Unless Congress acts in the next 11 days, physicians all across America are going to have no choice but to drastically limit access to Medicare and Tricare patients.
Many will close the door only to new patients. But a significant number may stop seeing these patients altogether, and opt out of the Medicare system completely.
Physicians do not hate Medicare and Tricare patients. They are not doing this to make a political statement. In fact, every physician I know who is not employed by a large corporate practice is being torn to shreds in facing what will be a very painful and difficult decision.
We are literally now down to the wire. Nothing seems to be happening in Congress to prevent this.
This is going to cause chaos, confusion and anger for millions of seniors. The backlash against Democrats has the potential to be overwhelming. Faith in the Dems ability to do anything useful will plummet.
The public option, now struggling to be resuscitated, will die, and no amount of CPR will save it.
But we are engaged in an annual game of chicken, and so far, nobody is blinking.
Why is this going to happen? Because, on March 1, across-the-board payment rates to physicians (not to hospitals or nursing homes, not to device makers, not to pharma -- only to physicians) are slated to be slashed by an average of 21.2%.
The cuts in physician payments are mandated by a fatally flawed and ironically named formula called the Sustainable Growth Rate (pdf), or SGR. The simple summary: this formula was created to maintain budget neutrality in the part of Medicare (Part B) that pays physicians, and looks only at costs to Medicare, and totally ignores the costs to physicians of keeping their doors open. Costs like rent, salaries, supplies and insurance. Costs that make the average overhead of a medical practice in the neighborhood of 60%.
By 2016, absent Congressional intervention, Medicare rates will be cut by approximately 40%. During this same time, practice expenses are expected to rise by 20%.
If you want to read more about this, I diaried it in detail a few weeks ago, so I won't repeat all the boring details here.
But I will mention that when I wrote the last diary, a number of the comments dismissed this looming crisis as simply a "greedy doctor" issue. While I understood where this was coming from, I found it somewhat dismaying, and I talked about it in updates to that diary. I'll simply mention here that physicians aren't looking for sympathy. Physicians WANT to take care of Medicare patients. This isn't a greed issue -- and yes, I'm sure almost everyone can relate an anecdote or two about doctors they've encountered who have crappy bedside manners, or seemed uncaring, or incompetent, or downright greedy. That's not what this is about. The vast majority of physicians work incredibly hard and care tremendously about doing the very best for their patients. And most medical care in this country is still provided by physicians who are running small businesses, employing nurses, technicians, receptionists, and a small army of people to deal with paperwork.
If you like, we can debate whether this model is better or worse than big corporate medicine, which is fast replacing the small business model.
My own opinion is that big corporate medicine is no better than big corporate everything else. If you like Walmart, then you'll be fine with Walmart medicine, because that's what's already happening across the country. In fact, almost nobody coming out of medical school today plans to practice in a small business.
But I'm not writing today to discuss practice models. Even if you think that the small business model of medicine is obsolete and should be replaced, and even if you're a dyed-in-the-wool-single-payer advocate who thinks that nothing other than a national health service model is acceptable, you should be very alarmed by what is gong to happen on March 1.
You should be alarmed because causing a major health system failure for seniors and military personnel is NOT going to get you to the model you'd like to see. If anything, it's going to do exactly the opposite, because the federal government, and most especially the Democrats and President Obama, are going to be blamed for not preventing this meltdown, and the faith in a government sponsored solution is going to plummet even further than it's already fallen.
You should be alarmed because crippling Medicare and making that look like the Democrats' fault is a Republican wet-dream, and we are on the verge of making that dream come true.
You should be alarmed because getting the physician community on board with true health care reform is really important, and historically has been a struggle that we have been slowly winning, but giving physicians a reason to lose faith makes achieving reform that much more difficult. And I say this as a physician who has been involved for many years with organized medicine.
You want a Public Option? Like many of you, I've signed Sen. Bennet's excellent letter to get the Senate to pass the public option via reconciliation. My prediction? If this Medicare meltdown happens in two weeks, you can kiss any hope of passing a public option good-bye.
I'm sure that despite what I've said above and in my prior diary, some of you will point at physicians and say, "This is YOUR fault. You shouldn't even be in business."
To that, I would only express amazement that people here expect professionals who are in training until they are 30 or older and have accumulated hundreds of thousands of dollars of debt should be punished for having the temerity of also being small businesspeople. In fact, most physicians treat their employees well, give them excellent benefits, and are model employers. And if you're in business, you simply have to pay the rent, and be able to purchase your supplies and pay your employees. Otherwise, you close your doors.
With a 21% cut in Medicare payments, most physicians would be TAKING A LOSS on every single Medicare and Tricare patient. You can't make that up on volume. For some practices, Medicare makes up a majority of a clinic's business. In Florida, it can be as high as 75%.
Am I being Chicken Little? Judge for yourself: Amongst internal medicine physicians, who take care of only adults and are disproportionately affected by the challenges of taking care of Medicare patients, what is happening right now, before any additional cuts, has already reached crisis levels. Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare, according to the New York Times. Many are already opting out of Medicare.
The House passed H.R. 3962 that would fix for the SGR, back in November. The Senate, ever the prisoner to its own refusal to deal realistically with the budget and taxes, has so far refused to touch it. It hasn't made it any easier that Congress long ago realized that the SGR was a very convenient device to extract whatever concessions it wanted each year from physicians: go along (e.g. with the horrible provisions in Bush's "Medicare Improvement Act of 2004") or else you don't get your SGR fix this year.
The AMA and the AARP jointly sent a letter (pdf) to Congressional leadership on January 21, urging action to prevent what could be a major crisis. The cuts are slated for just one week after President Obama's new health care "summit". How embarrassing is it going to be if the focus and the inertia of newly revitalized reform efforts suddenly shift to millions of seniors who can no longer get care because Congressional Democratic leaders refused to act? How are the stories on the evening news of seniors becoming ill or dying because they couldn't get in to see their physician, or because they couldn't get the chemotherapy they needed, going to play?
This isn't a doctor issue. It's a people issue, and it's a health system issue. If you want real reform to happen, this simply has to be fixed. Optimally, not just another band-aid, like we've been doing for the past twelve years, or we'll be doing this again 9 months from now, when the next round of drastic cuts is already scheduled to take place. But this needs to be fixed and a band-aid fix is better than no fix at all. Tell your Reps and Senators to intervene immediately to prevent the 21% cuts from going into effect on March 1, and tell your Senators to pass H.R. 3962 that repeals the SGR.
I think this is really important, or I wouldn't have written about it yet again. I can guarantee you that if your your physician is a small businessperson, she or he thinks this is important, and is very likely struggling right now with what to do on March 1 if this isn't fixed. As much as I find it very uncomfortable to ask for recs, if you agree, you might considering recommending this diary so that the word gets out about how important this is.
I'm about to spend the next couple of hours traveling, so I apologize in advance for not being able to reply immediately to comments, but I promise to do so as soon as a can.
Thanks.
