Seniors lose out with payment cuts to primary-care doctors

By Jerald Winakur
Thursday, December 9, 2010;

The temporary fix that Congress has passed to stave off the looming 23 percent reduction in Medicare reimbursements to physicians is better than nothing - but the long-term problem remains unsolved. Lawmakers have for years kicked down the road tough choices on a critical issue - and those who stand to suffer the most should physician pay be cut are elderly Americans.

I have been a privately practicing geriatrician for 35 years. I have managed to keep my office doors open despite the edicts that come down from Medicare year after year.

As a geriatrician in the United States, I work in a single-payer system. In fact, I hope our nation might see a retooled public option plan arise after the health-reform legislation passed in March is rejiggered.

I want to stress that I am not against all payment cuts for physicians' services. There is growing recognition among doctors that many of the services at issue - primarily technical procedures - are over-compensated. We can thank the American Medical Association and its subspecialty-stacked "Resource Utilization Committee" for this state of affairs.

The implement that is needed to make these payment cuts, however, is a scalpel, not the meat cleaver that has hung menacingly over the program since Congress set a plan in motion in the 1990s to keep Medicare spending in line.

Here are some simple facts:

l Those who practice primary care for the oldest among us are a vanishing breed. More geriatricians retire each year than are trained - and this at a time when every eight seconds, one of our countrymen turns 65.

l Geriatrics is the lowest-paying specialty in all of adult medicine. Meanwhile, medical students graduate with six-figure debt loads. Is it any wonder why they choose to practice in other areas of medicine?

l Geriatricians derive their incomes from actually seeing patients - at their office, in hospitals, nursing homes and even home visits - not from doing things to patients. We minister to them, face to face, and bring our cognitive skills and experience, not procedural wares, to aid in decision-making. Medicare has, from the inception of the program, undervalued these cognitive services. When an ear, nose and throat specialist receives significantly more for cleaning wax out of a senior's ear than a geriatrician receives for a "complex office visit" to evaluate that same senior's many medical problems, something is seriously out of balance.

l Overhead costs for those of us in office practice range from 55 percent to 60 percent of collections. By necessity we have already trimmed to the bone our expenses for rent, employee salaries, malpractice insurance and so on, because Medicare payments to doctors have, in essence, gone unchanged since 2001.

Given all this, I think it is fair to say that should Medicare proceed with its planned 23 percent cut in reimbursements for physician services, the current system of privately rendered, office-based primary care for seniors is in danger of becoming extinct.

My patients realize this, even if our legislators and bureaucrats do not. It is increasingly common for primary-care doctors in my community to decline new Medicare patients or to restrict the number of Medicare patients in their practices. Not a day goes by when one of my aging patients doesn't ask me, "You're not going to retire, are you?"

For years now I have said, "Of course not. I'll be here for as long as you need me." And I want to be there, I really do.

But for me and other primary-care doctors around the country - especially geriatricians - this is a critical time. Congress must act to fix this unfair and ailing system for the long term. It must find an equitable substitute for Medicare's flawed "sustainable growth rate formula" that caused this problem in the first place.

These days I can no longer promise my patients that I will be there when they need me. If Congress allows these unkindest of cuts to occur, the already-fragile health-care system serving our seniors will bleed.

Jerald Winakur is the author of "Memory Lessons: A Doctor's Story" and a clinical professor of medicine and an associate faculty member at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center in San Antonio.

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