Will Physicians Flee Healthcare?

Download a copy of this Editorial
Will Physicians Flee Healthcare?
By Roger K. Howe
Tuesday, 20 July 2010

Today, my newspaper ran two editorials from the McClatchy News Service on “Medicare’s Future.” The two editorials were pretty well balanced by opinion on the answer to the lead question: “Will health care reform cause an exodus of doctors from Medicare?” On the other hand, the two editorials were not evenly matched in terms of the quality of information used or disseminated in them.

“Doctors will flee low reimbursement, rules” reads the “screamer” on the editorial by Grace-Marie Turner, noted at the foot of the article to be the founder and President of the Galen Institute, “funded in part by the pharmaceutical and medical industries.” (I am not sure exactly what that means.) The information in the editorial is generally flimsy and frequently misconstrued.

“The exodus of doctors from Medicare – and likely from private practice altogether – is accelerating. The signs are undeniable: A 2008 poll by an independent Medicare commission found that 28% of seniors had trouble finding a primary care doctor, up from 24% the year before.” This tends to confirm only that primary care physicians are becoming more and more scarce as fewer of them are trained than are retiring. Difficulty finding a primary care physician is not isolated to Medicare patients – it is a generic, nationwide trend, as more and more primary care health manpower shortage areas pop up on the map every year. The primary care shortage is due to differential reimbursement to primary care physicians lower than to procedural specialists – reimbursement for procedures is higher than for cognitive services (taking a history, listening to the patient, doing a physical examination, making a diagnosis and helping the patient in managing a chronic disease). This problem has been in train for decades. The number of family physicians being trained in California was inadequate to replace retiring family physicians in the late 1980s, and (after a brief respite during the heyday of HMOs in the early 1990s) has only gotten worse since then.

“Doctors are on the front lines of ObamaCare’s changes. The legislation requires more than $500 billion in cuts to Medicare to fund new entitlement spending, including a 21% cut in physician payments. Congress just postponed the cut until December, but in January it will be 30%,” the editorial continues. It is true that physicians are on the front lines of health care, and will be affected by ANY reform legislation. It is true that the bill requires some savings in Medicare to make up for the increase in expenditures elsewhere, but the implication that the changes come at the expense of physicians is just not true. Medicare Advantage plans will see capitation rates cut. Hospitals face a reduction in reimbursement. Primary care physicians are scheduled for a 10% INCREASE in compensation. The 21% cut is the result of a budget-balancing formula passed by a Republican-dominated Congress over a dozen years ago, which has never been fully implemented, will be changed at some point in the near future, and is not part of the healthcare reform legislation. I have no idea about the 30% reduction scheduled for January first, but I suspect that this is a made-up number. It is disingenuous to attribute this dozen-year-old formula to the healthcare reform legislation and further suggests that the author’s purpose is not to provide information, but to alarm people. She continues to conflate the issue by indicating that many physicians indicate that if the 21% reduction were to happen, they could not continue to see Medicare patients. This may be true, but is completely irrelevant to a discussion of the healthcare reform legislation, as noted above.

Ms. Turner continues with the information that physicians “fear the barrage of new rules and regulation.” I suspect that this is an overstatement, but the barrage is real – the current compilation of Medicare rules and regulations would occupy, I understand, about 10 feet of shelf space – it constitutes a volume of regulation that is impossible for anyone to remember perfectly (or even imperfectly). The issue of physician non-use of clinical guidelines is an old subject undergoing a renaissance – and digital medical record systems connected to appropriate internet-based resources can provide the real-time assistance physicians need to assure not only compliance to the rules, but also adherence to a higher quality of medical practice. No one would suggest that airline pilots stop using check lists to assure the safety of passengers just because the checklists are a burden on the pilots – a similar sacrifice in safety is made by not insisting on their use in healthcare. Facilitation of the guideline process is something physicians have been awaiting for some time. Considerable federal funding will assure that, far from requiring that physicians “must invest in federally approved information technologies to get paid by the government,” available funds will relieve the physician of having to invest heavily in such systems, because the federal government will reimburse for almost all of the cost of acquisition (up to $44,000, according to information released by the AMA), provided the system is put to good use.

Ms. Turner’s solution? Put “doctors and patients, not government bureaucrats, in charge of medical decisions,” in spite of the fact that it is precisely unregulated medical decision-making that got us into this mess in the first place. We have tried putting doctors and patients in charge of medical decisions, and we know that when a third party pays for the care occasioned by those decisions, this is a recipe for overuse of interventions and over-spending on care. It is, in essence, the reason why the US spends twice as much per capita on health care as the average industrialized nation. Further, the “government bureaucrats” who work on medical decision-making are likely all to be physicians, as they are in private health plans.

I don’t know exactly how to counter so much misinformation and misconstruing of the information provided. Fortunately, this editorial was accompanied by another written by Dr. Jim McDermott, a Democratic Congressman from Washington and a psychiatrist. His refutation of Ms. Turner was neither so long nor so detailed as mine, but hit many of the high points I have mentioned.

It was an interesting Sunday paper.

{ 0 comments… add one }

Leave a Comment

© Roger K Howe. All Rights Reserved.