HCR -- Myths and Facts

By John Ballard

Get out the word. Stop the misinformation.

MYTH #1: Reform legislation calls for a 21% cut in Medicare payments to physicians.

FACT: First, the 21% cut has nothing to do with reform legislation. Secondly, it is never going to happen.

Back in 1997 Congress passed legislation which said that if Medicare spending on physicians exceeds a complicated �Sustainable Growth Rate� (SGR) formula in a given year, Medicare fees to all doctors would be trimmed the next year. Since then, Congress actually followed the SGR formula only once. Every other year, it postponed the cuts until the following year�which is why the accumulated postponed cuts now exceed 22%.

The SGR rule was, from the beginning, a crude solution to health-care inflation. ...

The Medicare Payment Advisory Commission (MedPAC) has recommended that the payment schedule be readjusted with an eye to how much benefit the patient derives from the service. MedPAC also suggests targeting particularly lucrative procedures in cases where high fees may encourage overtreatment. For example, fees for certain diagnostic tests are generous enough that some doctors have begun leasing or buying very expensive diagnostic testing equipment for their offices. The equipment can easily cost more than a million. Research shows that these doctors then recommend twice as many tests in order to recoup the capital investment.

Meanwhile, from 2000 to 2006 Medicare spending on diagnostic imaging doubled from $7 billion to $14 billion�without any clear benefit to patients. To the contrary, we know that unneeded tests may expose patients to the dangers of excess radiation-- or the risk of false positives which can lead to unnecessary treatments.

Reform legislation addresses the problem. This year, Medicare will assume that diagnostic testing equipment in a physicians� office is being used 65% of the time �up from 50% of the time. As of January 1, 2013, Medicare will base payments on the assumption that doctors are using the equipment 75% of the time. Since this metric determines how much doctors need to be paid to cover the cost of the equipment, the change will lead to lower reimbursements per test. According to the Congressional Budget Office, Medicare will save $1.9 billion over ten years.

Given lower reimbursements, it is likely that in the future, many fewer doctors will buy or rent the equipment for their offices. This will help rein in health care inflation: if pricey diagnostic equipment is found primarily in hospitals or radiology centers where it is used close to 100% of the time, those who provide the testing service can afford to charge less per test, while still making a reasonable profit.

In contrast to the SGR formula, which would try to save health care dollars by making blind, broad-based cuts, this is an intelligent, targeted change.

Why is the SGR formula still law? For years, Bush administration budgets assumed that Congress would enforce SGR cuts that year; this made the administration�s budget look leaner. But eventually most people in Washington understood that the SGR cuts were merely an accounting fiction. When President Obama took office, he did not include savings from SGR cuts in his initial budget. And he has proposed repealing the SGR law. The House has voted to do this. But a fractured Senate has not yet voted to scrap the SGR formula. Instead, the Senate decided to postpone the 21% cut until October. Meanwhile, House legislators left for vacation without voting on that extension. When Congress returns to work this week you�ll hear more about the SGR. Some commentators may pump up the story to create suspense, drama�and fear. But trust me, the SGR axe won�t fall.

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MYTH #2: Healthcare reform means that doctors will stop taking Medicare patients.

FACT: This assertion is usually linked to the assumption that Medicare is going to slash all doctors� fees by more than 20 percent. (See MYTH # 1). Instead, under the reform legislation Medicare will hike payments to many doctors. The AMA lists the increases:

• 
  10 percent incentive payments for primary care physicians. All physicians in family medicine, general internal medicine, geriatrics and pediatrics whose Medicare charges for office, nursing facility and home visits comprise at least 60 percent of their total Medicare charges will be eligible for a 10 percent bonus payment for these services from 2011�16.


• 10 percent incentive payments for general surgeons performing major surgery in areas where more health professionals are needed. All general surgeons who perform major procedures (with a 10- or 90-day global service period) in a health professional shortage area will be eligible for a 10 percent bonus payment for these services from 2011�16.


• 5 percent incentive payment for mental health services. In 2010, Medicare is boosting payment for psychotherapy services by 5 percent.


• Geographic payment differentials. In 2010 and 2011, Medicare will make a separate adjustment for the practice expense portion of physician payments that will benefit physicians in rural and low cost areas.


• In 2013 and 2014 Medicaid payments to primary care physicians will be lifted to match Medicare rates. Today, Medicaid typically pays doctors 30% less than Medicare for the same service. The federal government is providing 100% of the funding needed for states to meet this requirement.
  

Why don�t we ever hear about the good news for doctors on Fox? Because Fox News is bent on spreading the canard that, thanks to reform, seniors will lose their doctors. The truth is that many physicians will see their incomes rise, beginning next year. Why would they possibly choose to stop taking Medicare patients just when Medicare fees are climbing?

Not only will many physicians profit from increases in Medicare and Medicaid payments, they also will benefit from an influx of formerly uninsured patients who, thanks to government subsidies and new regulations will be able to seek care. Many of these patients will suffer from pre-existing conditions; others will be low-income Americans who may not have seen a doctor for some time.

As I noted in part 1 of this post, for insurers this is bad news. These could be very expensive customers. But under health care reform, health care providers will be the winners. The AMA estimates that physicians provided $24 billion in charity care in 2008, much of it to uninsured patients. Under reform, it�s less likely that doctors will be faced with patients who cannot pay, or who show up too late for effective treatment.

Allen Mondzac, an oncologist at the George Washington University Medical Center is enthusiastic. He recently told the Washington Post that he�s preparing for a "deluge" of new patients, "I hope I'll [be] seeing earlier stages of cancer,� added Mondzac, who specializes in brain tumors and breast cancer. That people will not be afraid to go to the doctor because of the expense and will get symptoms taken care of and looked into early."