Friday, February 26, 2010

Jim Bunning throws doctors a curve ball

Last night, retiring Senator Jim Bunning (R-KY) single-handedly held up passage of legislation to stop a devastating Medicare payment cut that will go into effect on Sunday. Unless the Senate finds a way to clear the legislation this morning by a unanimous voice vote - considered unlikely because Bunning has stated that he will not withdraw his "hold" on the bill - starting next week, all Medicare claims submitted by physicians will be reduced by 21 percent.

Probably only for a few days, though, because I anticipate that Congress will come back next week and find another route to stop the cut and hold physicians and patients "harmless" (that is, to restore payments for the period when the cut was in effect). CMS may also hold up on processing claims for a few days to give Congress time to act. Still, even if this all comes together, it looks like the result will be another 30 day extension of current rates, meaning that Congress will have to revisit the issue again and do something to stop the next scheduled cut. And at some point, Congress has to figure out what to do about the underlying problem: an unworkable formula (SGR) that triggers cuts in Medicare payments whenever spending on physician and related services grows faster than the overall economy.

It isn't just physicians who are being held hostage to the Senate's dysfunction; the bill also includes an extension of jobless benefits and COBRA coverage for people who otherwise will lose their coverage along with their jobs, and many other popular provisions set to expire at the end of the week. (The House of Representatives has done its part by passing legislation to provide a 30 day extension of the expiring programs. It also has passed legislation to permanently repeal the SGR and replace it with a new formula to provide more stable updates going forward.)

Let me say this as clearly as I can. The continued dysfunction in the Senate is unacceptable. Temporary patches to the SGR are unacceptable. ACP has made it absolutely clear that the only acceptable outcome is permanent repeal of the SGR.

But the current dysfunction in the Senate endangers much more than patients' access to Medicare. It has put health care reform on life support. It has created an unprecedented loss of public confidence in government's capacity to do the right thing. It has led to an increasing degree of anger among the electorate, as more and more of us feel like channeling Howard Beale's "I'm mad as hell, and I'm not going to take it any more ..." rant from 1976's "Network."

Meanwhile, President Obama's bipartisan summit may have produced the ironic result of getting Democrats behind a strategy of enacting the bill without GOP support by using the "majority rules" reconciliation process. Mike Allen blogs in Politico's Playbook that Bloomberg news' headline "Obama Bipartisan Health Summit Clears Path to Party-Line Vote" pretty much says it all. I'll have more to say about the summit next week, but I think one of the President's greatest challenges will be to get the public behind completing the bill on a party-line vote, when confidence in Congress, understandably, is at a historically low point.

Today's question: What do you think physicians and patients should tell their Senators about the SGR?


Harrison said...

We have to continue to be careful about advocacy.
The US economy is precarious. Our patients are increasingly unemployed.
It is right for us to advocate for our patients.
It is right for us to point out that a 21% cut will lead to an impact on thousands of small businesses and to our employees.
But if we start to say that we are going to stop seeing Medicare patients because we are going to get paid $80 per 99214 instead of $100 for a 99214 visit, well...I don't think that is going to go over so well.
We have to emphasize that this cut will result in decisions about how we run our businesses.
But the economy is slumping, and if we react to this by saying we will take out any threat to our business model by jeopardizing our patients care or by eliminating services that people need -- I'm not sure we are going to win that debate.

I am accepting new patients.
Recently one of them came from a practice where the doctors had chosen to move exclusively to Concierge care. He couldn't afford to stay with the doctor he had known for years.
He was bitter about that.

Not all of us will be able to do that and make the model work successfully.

Those who go to it early will take care of those wealthy enough to afford it, and in this economy those numbers are falling.

The ACP is right to advocate for health care system reform. It is right to advocate for repealing the SGR.
It would be best if the two things could be linked.
As a separate issue, the SGR repeal argument has to be made with care.
It is easy to make errant statements that make us look bad in a bad economy.


Arvind said...

For the first time, I am wishing for an "all or nothing" resolution to this perennial problem. The ACP and other organizations have been e-mailing every year to call our Senators so that we can keep Medicare rates at the previous year's level. I don't know of any profession that is forced to do this like we have done since 2002. We should really hang our heads in shame.

I disagree with you Harrison. We have stopped taking new Medicare patients since Jan since all our patients are referred for Consultations and they no longer exist as per Medicare rules. The public must understand that their so-called government is putting their lives in jeopardy by enacting arbitrary rules. And they must understand that we have a business to run, and cannot keep absorbing cuts year after year. Most of my patients understand when I explain it this way. The other way to explain would be "we are willing to take a 21% pay cut if the government is willing to reduce our taxes proportionately.

The ACP has to get out of the business of being politically correct. It is time to say "get rid of price-fixing and CPT codes". Let medical service be a service, not a commodity.

I an waiting eagerly for the 21% cut to go through; then I will not have to worry about my conscience and can opt out of Medicare altogether. There has to be a tidal wave of anger and protest for the politicians to understand the consequences of their actions! Mr. Bill Clinton, hope you are listening.

jfddoc said...

The very first professional baseball game I attended back in 1967 featured Phillies pitching ace Jim Bunning. How long ago that now seams.

I disagree with the comment about Bunning acting "single handedly" as Sen Bob Corker was on the Senate floor offering encouragement. Since Bunning is not running for re-election, it is more likely that he was just a figurehead.

But then again, a six month extension of SGR was part of a bipartisan Jobs Bill that Majority Leader Reid yanked on Monday in favor of his own, stripped down, version.

I blame both political parties for this one.

Robert J. Sobel, M.D. said...

The House passed a simple legislation. The Senate should too. The game of chicken is a shame and the potential landslide of physicians dropping out of Medicare participation should not be discounted. There are cuts to be made and they should not be to cognitive services.

It is clear that it seems right for the Medicare program to work for most physicians. It is a flawed bureaucracy but it has the potential to stabilize the unfettered industry growth. Unfortunately, the only formula here would have to slow down the infrastructure explosion in health care and regulate the price of the new. Raising eligibility gradually is also a reasonable consideration.

The private industry should then be stripped of its suped-up investor-driven bias and regulated as a series of state-based entities (or some other construct that brings a bit more balance to the strange landscape that is the American Health Care system).

PCP said...

The entire insurance industry has followed the lead of Medicare and held the medical profession hostage to insane regulation, price fixing, non stop interference in the Doctor-Patient relationship. The Gov't has over promised to a public by trying to be everything to everyone sans responsibility and asking us to foot the cost of their largese.
Then as if to add insult to injury, medicare B services which are not all physician delivered nor physician administered and hence out of our control (esp. those of us in cognitive services) have been subjected to the SGR. We have effectively been held hostage to the public demand for our services. Given the demographic factors, increasing morbidity and survival etc of patients on one hand and the fiscal crunch on the other hand, this trend is not going away atleast for the next decade or more. I'd rather it happen at once where we react as a profession rather than by sub-inflationary adjustments for the next 10 yrs when we keep trying to adapt and make our chosen work more and more detached/unsatisfying. In our state Medicaid(for a level 3 follow up visit) already pays doctors less than what it costs me to get a haircut. When the Gov't does not feel that is unfair, where does this end? The recent rejection of the SGR fix as well as the month to month extension of these cuts, tells me that Medicare is headed exactly the same place that Medicaid is in our state.
Once again I ask, where is the SGR on Medicare A, where is it on Medicare D. Far from cuts those programs are receiving inflationary adjustments and in Medicare D there is talk of filling the donut hole ie more funding. This after it was specifically written in that medicare cannot negotiate directly with drug companies. These programs are in bigger crisis than medicare B and in case of Medicare D the spending was not offset when the program created. Suddenly these imbeciles find fiscal sanity when the issue is SGR for Doctors?
With that as the backdrop, I reject the above poster's view that we come across as greedy. If anything we are guilty of being ineffective communicators, ineffective at leveraging our huge collective power to bring about the required changes. Perhaps a reading of the recent JAMA article about physician hours will be enlightening. Doctors are cutting back and choosing other priorities/pursuits. At current payment rates on the one side and planned tax rates on the other it would not surprise me to see the current trends hasten with current cuts, I know there is an inflection point, but it is not near. Retirement will look more and more appealing for those of us fortunate enough to have practiced in the pre-managed care era, and for the rest of us, other leisurely pursuits start to appeal more to us beyond the 40 hr work week. We start to look more and more like Europe. The bottom line is that spending of health care dollars needs to be redirected. We certainly spend enough as a nation but as a PCP, I am most certainly not a beneficiary of the largese. Given the size of the contribution I make, I am being short changed and I won't take it anymore. If the Politicians agree that we are already underpaid and then cut my reimbursement 21% and therefore my pay 40%, then I have a job to communicate this to my patients, not a need to be further taken advantage of as the poster above seems to suggest we do.
The Gov't does what it does because we are soft targets as opposed to Insurers, Hospitals, Drug companies, CHCs, Medical Device manufacturers, Home Health, etc etc.
When insurance is rejected, people choose value for money and primary care can thrive again.
21% should do the trick as far as creating a maelstrom required to get definitive change one way or the other.

Steve Lucas said...

The current compensation calculation for doctors is an abomination. Too allow one medical society to control doctor compensation through a secret committee, and then sell the resulting computer codes is the worse type government control imaginable.

This system needs to be replaced by one that is open and responsive to public input.

Compounding this problem is a political system made up of soaring egos who feel entitled to decide what is best for the country, and public opinion be damned. The Kings and Queens of both political parties are so out of touch with the reality of the electorate as to have become laughing points in comedy sketches.

I am mad as hell because I cannot find a doctor willing to look at me as an individual. Instead I am pushed into a box so as to fit a business model. Retainer medicine is not available in my area with the results being after just a few seconds you are interrupted and handed a fist full of prescription before any test, and are told the nurse will explain.

50 patients per day is the norm in my area with 90 day follow-ups. Doctors are blunt when they say all of their medical updates come from drug reps. I am waiting for statins to be put in the local water supply.

Our system is broken. Doctors are being forced to run ever faster on a wheel with no vision of the future, and no hope of ever moving ahead.

We need to rethink medicine in this country and it starts with compensation, as this drives behavior. I watch doctors try to care for those slipping through the cracks, but as a business person, I understand this is a battle they will loose.

Steve Lucas

Unknown said...

I agree with arvind. at some point we have to draw a line in the sand. With overhead of a typical office running at 60% a 21% cut in reimbursement translates into a cut in your take home pay of over 50%. If you can afford a 50% drop in your income-good for you, but the rest of us are not going take it anymore.

Rich Neubauer MD said...

The SGR has been a yearly "issue" for all too long. Layered on top of a payment system that is already dysfunctional, especially for primary care, it has had a set of unintended consequences that characterize our current sorry state of affairs.

As Harrison points out, we have to be careful about advocacy. To me, that means we need to advocate in a patient centered way. The demise of primary care would not be patient centered. Practices that are being brought literally to their knees by reimbursement rates inadequate to pay overhead does not lead to patient centeredness. Older physicians being essentially forced into retirement because their practices are not economically viable is not a way to enter gracefully into the future.

The fact that the SGR still looms is yet another embarrassing reminder that congress is abrogating its responsibility to govern. We need to keep reminding them of that until they get it and we move on to the rest of the things that need to be done in health care reform.

Ringlemate said...

I agree with Harrison the argument has to be carefully presented to patients. We passed out a flyer to Medicare patients in the office Friday asking them to call their Senators and Representatives about the 21% cut. The result was 10 minutes added to every encounter trying to either explain the SGR or allay fears that we were going to drop patients. The details are complex and hard for most of my patients to understand.

We took this step because 40% of our receipts come from Medicare and the office overhead is nearly 70%. Tough times indeed.

Jerry M said...

We ,of coarse, should continue to remind the senators of the SGR but they are already well aware of it’s implications. If medicare pays too far below what the other third payers pay, physicians will refuse to take new medicare patients. That is the only reason congress doesn’t let the cuts go through. That is ,unfortunately , the reason the President wants to control all of the third party payers so that physicians will be faced with cuts by all payers and unconstitutional penalties as we see in medicare. I may sound paranoid but the concept that spending reduction on medical care is a main object of medical reform is proof of this concept. I realize that we have been told that medical care will be made more efficient and that only unnecessary care will be eliminated but I don’t believe it for a minute. This is why ACP should withdraw it’s support for the gigantic bills before congress. I believe your assessment that the public is fed up with the gridlock is incorrect. The public does not like the bills. They are afraid of the cost, the red tape, the bureaucracies created and the reduction of services and ACP should also be afraid. In all other countries that have monolithic medical systems, shortages is the rule. If the system doesn’t have frank rationing like Germany it limits by not having the service available on a timely basis like Canada . Of coarse our government is going to invent a new universe.

Now that the bills are in trouble, we should withdraw support and insist on meaningful tort reform and free market principles that will keep total control out of the Feds hands. Having a seat at the table is not worthwhile if it only benefits the person at the table.