Sunday, July 11, 2010

More On the Risk of Growing Physician Non-Participation in Medicare

Wow. The two Disease Management Care Blog posts on the 1) non-death of small physician owned practices and 2) the risk of a physician boycott of Medicare caused a flurry web traffic, comments and emails. Thanks to all for their feedback.

The most interesting of all is a reply from the author of the HealthBeat blog, Ms. Mahar. It's in the Comment reply section of the original post. Since it makes so many interesting points, the DMCB decided to give it the visibility it deserves by reposting it here. (The DMCB answers are italicized.)


Thank you for linking to HealthBeat, but I didn't write the post suggesting that fears of doctors boycotting Medicare are overblowm.

The post was written by my associate, Naomi Freundlich (She came up with the idea, wrote it without any help from me.)

I doubt Naomi would characterize herself as a "liberal pundit." Formerly the Science Editor at Business Week, she's an excellent journalist and her posts tend to be fact-based. (I also wouldn't call myself a pundit--to me this suggests someone on TV who comes up with clever one-liners. But I am happy to be labeled liberal/progressive.)

(The DMCB regrets the error and not giving Ms. Freundlich her due. The good news is that the word "pundit," is from the Hindu word "pandit," meaning "learned" and "scholar." In addition, thanks for the reminder that all of us in the public square have a responsibility to minimize using single word labels to characterize complicated opposing points of view.)

Finally, I do agree with Naomi. The facts suggests that docs aren't moving away from Medicare in large numbers.

For what it's worth, I have a relative in NYC on Medicare who has no trouble specialists, and not too much trouble finding a new primary care doc--though everyone is having a hard time finding primary care docs. This is not unique to Medicare patients.

And the numbers support Naomi's argument.

Of course, it could be "different this time" but those three words usually turn out to be wrong. And docs have been threatening to stop taking Medicare patients for years.

(Use of the word "could" means that we agree that there is a likelihood that there could be a physician exodus. Since it could happen, the point of the DMCB post is that Congress has a duty to the taxpayers and to Medicare's beneficiaries to define the risk, understand its potential magnitude, minimize it and measure the progress in minimizing it. That duty transcends the size of the risk since, even if it is quite small, the implications are huge. It's simply good fiduciary business practice to carefully assess it.

The DMCB will leave it to readers to ponder the track record of similar "no problem" anecdotes combined with expert opinion when it came to our government's ability to assess other low risk situations, like say, deep water oil drilling, government-backed mortgage guarantees or invading countries in the Middle East.)

More importantly, only quite young, very successful docs would actually be able to keep a practice going without Medicare patients. (Younger patients tend to prefer younger docs).

More than 43 million Americans are on Medicare. Medicare patients account for over 22 percent of U.S. health expenditures .

And of course older people go to more specialists. The average age for a cancer diagnosis is 67, which means it would be particularly hard for oncologists, as well as cardiologist, orthopedic surgeon (who do all of those knee and hip implants) urologists or many other specialists to make it with Medicare customers.

Middle-aged people will come in for testing and check-ups, but seniors are much more likely to need the big-ticket invasive procedures that keep a practice afloat.

(The DMCB agrees that Medicare's monopsony will make physicians of all ages think twice before thumbing their nose at Uncle Sam. Yet, some replies to Ms. Freundlich's post as well as the ACP Advocate Blog suggest there are other forces at work including margin (if it's not there, economics 101 says shortages are inevitable) and a lesson from the Three Temptations: health care professionals live by more than government fees alone.)

Could docs begin turning down new Medicare patients? Sure--as long as the Medicare patients they have never die . .

Finally, it would be odd if, after all of these years, primary care docs dropped Medicare, just when they are about to get significantly better payment (up 10%) plus many opportunities for bonuses.

And by and large physicians are very enthusiastic about Berwick heading up Medicare.

All in all, a strange time for a cascade of physicians leaving Medicare.

(The DMCB agrees these are truly interesting times in health care policy which makes for great bloggery. It thinks we both agree on the need to assess the risk and to not let the risk upend the the Medicare program just when other parts of health reform beginning to kick in.

While the DMCB shares your admiration for Dr. Berwick, it's less sanguine about the cards he's been dealt: a recess appointment with the need to renew in 2011, a resurgent Republican Congress this fall and the remote possibility that anybody can tame Medicare's unwieldy bureaucracy. Will he make a tangible difference in the real world of patient care? We'll see.

As for the 10% increase, the DMCB recalls that only happened when long-made predictions of the collapse of primary care began to come true. Whether the better payment is enough to save primary care remains to be seen, which is the point. If Congress had credibly assessed the risk years ago and managed provider income expectations, it wouldn't have come up arguably a dollar late and a day short. They messed it up then and, by relying on MedPAC's shoddy methodology (focus groups? gimme a break), they run the risk of repeating the mistake with a potential for far greater problems for the beneficiaries and the President's still vulnerable agenda.)


a family doc said...

"seniors are much more likely to need the big-ticket invasive procedures that keep a practice afloat."

Exactly what big ticket invasive procedures does Ms. Mahar think keep primary care practices afloat?

Our bread and butter are the lowly E&M codes,not big ticket procedures. This type of work with Medicare seniors is usually much more time consuming (for less pay) than in working age and young patients.

Jaan Sidorov said...

Family doc points out what happens when fee schedules are toggled down until margins become unsustainable. And it's not just pure mono-dimensional $$: the time and effort may not be worth it even if a small profit is to be made.