• Medicare doc fix lemonade

    My latest Kaiser Health News column is out. Do you need a teaser?

    [T]he volume of [Medicare] health care services remains unconstrained. As it grows, so do costs. …

    The SGR problem is now so large it offers an opportunity for political leverage on the issue of volume. The American Medical Association and other physician groups may want it fixed badly enough that they’ll accept some payment system changes in return. …  As an illustration of the political power of a full SGR fix, the AMA supported health reform on the promise of one.

    What should Congress seek in exchange for scrapping the SGR methodology? At the top of my list would be …

    I know you can’t resist reading the rest.

    • Greetings Mr. Frakt:

      I have worked with over 45 different types of medical specialists over the past 25+ years. One thing is now very certain – very few primary care or specialty physicians have any margin from their Medciare and/or Medicaid patient populations. Even if the SGR had kept pace with medical inflation – this would still be the case. The reality is very few if any physician can bridge this gap by “making it up on volume.”The situation becomes more exacerbated when commercial payers are able to tie their payment rates very close to the Medicare fee schedule. While overutilization is one microeconomic cause, the deeper flaws are more macroeconomics – and cannot be easily fixed.
      Fundamentally, there are not enough tax payers to support the recipients (same problem as Social Security). This is due to the following reasons:
      1. Natural demographic shifts
      2. Change in family size
      3. Abortion
      4. Recipient age not indexing with life span

      The President and Congress have an impossible task to do the unpopular to fix this.


      Steve Coplon, MHA, CMPE

    • The following quote in your article “Specialists are responsible for hundreds of billions of dollars of unnecessary care annually and primary care doctors are predicted to be in short supply as more Americans obtain coverage under the new health reform law.” is a gratuitous — and not altogether factually accurate — comment against specialty medicine. The AAMC predicts a shortage of surgeons (41,000) and other specialists (8,000) by the year 2025. This compares to a shortage of 46,000 primary care physicians in this same year. Policymakers need to cease promoting the specialty vs. primary care division, and start acknowleding that the health system and our nation’s patients need BOTH primary care AND specialty care physicians and the payment and delivery systems need to support all physicians.

    • Katie
      It would be instructive to determine where the AAMC obtained their numbers and under what scenarios they envision these shortfalls.

      They have their own nickel in this game, and that is not to say some specialites will be in short supply, the most obvious being: geriatrics, primary care, pain and palliative care, etc.

      However, how would predictions change if:

      1) Imaging was cut back by 10% (less need for radiologists)
      2) Defensive medicine was curtailed and we needed 10% less invasive cardiiology testing (less need for cardiologists)
      3) Hospice care actually made some inroads and less chemo was administered. (less ICU personnel and oncologists)
      4) Assumptions about scope of practice and role of midlevels changed in our system (less primary care docs)

      Anyway, you get the idea. AAMC ratios are based on past and current predictions. Of course, anything can happen, but just because they say it is so, dont make it true.

      On a personal note, I think their numbers are way off, aside from which, we could come close to affording 100K plus new docs unless there were some major finanical workarounds or pay cuts.


    • ….could NOT come close….


    • Steve Coplon- Hi! I am one of those specialists. I look at MGMA numbers pretty regularly. What I see is doc salaries doing pretty well, with specialists, like me, making much more than primary care. That is with all payers mixed in of course, which is actually pretty important to remember. It is medical costs, what we pay per procedure or visit that needs to decrease. Without that, demographics, family size and even abortion do not matter. Private costs are going up just as fast. My group of docs was offered a renewal rate with a 26% increase if they want to keep the same Blue Cross plan.

      Overutilization is not the only cause of our problems, but it is a major one. Docs get defensive about this as it is often seen as an accusation. From my POV, there are medical entrepreneurs who are crooks, but most of this comes from practice style and performance pressures. It is just faster and easier to order the CAT scan kind of thing. My reading of the literature suggests that this is especially true for Medicare patients. This also matches my personal experience and observations.

      I have suggested elsewhere that it would be helpful to have an integrated journal with input from docs, administrators and even the dismal scientists to look at these areas of overutilization on a case by case issue. Say, just back surgery and antibiotics in one issue.