THCB contributor, radio talk show host and occasional orthopedic surgeon Eric Novack (just kidding, Eric!) sent me this story about the problems that Medicare recipients will be having getting access to doctors in California if the projected cuts in Medicare reimbursement for Part B actually materialize. So far the cuts for this year have been rescinded by the Senate and the arguing is still going on in the House. Eric has written on THCB recently about the possible bad effects on patient access from cutting physicians fees, and I do agree with him that it’s unjust that only physician fees get cut when hospitals and managed care companies get an increase.
But the problem physicians face is that they don’t really have an alternative. Sure some will retire early, some will move to cash only practices. But given that Medicare is about a third of the money in the system, realistically they can grumble all they like but they’ll end up taking it, and of course doing more things to those patients to make it up on volume. And that’s not just my opinion, it’s the findings of this five year study by the HSC folks. After all, they went to medical school and residency for all those years, what else are they going to do? There’s only so much room on the poker circuit and only so many of them can run health plans.
That’s why I say that physicians should be figuring out how they collude with government to reduce overall spending while maintaining as good a position as they can. That’s what’s happened in other countries, and one day it’ll happen here. Of course there’s lots of time for gnashing of teeth and entrepreneurial end-arounds before then.
I am possibly planning on going to all cash soon and dropping all insurance. Less headaches and there is a huge need so patients will still come. They will just have to pay up front and get reimbursed by their insurance on the back end.
I see alot of Medicare for a plastic surgeon, but this is my “service to the retired community.” I essentially make no money from it and I must monitor my exposure to the Medicare patients. My good will will only go so far however.
In 2004, Medicare was about 40% of my patient load, but represented about 17% of my revenue. If Medicare cuts payment significantly, I will reduce the patient load. This means the skin cancer reconstruction will go back to the dermatologists and wound care will stop. Wound care is a loser for my practice already.
Does the Fed really think they can mandate physicians to lose money? I know of several internists that have opened “boutique practices” in which patients must pay a membership fee. Limiting payment while overhead climbs is a sure way to get Medicare patients less care. There is this brand new concept in business (note sarcasm)…there needs to be a profit. Eliminate profit and you eliminate the business.
Who says doctors aren’t helping to make decisions at insurance co’s, pharma, device manufacturers, hospitals, and CMS? So far as I can tell, there is plenty of physician input at all these places.
I am not quite sure how I have left an impression of laissez faire. I admit I hold there is no “right” to medical services, and greatly prefer voluntary contracts to coerced commerce, but the common good might require mandatory participation in some activities. I fear, however, that doctors and others will be forced to leave medicine when someone decides there is a “right” to medical services that go contrary to conscience. The only thing worse is that they do not do so. We already see examples of this.
I don’t know how far we can push the “personal responsibility” angle. I chuckled at Dr. Gitlow’s system of “fines”: there is a poetic justice in this. And I am in favor of price-discrimination, wherever it can be accomplished But we know the fines will drive underutilization among his patients, and I hope he considers this.
I think the only way to “induce” boomers not to use the equity in their homes for world trips and second homes is to tax these things away before they are accumulated, and we have not done that. So for the boomers at least, it is too late. But if we had taxed them away, there is no guarantee the revenue would be spent on appropriate healthcare rather than Bridges to Places Where Relatives of Congressmen Own Lots of Property, and other such worthy causes.
There is no doubt that a simple ‘fix’ of the SGR (medicare payment formula for doctors) by adopting the MEI (medical economic index — what is used for payments under medicare part A) will casue spending problems. It would be, however, a levelling of playing field between the different payers.
We must not forget the differences in funding sources as well — hospitals are funded through payroll medicare taxes, though function as a pay as you go system (i.e. no lock box). Medicare part B (doctors) are 75% general federal revenues and 25% participant premiums.
We should restore the system to one of personal financial sanity— that would include the potential for intrusion on some personal rights (sorry, Tom). For example, a person should willingingly contribute to a society where funds are available to assist for the care of those in poverty with type 1 diabetes– children do not choose to be diabetic. People should be much more circumspect in contributing to the smoker who continues to smoke in the face of incontrovertible evidence of its dangers.
We must induce the baby boomers (reaching 60 at the rate of over 300 per hour) to not use the equity in their homes for world trips and second homes while expecting current workers to pay for their medical care and long term care and prescriptions.
Of all the groups involved at the healthcare table — I would still trust the doctors more than the insurance co’s, pharma, device manufacturers, hospital system execs, and bureaucrats to help make the best decisions for the care of the people of this country.