In his book The Problem of Pain, C.S. Lewis observes that whatever we think of pain, it nonethelss serves humanity in one useful way: It forces us to act. Without pain, we humans have a natural inclination to sit back and let evil creep over us. Often, only suffering shakes us from our drowsy malaise and spurs us into action.
Lately there have been hints that we medical people are about to be shouted at. In newsletters, magazines, and emails of late I have been hearing an increasingly frantic message. The federal government is about to cut Medicare physician's payments by 9.9%.
For years, Medicare has used a complex formula to calculate physician reimbursement. The formula bases reimbursement on how doctors as a group utilize medical services, and it was intended as a carrot-and-stick mechanism to keep physicians from running up health care costs. The idea was that if doctors spent increasing amounts of money on diagnostic tests, reimbursements would go down. If they spent less money on tests, reimbursements would go up, or at least stay the same.
This formula, whatever good intentions it may have engendered, has been a dismal failure. Every year since 2001 the formula has mandated a salary cut for doctors. And every year, to correct the cut, American doctors, and particularly the AMA, have successfully lobbied Congress to override the formula and restore the cuts. This year, however, could be a different story because 10% is the largest the cut has ever been. Congress is struggling to find money to finance a certain foreign military action the White House feels is more important than the health of elderly Americans. When all the military contractors are paid, there may not be enough borrowed money left lying around to make up the ten percent. There is a chance that the cut, or at least a good part of it, will go through. Making the situation even worse, the formula projects further budget cuts each year through 2015. If all of these cuts go through, Medicare could be paying doctors 40% less by then.
Everyone agrees that health care costs in the U.S. need to be controlled. But that is no excuse for allowing a formula to passively run U.S. health policy. Medicine is not a static field that can be circumscribed with mindless rules. Medicine constantly changes, and allowances have to made for new practice guidelines and treatments. You can't just plug X, Y, and Z into an equation and expect to find the answer to spiraling health costs. Not unless you want to be stuck with the medical technology we had in 2001 forever.
A 9.9% fee cut will make a significant impact in the medical community. Medicare is the largest insurance carrier in America, and most doctors depend on it for a significant percentage of their income. There are very few businesses that could endure a 10% cut in income without making significant compromises in the quality and type of services they offer. Doctors, however, are in a particularly difficult position -- despite the cuts, they will be expected to provide the same level of care as before. The ethics of medicine do not allow physicians to lower their standards, regardless of the size of the check in the mail. But without a major technological advance, it is unclear how doctors could (or would want to) deliver the same care for 10% less. How would you feel if your boss called you in to his office at work and told you (1) you will be paid 10% less and (2) you will be disciplined if your quality of work drops off? And that your salary will be cut again each year for the next 7 years, but by the way, don't you dare think about slacking off after those cuts either?
The AMA's position is that the 9.9% cut will severely harm health care in the U.S. There are a few naysayers who think the AMA is only whining, but I don't think so. I have listened to a lot of doctors complain about insurance reimbursement for a lot of years, and I think we are reaching the point of no return. If this cut sticks, this baby's gonna blow.
Here is what could happen. There are a number of doctors in their 60s and early 70s, nearing retirement, who will look at the cut and decide to hang it up. This group has already made its money in medicine and will decide that the aggravation of a significant pay cut is not worth the trouble. Another group of slightly younger but well-established doctors will decide that it has enough Medicare patients and will not accept any more. Others will cut loose the Medicare patients they already have. An AMA survey suggests that 45% of doctors will cut the number of Medicare patients they see if the cut goes through. Though some critics call this a bluff, I think the numbers could eventually be worse than that.
When doctors who do not need new Medicare patients start refusing them, a large pool of patients looking for doctors will form. At first, younger doctors building their practices will soak these patients up, but eventually they too will have their fill. They will start refusing Medicare patients too. In the end there will be a considerable number of Medicare patients who cannot find a doctor. And why I think this will happen? Because that is what has happened with Medicaid patients as Medicaid reimbursement was pared to nothing. Nationwide, only 25% of doctors will see Medicaid patients. Most doctors get tired of seeing patients with multiple medical problems that suck up time and pay very poorly. What has happened to Medicaid could very easily happen to Medicare.
Then the pain really starts. Angry voters show up in Washington, or at their local representative's office. They bring torches and pitchforks, and threaten to burn the place down if something is not done. Hopefully, and this is wishful thinking on my part, leaders will seizes the opportunity not simply to reinstate the cuts but to fix the problem permanently.
But we can't stop there. The AMA, in its sniveling ways, is likely to try to fix Medicare only, instead of using the momentum of the moment to fix everything at once. This is where we have to hope that enough doctors and hospitals and patients are hurt enough that they will not settle for that. That they will say, "No, this is not going to happen ever again. We want the whole system reformed, not just Medicare, and if you don't do what we say a lot of politicians will feel our pain."
I have been burning candles and wearing out rosaries in the hopes that the cut sticks, and that doctors revolt. I hate to pray for pain, but in this country we are like C.S. Lewis's gluttons, are fat and happy, and not caring what we are eating. The only way out of this is if there is enough suffering all around that the suffers refuse to be satisfied with the usual bone thrown their way.
The sooner we get on with this pain the better off we are going to be. If we keep patching our sinking system instead of rebuilding, very soon our entire ship will be nothing but patches.
Medicare is a very good place for this reconstruction talk to begin. Medicare alone covers 14% of the population according to 2004 numbers, and together with Medicaid covers 27%. This is by far the single largest group of insured individuals. Collectively private insurance covers 59%, but this is a piecemeal group comprised of hundreds of carriers. Medicare alone accounts for about 15% of all healthcare expenditures ($330 billion in 2006), Medicaid roughly 14% ($305 billion). When the millions of government employees who are on private insurance plans paid for by the government are added in, it is plain that the government has controlling influence over the U.S. health care sector, even without meaning to.
Patients who have private insurance may think they will not be affected by this fight, but they are mistaken. Doctors and hospitals routinely determine the services they will offer based on perceived profit margins. We might see fewer hospitals offering knee replacement surgeries or cardiac bypass operations because it is no longer profitable. Many home health companies could close, and inpatient rehab units could dwindle in number. One hospital I worked at lost two neurosurgeons in one year and had to stop offering neurosurgery services because there were too many Medicaid and uninsured patients in the payor mix. The surgeons got sick of not being paid and walked away. Add Medicare to the list of hated carriers and you may see your own doctor leave town if too many of your neighbors are retirees.
Healthcare reform in the U.S. has proceeded at an astonishingly sluggish pace, considering the stakes. I am now convinced that nothing is going to change until there is a serious breakdown that results in true human suffering. My only hope is that this breakdown is a flat tire and not a gasoline truck going over the bridge rail. That is why I hope the 10% cut sticks, and enough people lose their tempers that we can have this thing out once and for all, right now. Let's all get together and pray that she does blow, and blows very soon.
Pain is not only immediately recognizable evil, but evil impossible to ignore. We can rest contentedly in our sins and in our stupidities; and anyone who has watched gluttons shovelling down the most exquisite foods as if they did not know what they were eating, will admit that we can ignore even pleasure. But pain insists on being attended to. God whispers to us in our pleasures, speaks in our conscience, but shouts in our pain.
Lately there have been hints that we medical people are about to be shouted at. In newsletters, magazines, and emails of late I have been hearing an increasingly frantic message. The federal government is about to cut Medicare physician's payments by 9.9%.
For years, Medicare has used a complex formula to calculate physician reimbursement. The formula bases reimbursement on how doctors as a group utilize medical services, and it was intended as a carrot-and-stick mechanism to keep physicians from running up health care costs. The idea was that if doctors spent increasing amounts of money on diagnostic tests, reimbursements would go down. If they spent less money on tests, reimbursements would go up, or at least stay the same.
This formula, whatever good intentions it may have engendered, has been a dismal failure. Every year since 2001 the formula has mandated a salary cut for doctors. And every year, to correct the cut, American doctors, and particularly the AMA, have successfully lobbied Congress to override the formula and restore the cuts. This year, however, could be a different story because 10% is the largest the cut has ever been. Congress is struggling to find money to finance a certain foreign military action the White House feels is more important than the health of elderly Americans. When all the military contractors are paid, there may not be enough borrowed money left lying around to make up the ten percent. There is a chance that the cut, or at least a good part of it, will go through. Making the situation even worse, the formula projects further budget cuts each year through 2015. If all of these cuts go through, Medicare could be paying doctors 40% less by then.
Everyone agrees that health care costs in the U.S. need to be controlled. But that is no excuse for allowing a formula to passively run U.S. health policy. Medicine is not a static field that can be circumscribed with mindless rules. Medicine constantly changes, and allowances have to made for new practice guidelines and treatments. You can't just plug X, Y, and Z into an equation and expect to find the answer to spiraling health costs. Not unless you want to be stuck with the medical technology we had in 2001 forever.
A 9.9% fee cut will make a significant impact in the medical community. Medicare is the largest insurance carrier in America, and most doctors depend on it for a significant percentage of their income. There are very few businesses that could endure a 10% cut in income without making significant compromises in the quality and type of services they offer. Doctors, however, are in a particularly difficult position -- despite the cuts, they will be expected to provide the same level of care as before. The ethics of medicine do not allow physicians to lower their standards, regardless of the size of the check in the mail. But without a major technological advance, it is unclear how doctors could (or would want to) deliver the same care for 10% less. How would you feel if your boss called you in to his office at work and told you (1) you will be paid 10% less and (2) you will be disciplined if your quality of work drops off? And that your salary will be cut again each year for the next 7 years, but by the way, don't you dare think about slacking off after those cuts either?
The AMA's position is that the 9.9% cut will severely harm health care in the U.S. There are a few naysayers who think the AMA is only whining, but I don't think so. I have listened to a lot of doctors complain about insurance reimbursement for a lot of years, and I think we are reaching the point of no return. If this cut sticks, this baby's gonna blow.
Here is what could happen. There are a number of doctors in their 60s and early 70s, nearing retirement, who will look at the cut and decide to hang it up. This group has already made its money in medicine and will decide that the aggravation of a significant pay cut is not worth the trouble. Another group of slightly younger but well-established doctors will decide that it has enough Medicare patients and will not accept any more. Others will cut loose the Medicare patients they already have. An AMA survey suggests that 45% of doctors will cut the number of Medicare patients they see if the cut goes through. Though some critics call this a bluff, I think the numbers could eventually be worse than that.
When doctors who do not need new Medicare patients start refusing them, a large pool of patients looking for doctors will form. At first, younger doctors building their practices will soak these patients up, but eventually they too will have their fill. They will start refusing Medicare patients too. In the end there will be a considerable number of Medicare patients who cannot find a doctor. And why I think this will happen? Because that is what has happened with Medicaid patients as Medicaid reimbursement was pared to nothing. Nationwide, only 25% of doctors will see Medicaid patients. Most doctors get tired of seeing patients with multiple medical problems that suck up time and pay very poorly. What has happened to Medicaid could very easily happen to Medicare.
Then the pain really starts. Angry voters show up in Washington, or at their local representative's office. They bring torches and pitchforks, and threaten to burn the place down if something is not done. Hopefully, and this is wishful thinking on my part, leaders will seizes the opportunity not simply to reinstate the cuts but to fix the problem permanently.
But we can't stop there. The AMA, in its sniveling ways, is likely to try to fix Medicare only, instead of using the momentum of the moment to fix everything at once. This is where we have to hope that enough doctors and hospitals and patients are hurt enough that they will not settle for that. That they will say, "No, this is not going to happen ever again. We want the whole system reformed, not just Medicare, and if you don't do what we say a lot of politicians will feel our pain."
I have been burning candles and wearing out rosaries in the hopes that the cut sticks, and that doctors revolt. I hate to pray for pain, but in this country we are like C.S. Lewis's gluttons, are fat and happy, and not caring what we are eating. The only way out of this is if there is enough suffering all around that the suffers refuse to be satisfied with the usual bone thrown their way.
The sooner we get on with this pain the better off we are going to be. If we keep patching our sinking system instead of rebuilding, very soon our entire ship will be nothing but patches.
Medicare is a very good place for this reconstruction talk to begin. Medicare alone covers 14% of the population according to 2004 numbers, and together with Medicaid covers 27%. This is by far the single largest group of insured individuals. Collectively private insurance covers 59%, but this is a piecemeal group comprised of hundreds of carriers. Medicare alone accounts for about 15% of all healthcare expenditures ($330 billion in 2006), Medicaid roughly 14% ($305 billion). When the millions of government employees who are on private insurance plans paid for by the government are added in, it is plain that the government has controlling influence over the U.S. health care sector, even without meaning to.
Patients who have private insurance may think they will not be affected by this fight, but they are mistaken. Doctors and hospitals routinely determine the services they will offer based on perceived profit margins. We might see fewer hospitals offering knee replacement surgeries or cardiac bypass operations because it is no longer profitable. Many home health companies could close, and inpatient rehab units could dwindle in number. One hospital I worked at lost two neurosurgeons in one year and had to stop offering neurosurgery services because there were too many Medicaid and uninsured patients in the payor mix. The surgeons got sick of not being paid and walked away. Add Medicare to the list of hated carriers and you may see your own doctor leave town if too many of your neighbors are retirees.
Healthcare reform in the U.S. has proceeded at an astonishingly sluggish pace, considering the stakes. I am now convinced that nothing is going to change until there is a serious breakdown that results in true human suffering. My only hope is that this breakdown is a flat tire and not a gasoline truck going over the bridge rail. That is why I hope the 10% cut sticks, and enough people lose their tempers that we can have this thing out once and for all, right now. Let's all get together and pray that she does blow, and blows very soon.