Physicians worried over Medicare cuts

By MARK ANDERSEN / Lincoln Journal Star | Posted: Wednesday, March 3, 2010

Poor Medicare pay to doctors had nearly tipped the scale, even before a rogue elephant briefly stepped on it Friday, local physicians say.

The Senate on Tuesday approved a one-month delay in a 21 percent Medicare pay cut to physicians that went into effect Monday.

Physicians had predicted the drastic pay cut would increase what Medicare patients pay and decrease their ability to see doctors.

But the shenanigans of the past few days pushed physician frustration to the point a one-month pay cut reprieve may matter little.

Three days of lobbying in Washington, D.C., left Dr. Les Spry of Lincoln to conclude, “Medicare is just an unreliable partner here.”

Spry, past president of the Nebraska Medical Association and legislative liaison to the Lancaster County Medical Society, will offer recommendations to his partners and Lincoln doctors.

Before flying home Wednesday, Spry said he’d become convinced he can’t count on Congress or Medicare to fix the mess.

Spry, a kidney doctor, said he must act to shore up his business.

While the Senate pay-cut crisis has passed, the result may not have changed: Medicare patients could find themselves paying more and having a harder time getting in to see a doctor.

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For the past two years, said Dr. Melvin Churchill, a rheumatologist with the Arthritis Center of Nebraska, patients upon reaching Medicare age have asked him to find them a primary care physician.

“I sometimes can,” he said. “It’s gotten steadily more difficult.”

With nearly one in six Nebraskans enrolled in Medicare, the federal health program for retirees, recent events could accelerate the program’s transformation into an ugly twin of underfunded Medicaid.

Medicaid, the state/federal health insurance programs for the poor, sometimes get likened to a hunting license in that the newly enrolled must hunt for a doctor to treat them.

Spry had predicted Monday the week’s crisis might leave physicians feeling justified in taking steps that the long decline in Medicare profitability had forced them to consider.

“This has been madness for 10 years,” Spry said.

“I do have to make decisions that are good for my employees and my business,” he said. “I don’t like those decisions. Normally, I abhor those decisions.”

“Medicare is an unreliable payer right now,” he repeated. “We cannot count on an unreliable payer in the future.”

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Physician frustration with Medicare’s poor pay has grown for seven years, driven by flat federal reimbursement despite the rising costs of providing care.

Early this week, attention shifted to the one-man rebellion of Republican Sen. Jim Bunning of Kentucky, who had single-handedly triggered Monday’s 21 percent pay cut.

The origins of the cut lay in the sustainable growth rate provision Congress adopted in 1997, tying physician Medicare payments to a national economic barometer.

Since 2003, Congress has repeatedly delayed the cuts it would have triggered, but lawmakers never repealed them. To do that, they would have had to identify where the money was coming from to pay the doctors.

Meanwhile, doctors say, their own costs of doing business have risen 4 or 5 percent each year, eroding Medicare’s profitability, especially for family doctors at the low end of the doctor pay scale.

As Congress repeatedly kicks this can down the road, said Dr. Ardis Hoven of Kentucky, chairman-elect of the American Medical Association, the problem grows.

What would have required $45 billion to fix in 2005 will take $210 billion in 2010, she said. It will take more than $300 billion if delayed to 2015, Hoven said recently in Lincoln.

Last October, Senate Democrats failed in an attempt at a permanent fix, which was then rolled into proposed health care reform. That was derailed by January’s upset victory of Massachusetts Sen. Scott Brown, which eroded Democrats’ 60-vote super majority.

In late February, the House approved a monthlong delay of the 21 percent pay cut, including it in a package extending unemployment benefits.

And then on Friday, Sen. Bunning demanded the bill’s $10 billion price tag be paid from approved stimulus funds rather than added to the deficit.

Unanimous approval was necessary for the accelerated legislation, sending the issue into freefall.

Tuesday night, Bunning relented under pressure.

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But the threat of a cut remains, and with a deadline fast approaching.

Should the 21 percent pay cut take effect, said Lincoln family practice physician Dale Michels, it will cost him $13.75 every time he sees a Medicare patient. His calculations include the costs of rent, insurance, staff, supplies and utilities, he said, but they exclude physician salary.

The American Medical Association estimates a 21 percent cut would reduce the average annual pay to Nebraska doctors by $18,000.

Nationally, said Dr. David Filipi, president of the Nebraska Medical Association, 60 percent to 70 percent of doctors will not take new primary care patients, and half of all physician clinics will be forced to cut staff.

The implications extend to military families insured through TRICARE, because its pay rates are linked to Medicare.

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The longtime decline in what Medicare pays physicians has already begun to affect patients, doctors say.

Medicare currently reimburses state physicians about 30 percent below what Blue Cross Blue Shield pays, Filipi said.

“Locally,” he said, “we’re at the point a lot of primary care physicians cannot afford to take Medicare.”

A number of physicians, Spry said, have cut back on the number of Medicare patients they will see.

As a kidney doctor, Spry said, about two-thirds of his patients are in Medicare.

“I can’t stop seeing Medicare,” he said.

But he could go “nonparticipating,” causing drastic billing changes.

When physicians participate, they agree to bill Medicare patients a typical 20 percent deductible and accept Medicare’s set payment for the balance. In exchange, they receive a 5 percent payment bonus.

The patients of “nonparticipating” doctors can be charged an additional 9 percent. These patients also must file their own claims with Medicare.

***

“I don’t know exactly what we’re going to do,” said Spry, still sorting through the options.

“Likely what’s going to happen,” he said, looking more globally, “Medicare is going to have to restrict (patient) access.”

The Lincoln medical delegation heard the same message at all the offices of Nebraska delegates.

“We’re being told there’s no money,” Spry said, “and they will try to fix this as best they can.”

Another 31 days won’t change anything, he said.

“Most of us (doctors) have a certain feeling that we should take care of patients as they come,” he said, “that there shouldn’t be two tiers of medical care,” one for the rich and another for the poor.

“But right now I’d have to say they’re going to create a two-tier system. I didn’t do that,” he said.

“They did this to me.”

This story is found here: http://journalstar.com/news/local/article_9c4ef320-2721-11df-97c1-001cc4c002e0.html