Medicare Funding Cut Affects Practices And Patients

The House last night passed a measure to prevent a 21-percent cut in Medicare fees paid to doctors, at least for the next 6 months. Dr. Michael Newman, a Washington DC-area physician explains how the yearly threat of cuts affects his practice and patients.

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IRA FLATOW, host:

This is SCIENCE FRIDAY from NPR. I'm Ira Flatow.

Physicians around the country have been threatening to drop Medicare patients because they say they just can't put up with the way the federal government keeps tinkering with Medicare coverage, and this week was a prime example.

The House of Representatives let a bill that would shield doctors from a 21 percent cut in Medicare payments hang in limbo for a week, and when the House came back in session last night, they voted to spare doctors the cut in Medicare funding - for the next six months anyway, sort of a congressional Band-Aid for a wound that continues to fester. And President Obama signed that bill today.

Is this any way to run a health care system? Caught in the middle of all this congressional to and fro, health care providers who say Medicare payments are already too low without the annual threat of cuts, and seniors who well, if they get dropped by their Medicare-paid doctor, they have to go out and look for other doctors who will pick them up, which could be pretty risky if more and more doctors are concerned about these Medicare payments.

Joining me now to talk more about it is Michael A. Newman. He is a physician. He's been practicing general internal medicine in Washington, D.C. for almost 35 years. He even makes house calls. His op-ed on the now-avoided Medicare cuts appears in the Washington Post. It appeared there last week. Welcome to SCIENCE FRIDAY.

Dr. MICHAEL NEWMAN (Physician): Thank you.

FLATOW: How much do physicians depend on Medicare payments?

You know, it depends on what the practice is. If you look at primary care physicians - that would be internist, family practitioners, certainly geriatricians, people that take care of older folks - their practices, anywhere from 45 to up to 75 or 80 percent would be Medicare-based.

FLATOW: That's a pretty good chunk.

Dr. NEWMAN: The other part is that the older the physician, his practice ages, as my practice has aged, so that patients who started with me when they were in their 30s or 40s are now Medicare enrollees. So just by being in practice for a long time, the percentage of patients who are in Medicare increases greatly.

FLATOW: And so - and I have been talking to doctors lately about this - and this week they were livid about this, this gap this time. They were saying: I'm dropping my Medicare patients because I just can't do this anymore.

Dr. NEWMAN: It's bothersome, isn't it, for physicians, for the country to be caught up in this issue. And I think it's just another reflection of Congress being unable to come to grips with making real decision to solve problems.

Certainly the - you know, the fix, the upshot of the fix, which lasts for six months, simply leaves us all a fix because it really doesn't address what the problem is. So doctors and Medicare enrollees ought to be increasingly frustrated that Congress just can't get it straight.

FLATOW: So what is the fix, Doctor? What is the diagnosis and the prognosis here?

Dr. NEWMAN: What is the diagnosis and the prognosis? The diagnosis is that we need a better-organized system, not just for Medicare enrollees but across the board. I think that the health care reform changes the paradigm and gives us an opportunity to do that.

Medicare itself has been constrained. Let me just give you an example. Medicare, if something is demonstrated to be effective, Medicare is to approve it. It doesn't relate to, for example, the appropriateness of the service.

Across the board, probably maybe conservatively, 15 or 20 percent of health care provided is unnecessary or inappropriate, and yet Medicare really can't look at that.

You know, the way to deal with cost, I always thought the most cost-effective approach to medical care is to do what's right and do what's appropriate. And Medicare doesn't really look at that. So now that they come up on a budget problem, they say, well, we'll just whack the doctors. We'll cut them back 20 percent. And that really doesn't solve the problem.

FLATOW: So they say Medicare is paying for wasteful medicine, so we'll just cut back the Medicare coverage.

Dr. NEWMAN: Well, that's right. Rather than looking at the level of care that's provided, how much value there is in each level of care, you know, I mean, physicians, look, we are all citizens. You know, I want to be sure that every dollar spent on health care is a dollar well-spent. And we can't say that today, and I don't think Medicare has any mechanism right now for seeing that that's accomplished.

Hopefully, the - you know, Donald Berwick, if he gets confirmed, which I hope he does, has a lot of good ideas about how to make that happen. But Medicare needs to see that there's more value in the system rather than just having this kind of blunt instrument. And it isn't Medicare, it's Congress.

FLATOW: I think a lot of people out there say to themselves, oh, these doctors, they make so much money anyhow. Why do they need to worry about Medicare?

Dr. NEWMAN: Right. You know, this is not an income bill for doctors. This is reimbursement. You know, I'm a physician. I'm a small businessman. That is, I have a staff, I have overhead, I have expenses. Imagine any small businessman, and someone comes along and says we're going to reduce your revenues by 21 percent.

Imagine if you had a restaurant and someone came in and said, all right, for 65 percent of your patrons, we're going to reduce your revenues by 20 percent. You know, I mean, most medical practices are small businesses, and the 21 percent isn't a matter of income. It's a matter of salaries. It's a matter of jobs. You know....

FLATOW: Well, I think a lot of people think that all these doctors, every physician is making a million bucks every year.

Dr. NEWMAN: Yeah.

FLATOW: And it's not true, is it?

Dr. NEWMAN: That is absolutely I mean, if you look, I mean, listen. Physicians are well-paid. Physicians do have a comfortable income. But if you want I don't know when I went to medical school, I didn't see anybody that wanted to be a physician because they wanted to make a lot of money.

I mean, if you wanted to make money, there are a lot of other places to go to, starting with Wall Street or be a lawyer or so forth. Physicians are go into medicine because they want to be involved in the care of patients.

Now, over time, for sure, we all know there are instance of physicians that change that. But basically, you know, I mean, I don't think physicians are making a ton of money. If you look at average income for primary care physicians, probably their income can range from, depending on the region of the country, somewhere from 135,000 to 225,000.

You know, I mean that's very comfortable, particularly in these economic times, but considering the years of education, the fact that they don't start their earning potential until their mid-30s, you know, I mean, it the issue of Medicare reimbursement is not an issue of physician income. It's an issue of supporting physicians' small businesses.

FLATOW: Do you think we're going to continually see these six-month reprieves? This Band-Aid, as I called it, is only good for another six months, right?

Dr. NEWMAN: You know, as a physician, it's tough to make a prognosis, particularly when you're looking at Congress. Are you good at making prognoses about our current Congress and how they're behaving, particularly...

FLATOW: You got me on that one.

(Soundbite of laughter)

Dr. NEWMAN: So but by God, the administration has been pressing to try and get this straight, and the president, you know, clearly called for said we're not going to do this on the backs of physicians and patients. Let's have a definitive solution.

FLATOW: And you write in your editorial in the Post: If Congress does not address this issue, the much-heralded health care reform is at risk.

Dr. NEWMAN: Well, I think it is in some respects. But this is a terrific opportunity. Health care reform is historic. It changes the paradigm. But we do need physicians to participate in this, and if physicians are subject to uncertainty or threats of what their reimbursement's going to be, physicians are not going to be participating. Physicians may start to retire earlier.

I mean, these are the kinds of problems, instead of giving physicians incentives to go forward, reform their practices, restructure the delivery system, you know, it just isn't going to go well unless we get it off on a solid foundation, and that includes appropriate levels of reimbursement.

FLATOW: And you're hoping that Donald Berwick, the doctor who President Obama has nominated to be head of all the Medicare stuff there, you're hoping he takes this on as a project?

Dr. NEWMAN: Yeah, because, I mean, his background has been to look at the delivery system, look at the care that's provided and show how we can provide care that's more appropriate, a better value, you know, and everybody benefit.

You know, and you know, there are different ways in which we can get more value out of the system without having to necessarily reduce payments to physicians.

I think of payments I think, rather, some physicians' incomes are going to go down, and they should. You know, I mean, between spending and hour with a patient to do a complete history and physical and go over all their problems and coordinate their care and be reimbursed for that versus spending 30 minutes and doing a procedure or a nuclear stress test and getting $3,500, I mean, there's a huge difference there.

So we need to start looking at those procedures, what they're done, how appropriate they are, those kinds of things. And I think Berwick and others like the Dartmouth Group have been looking at that, and that's what we need to pay attention to.

FLATOW: So you could pay doctors more to spend more quality time with them.

Dr. NEWMAN: More quality time.

FLATOW: Instead of just these costly procedures that Medicare will reimburse and give them a lot of money.

Dr. NEWMAN: You know, I've never been in the Medicare building. I have no idea. I am impressed with the professionalism of some of the people. But I imagine they're under pressure to say cut the budget here, one percent here, three percent there, whatever it is, I don't quite know. And so they look for opportunities to cut.

I just got something our insurance person today explained that we recently got a notice from Medicare that if a patient who has a earwax problem, Medicare will reimburse $5.

FLATOW: Five bucks.

Dr. NEWMAN: Five bucks.

FLATOW: All right. That says it right there. We've run out of time, Doctor. Thank you for taking time to be with us.

Dr. NEWMAN: Take care, bye-bye.

FLATOW: You're welcome. Michael Newman, a physician, has been in practice in Washington for almost 35 years. We're going to stay on medicine, when we come back, this time talk about medical marijuana, controversial. So stay with us. We'll get your opinions after this break.

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