RENEE MONTAGNE, host:

Doctors who treat Medicare patients will face a huge pay cut, 21 percent, unless Congress acts by the end of this month. It's the third time this year that doctors, seniors and lawmakers have faced the issue. Just about everyone agrees that such an abrupt change in payments could have a devastating effect.

NPR's Julie Rovner explains.

JULIE ROVNER: What worries people most about the possibility of such a big cut in Medicare payments to doctors is that it will produce more people like Janice Jessup. She's a Medicare beneficiary in Virginia Beach, Virginia. The last time she needed to find a new primary care doctor a couple of years ago, she says she called doctors all over town.

Ms. JANICE JESSUP: Twenty-five, 30, 40, something like that - an awful lot of doctors.

ROVNER: And what did they tell you?

Ms. JESSUP: They weren't taking Medicare patients anymore.

ROVNER: Jessup ended up going to a walk-in clinic, where she got the immediate care she needed.

Ms. JESSUP: But it isn't the full medical attention you need with a primary physician - you know, no lab tests or anything.

ROVNER: From the doctor's point of view, however, it's not hard to see why they're getting more and more reluctant to take on new Medicare patients.

Dr. JOSEPH STUBBS (Immediate Past President, American College of Physicians): We haven't had a raise in seven years.

ROVNER: Joseph Stubbs is immediate past president of the American College of Physicians, which represents more than 100,000 internists. He says, as professionals, doctors feel a strong sense of duty to continue to care for their patients, even when profits erode. But at some point, the balance will tip, he says, including for his own group of nine doctors in Georgia.

Dr. STUBBS: We're having to face, well, if those cuts go into effect, we need to cut personnel. It will cost us, instead of reimburse us, to take care of Medicare beneficiaries.

ROVNER: And Congress has now made matters even worse, Stubbs says, by delaying the cuts not a year at a time, but by only a month or two. That's left physicians wondering what their income might be and what to tell patients. Stubbs calls it chaos.

Dr. STUBBS: What business could deal with not knowing whether your price is going to be up in the next month, or the same, or be cut by 21 percent? It's no way to be able to plan.

ROVNER: So how exactly did we get here? Well, the problem dates back to a law passed by Congress in 1997. John Rother is with the senior group AARP.

Mr. JOHN ROTHER (AARP): Well, I think it's good intentions gone awry. The intent was to limit what we pay doctors to a sustainable growth rate, SGR.

ROVNER: For the first couple of years, the new limits worked pretty well. Doctors actually got fairly generous raises. But then the limits started to bite. In 2002, they started calling for cuts in doctor pay.

Congress let that happen the first year, but then it worried that if the cuts continued, doctors would stop taking Medicare patients. So lawmakers started voting to make the cuts go away, at least temporarily, only there the was a problem: budget rules meant that cancelling the cuts added money to the federal deficit. And the longer the cuts got delayed, the bigger the price tag got.

Mr. ROTHER: Each year, the threatened reduction is so unmanageable that we can't even figure out how to pay for it.

ROVNER: That led Congress shorten the delays from two years to one year, and now to a month or two at a time. But while it's a real emergency for those involved, Rother says the problem hasn't registered much on the national radar.

Mr. ROTHER: So it's really hard to explain and really hard for anyone to understand, who's not in the middle of it.

ROVNER: But those who are in the middle of it, like the American Medical Association, are furious with Congress for letting it get to the point where whether or not doctor pay will be cut is decided on a month-to-month basis. James Rohack is the AMA's president.

Dr. JAMES ROHACK (President, American Medical Association): From a fiscal standpoint, when they say, well, gee, we can't do it because it will add to the deficit, well, the reality is every one of these temporary patches has grown the deficit. They could have fixed this three years ago for less than $50 billion. Now it's over $210 billion. It'll continue to grow if they don't deal with the actual formula.

ROVNER: But the doctor's proposed fix - to repeal the current formula in its entirety - isn't a good solution, either, says Rother of the AARP.

Mr. ROTHER: We don't want to just remove all limits on what doctors can charge. That's a good way to get to bankruptcy.

ROVNER: So the search continues for a new system that would pay doctors on Medicare fairly, but neither too much, nor too little. That search has, so far, been elusive, and Medicare patient Janice Jessup did finally find a primary care doctor late last year, but she doesn't know if he'll continue to see her if this latest round of cuts takes effect.

Ms. JESSUP: I'm afraid to ask. I just bless him for taking me.

(Soundbite of laughter)

ROVNER: The latest delay in the cut expires on May 31st.

Julie Rovner, NPR News, Washington.

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