THE END OF MEDICARE? YOU BET AND THIS IS JUST THE START OF THE LACK OF PRIMARY CARE AND SPECIALIST DOCTORS WHO WILL NOT ACCEPT PATIENTS

There are always consequences to every act, and when doctors are told that the amount that they get paid to treat a medicare patient will be cut another 20% of so for 2010, they stop accepting medicare covered patients.

Imagine that your employer told you that this year your salary will be cut 20%, and that these cuts are on top of prior year cuts, and that they will likely continue each year!

Well that is the Medicare program, and how it pays your doctor. If you have a special condition, and its diagnosis and treatment may require a "specialist" you may be totally out of luck, since the additional specialized treatments and the added medical training that it took to be able to provide it do not provide any incentive for that specialist to work for fees that often do not cover even basic time expended with the patient.

Doctors are opting out of Medicare at alarming rates, frustrated by reimbursement cuts they say make participation in government-funded care of seniors unaffordable.

Two years after a Texas survey found nearly half of Texas doctors weren't taking some new Medicare patients, new data shows 100 to 200 a year are now ending all involvement with the program. Before 2007, the number of doctors opting out averaged less than a handful a year.

“This new data shows the Medicare system is beginning to implode,” said Dr. Susan Bailey, president of the Texas Medical Association. “If Congress doesn't fix Medicare soon, there will be more and more doctors dropping out and Congress' promise to provide medical care to seniors will be broken.”

More than 300 doctors have dropped the program in the last two years, including 50 in the first three months of 2010, according to data compiled by the Houston Chronicle. Texas Medical Association officials, who conducted the 2008 survey, said the numbers far exceeded their assumptions.

The largest number of doctors opting out comes from primary care, a field already short of practitioners nationally and especially in Texas. Psychiatrists also make up a large share of the pie, causing one Texas leader to say, “God forbid that a senior has dementia.”

The opt-outs follow years of declining Medicare reimbursement that culminated in a looming 21 percent cut in 2010. Congress has voted three times to postpone the cut, which was originally to take effect Jan. 1. It is now set to take effect June 1.
Not cost-effective

The uncertainty proved too much for Dr. Guy Culpepper, a Dallas-area family practice doctor who says he wrestled with his decision for years before opting out in March. It was, he said, the only way “he could stop getting bullied and take control of his practice.”

“You do Medicare for God and country because you lose money on it,” said Culpepper, a graduate of the University of Texas Medical School at Houston. “The only way to provide cost-effective care is outside the Medicare system, a system without constant paperwork and headaches and inadequate reimbursement.”

Ending Medicare participation is just one consequence of the system's funding problems. In a new Texas Medical Association survey, opting out was one of the least common options doctors have taken or are planning as a result of declining Medicare funding — behind increasing fees, reducing staff wages and benefits, reducing charity care and not accepting new Medicare patients.

In 2008, 42 percent of Texas doctors participating in the survey said they were no longer accepting all new Medicare patients. Among primary-care doctors, the percentage was 62 percent.

The impact on doctors has not been lost on their patients. Kathy Sweeney, a Houston retiree, twice has been turned away by specialists because they weren't accepting new Medicare patients. She worries her doctors might have to drop her if Medicare cuts go through and they can't afford to continue in the program.

“I've talked to them about the possibility,” said Sweeney, who sent her legislators a letter calling on them to fix Medicare. “They're hanging in there as long as there's not a severe cut, but just thinking I couldn't continue doctor-patient relationships I built up over years is disturbing. Seniors should be able to see the doctors they want.”

The problem dates back to 1997, when Congress passed a balanced budget law that included a Medicare payment formula aimed at reining in spending. The formula, which assumed low growth rates, called for payment cuts if spending exceeded goals, a scenario that occurred year after year as health care costs grew. The scheduled cuts, expected to be modest, turned out to be large.

Congress would overturn the cuts, but their short-term fixes didn't keep up with inflation. The Texas Medical Association says the cumulative effect since 2001 already amounts to an inflation-adjusted cut of 20.9 percent. In 2001, doctors receiving a $1,000 Medicare payment made roughly $410, after taking out operating expenses. In 2010, they'll net $290. If the scheduled 21.2 percent cut goes through, they'd net $72, effectively an 83 percent cut since 2001.

The issue caused the Texas Medical Association to break ranks with the American Medical Association and oppose health care reform efforts throughout 2009. Then TMA President Dr. William Fleming said “reform is doomed to failure” without Medicare reform and called Congress' failure to devise a rational payment plan “an insult to seniors, people with disabilities and military families.”
No surprise to senator

U.S. Sen. John Cornyn, R-Texas, said he isn't surprised by the new opt-out numbers, allowing that Congress' inability to reform Medicare is leaving “seniors without access and breaking the promise we made to them.”

“The problem has been how to eliminate the cuts without running up the deficit,” said Cornyn, responding to blame U.S. Rep. Gene Green, D-Houston, placed on the Senate for not passing a House bill that would have provided a longer-term Medicare fix. “There hasn't been the political will, but we really have no choice but to fix it.”

Cornyn acknowledged the task is daunting. The Congressional Budget Office recently estimated that eliminating scheduled Medicare payment cuts through 2020 would cost $276 billion.

The growth in Texas Medicare opt-outs began in earnest in 2007, when 70 doctors notified Trailblazer Health Enterprises, the state's Medicare carrier, they would no longer participate, up from seven in 2006. The numbers jumped to 151 in 2008, fell back to 135 in 2009 and are on pace for 200 in 2010. From 1998 to 2002, by contrast, no more than three a year opted out.

Now, according to a Texas Medical Association new poll, more than four in 10 doctors are considering the move.

“I've been in practice 24 years, and a lot of my patients got old right along with me,” Culpepper said. “It's stressful to tell them you're leaving Medicare and they're responsible for payments if they want to stay with you. You feel like you're abandoning them.”

That is just the start to the destruction of the American medical system that was able to provide some of the best care, the best drugs to prolong life without the misery that accompanies long term pain associated with many conditions related to old age.

Furthermore, emergency rooms will be overwhelmed with every type of patient insured and uninsured. The mandate to have to provide care is killing hospitals as they in effect are forced to provide care to those showing up.

The new health care law will pack 32 million newly insured people into emergency rooms already crammed beyond capacity, according to experts on health care facilities.

A chief aim of the new health care law was to take the pressure off emergency rooms by mandating that people either have insurance coverage. The idea was that if people have insurance, they will go to a doctor rather than putting off care until they faced an emergency.

People who build hospitals, however, say newly insured people will still go to emergency rooms for primary care because they don’t have a doctor.

“Everybody expected that one of the initial impacts of reform would be less pressure on emergency departments; it’s going to be exactly the opposite over the next four to eight years,” said Rich Dallam, a healthcare partner at the architectural firm NBBJ, which designs healthcare facilities.

“We don’t have the primary care infrastructure in place in America to cover the need. Our clients are looking at and preparing for more emergency department volume, not less,” he said.

Some Democrats agree with this assessment.

Rep. Jim McDermott (D-Wash.) suspects the fallout that occurred in Massachusetts’ emergency rooms could happen nationwide after health reform kicks in.

Massachusetts in 2006 created near-universal coverage for residents, which was supposed to ease the traffic in hospital emergency rooms.

But a recent poll by the American College of Emergency Physicians found that nearly two-thirds of the state’s residents say emergency department wait times have either increased or remained the same.

A February 2010 report by The Council of State Governments found that wait times had not abated since the law took effect.

“That is not an unrealistic question about what’s going to happen in the next four years as you bring all these people on; who are they going to see?” McDermott said.

The Washington congressman tried to include a provision in the health care bill he thought would increase the number of doctors.

McDermott’s legislation would have required the government to pay for students’ medical education in return for students serving four years as a primary care physician. The measure did not make it on the final bill that eventually became law.

McDermott stressed that creating a “whole new cadre of doctors” needs to begin now to meet the rising need from patients in the future.

While the measure wouldn’t prevent the infrastructure crunch, it would have provided new doctors for people seeking care.

Richard Foster, Chief Actuary at the Centers for Medicare and Medicaid Services, told The Hill that the current dearth of primary care physicians could lead to greater stress on hospital emergency rooms.

“The supply of doctors can’t be increased very quickly – there’s a time lag,” he said, adding, “Is the last resort to newly covered people the emergency room? I would say that is a possibility, but I wouldn’t say anybody has a very good handle on exactly how much of an infrastructure problem there will be or exactly how it might work out.”

The Academy of Architecture for Health predicts hospitals will need at least $2 trillion over the next 20 years to meet the coming demand.

“As more people have access, you have to deal with the increased capacity,” said Andrew Goldberg, senior director of federal relations at the American Institute of Architects. “At the moment there is not a lot of building going on because of the economy and a lot of health care facilities can’t get the financing. We’ve been working on the Hill to try to address that issue.”

The group has called on Congress to beef-up bonding authorities and expand energy efficient tax breaks for professional buildings. The vehicle targeted is the green energy legislation making its way through the House Ways and Means Committee and Senate Finance.

Dan Noble, a principal at the Dallas-based architecture firm HKS Inc., which also specializes in designing health care facilities, believes the only remedy to meet the coming demand on hospitals is to start projects immediately.

“We would have to get very busy soon,” he said. “It would take a fairly aggressive building campaign for the next decade.”

Of sure..dream on.