Contrary to a report on the Federal Page Tuesday, Rep. J. Roy Rowland (D-Ga.) is not the only medical doctor in Congress. Rep. Jim McDermott (D-Wash.) is a psychiatrist. (Published 10/4/90)
They call it "the hassle factor."
Simply put, many American doctors believe that in an attempt to curb soaring costs of medical care in the United States, the Medicare program and private health insurers are imposing so many regulations, restrictions and paperwork requirements on physicians that "America's health care system is strangling in red tape."
"All day long, from the opening gun until you stop making phone calls at night, it's a pervasive, frustrating and adversarial type of environment that I'm referring to, with little bits of sunlight when you're with a patient one-on-one and the doctor-patient relationship is pristine," said Charles Duvall, a physician here who heads the American Society of Internal Medicine (ASIM).
So the American Medical Association and ASIM, plus several other medical groups, have launched a campaign to beat back what they view as a tide of excessive regulation and "niggling" rules. That tide continued this week: The new budget agreement recommends an additional series of Medicare restrictions that many doctors are likely to see as added "hassles."
In their focus on Capitol Hill, the medical groups are backing a bill sponsored by Rep. J. Roy Rowland (D-Ga.), the only doctor in Congress, and Sen. Max Baucus (D-Mont.) to reverse recent Medicare rulings. The bill has 248 House sponsors and 31 Senate sponsors, a reflection of the political muscle doctors bring to their campaign. The AMA has long been one of the biggest campaign contributors to congressional candidates -- $1.1 million so far for the 1990 election, fourth highest of all groups -- and its spokesmen and lobbyists are among the most persuasive in Washington.
"Physicians today are overwhelmed by government paperwork," one AMA staff paper says. "In the last 10 years, under the guise of cost-containment, the government has shackled the medical profession with rules and regulations."
The rules that would be reversed by the Rowland bill are illustrations of the kinds of things doctors don't like -- particularly those in solo practice.
Under one rule, doctors can be penalized if there is evidence that they are getting patients to come in too frequently or receive unnecessary treatments simply because the doctor wants to make extra money. Medicare uncovers such doctors by running patient records through a computer to see whether the number of treatments by any doctor exceeds a "normal" range that Medicare uses internally to judge physician actions. The doctor may be penalized if he cannot justify the excess treatments.
Doctors complain that they are not told in advance how many treatments within a given time span trigger the penalties. The bill would give them this information, though officials fear this will undercut the system. Said Medicare administrator Gail Wilensky, "We are doing a demonstration in a few sites to test making this information available to doctors to see whether it is used to game the system."
Doctors are also annoyed about payment arrangements when they get a colleague to "cover" for them when they are away, and return the favor at some other time. In the past, the patient's regular physician did the billing even though the service was provided by his covering colleague. But Medicare now requires the covering doctor to do the billing. Doctors say this creates extra paperwork. The bill would let them use the old arrangement.
"We believe a legitimate issue is raised on coverage by a colleague, and we are reviewing our policy," Wilensky said.
Requirements of this type, said John Zapp, AMA vice president for government affairs, are examples of "the incredible hassle factors that affect both patients and physicians."
The doctors are upset at numerous other provisions not covered by the bill. For example, some are extremely annoyed that under new Medicare rules, they must submit to Medicare all claims for reimbursement on behalf of the patient -- including those that previously handled by the patient.
Doctors are wary of a possible new requirement that each time they submit a bill to Medicare that must be handled manually rather than electronically that they will be charged a $1 processing fee -- a provision that doctor spokesmen say could net Medicare $300 million a year.
"There is a guideline for everything," one AMA spokesman said. Doctors "feel their judgment and professional competence is being questioned."
The motive for the government's greater regulation is not in dispute. Medical costs, more than $600 billion a year for the nation, are growing at about twice the rate of inflation each year and are nearly 12 percent of gross national product, the highest figure for any developed nation. Numerous studies suggest that at least some of the soaring costs are due to inefficiencies or to doctors performing services that really are not medically necessary but which increase doctor income.
Many of the steps to curb doctors were taken, said Rep. Fortney H. "Pete" Stark (D-Calif.), chairman of the House Ways and Means health subcommittee, to ensure that doctors do not charge too much; order excessive, expensive tests and surgery or run patients in and out of the clinic door more often than medically necessary. He emphasized that underlying standards on medical necessity are not set by Congress but by doctor groups.
"To some extent I agree with the doctors and Rep. Rowland. To the extent that he has touched on the aggravations of bookkeeping, he has my support," Stark said. "But where he wants us to give away our investigative secrets, like the screening information, that's like telling the drug dealers when we're going to carry out the raid. The IRS doesn't tell you what the criteria are to trigger an audit."
Over the years, new rules have been set:
Limiting freedom to shift a patient from one hospital to another.
Imposing tough limits on what hospitals are paid for a Medicare patient, which can exert pressure on doctors to shorten patient stays.
Imposing tough fee limits and eventually forbidding doctors to charge Medicare patients more than 15 percent above the amount recommended by program guidelines, even if the patient is willing to pay.
Sharply cutting fees paid by Medicare for cataract and other surgery.
Restricting how doctors run laboratories within their offices and whether they invest in outside laboratories.
Establishing a "peer review" system under which government-supported medical review groups in each state can monitor the medical practices of doctors in the Medicare program to determine competency.
The government is also establishing a national data bank that will be a central repository of information on malpractice, loss of license and the like by doctors. The aim is to prevent a doctor disciplined in one state from moving somewhere else where no one knows of his record.
In addition, doctors who cheat are more likely to be investigated by the government these days. The AMA recently asked President Bush to fire Health and Human Services Inspector General Richard P. Kusserow on grounds he has breached procedural safeguards.
Wilensky acknowledged that "it may now be time to step back and look at the whole mass of regulations for the accumulated burdens they may impose."
In the long run, however, regardless of such reviews, the prospect is for more rather than less regulation, since the federal and local governments pay 42 percent of all medical bills in the nation.