply the penalty. There is true fraud but there is also fraud that is being fabricated by the inspection process.

The auditors are paid on commission so the last thing on their mind is the service provided. They simply want to find a paperwork error so they can walk home with a big paycheck. It has nothing to do with the services that were actually rendered.

Throw the regulatory mess on top of the poor reimbursement and there is almost no reason for any Alaska physician to see a Medicare patient, let alone a primary care physician. That trend is starting to spread to the lower 48 and would accelerate quickly if Medicare reimbursement fell precipitously.

The Senate recently defeated a bill which would have done away with the Sustainable Growth Formula that is used to determine physician reimbursement. For seven years now Congress has stepped in and prevented cuts and if those cuts were to hit now the result would be over a 20% drop in reimbursement rates.

It sounds good until you consider the bill would would have frozen reimbursement rates for 10 years. Do you think Senator Begich's union buddies would agree to a ten year pay freeze? Would Marky Mark would even consider such a thing?

The AMA supported the bill and this may be the reason less than 20% of doctors are AMA members. This bill would have doomed Alaska seniors to 10 more years without access and every Alaskan over 65 should remember when Marky Mark runs again. The spin by the Democrats on this one is beyond reprehensible.

Another provision of the current bill is the use of demonstration projects to promote "bundling." The idea is that one flat fee would be paid for a hospital or other visit to cover every provider involved. This is the equivalent of having a pipe burst in your house and you being able to pay one fee that the plumber, the dry waller, the floor man, the furniture store, the appliance store and anybody else involved would have to haggle over.

Even worse, they want to apply the "bundling" for 30 days after discharge from the hospital and include any visits after under the fee. If the patient develops complications or has to be readmitted even if it has nothing to do with the care Medicare would pay no extra money.

This policy would require hospitalists and other hospital based physicians to become hospital employees because the hospital would have the money. It would undoubtedly lead to rationing because the only way to squeeze out money might be to not offer every service.

Medicare is a system that is failing. The hospital fund will be out of money by 2017 at the latest. The outpatient and drug benefits will require an increase in taxes or cuts in benefits to remain balanced. Social Security will follow in the failure towards the middle of the century.

How does one fix Medicare? It is a tough assumption to make that it can be fixed. Here are a few thoughts.

An argument has been made to let physicians balance bill so that they can collect more than Medicare currently allows. In other words if Medicare pays 30-40% let the patient or their secondary insurance pick up the rest of the tab instead of only 20% of the Medicare allowable.

This may work for independently wealthy seniors but would be an impossible situation for lower income patients. The solution to go for is likely in the middle somewhere. Make what Medicare pays 70% or 60% of what gets paid. Many of the secondary insurance programs are making a killing and could certainly afford to pump in some extra dollars.

The biggest issue with access is primary care. A Medicare patient should be allowed to declare a primary care doctor. That doctor should be paid at a higher rate for services or potentially given a global fee annually for taking care of the patient.

The federal government should also look for a way to provide tax breaks for seeing Medicare patients. If a physician has a given number of Medicare visits in a year there should be a tax deduction in it. Perhaps a $5 deduction per visit with a minimum 200 visits to get a $1000 tax deduction that is not otherwise taken away by any other tax law. It is a small amount but the gesture would go a long way.

Medicare also needs to bring care back to the basics. The use of the program to cover everything from gauze to scooters is something that needs to be looked at carefully. These are areas that are frequent fraud targets. Many times there are things being covered that are not necessities and at a minimum there likely should be a careful definitive process to license providers of supplies.

The sad part of the debate right now is the move towards giving government a bigger role in health care. Perhaps Congress should fix the failing system they already have before they build another destined to fail.

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