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This is MORNING EDITION from NPR news. I'm Rene Montagne.

Congress is scheduled to leave at the end of this week, but a big item remaining on lawmakers to-do list is deciding whether to cancel a scheduled cut in Medicare payments to doctors, and if they do, whether to pay doctors different amounts based on how well they do their jobs.

NPR's Julie Rovner has more.

JULIE ROVNER: If Congress doesn't act, Medicare payments to doctors will drop by 5.1 percent starting next January 1st. The cut isn't intentional. It's the product of a funding formula originally implemented in the 1990s, says Paul Ginsburg, president of the Center for Studying Health System Change.

Mr. PAUL GINSBURG (Center for Studying Health System Change): It's a policy that nobody really wanted to happen, but they don't want to face the consequences of doing something about it.

ROVNER: Those consequences being that eliminating the cut will potentially add tens of billions of dollars to the federal deficit. And because Medicare premiums are linked to what Medicare pays doctors, any increase in doctor payments will come in part from patients' own pockets.

On the other hand, if lawmakers don't cancel the cut, doctors have threatened to stop seeing Medicare patients. And because Medicare is such a big part of most doctors' incomes, they say it will affect non-Medicare patients as well. Steve Nissen is president of the American College of Cardiology.

Dr. STEVE NISSEN (American College of Cardiology): We have a crisis. You know, rural and inner city communities don't have cardiologists. And if we don't fix this problem, I think our health care is going to seriously deteriorate.

ROVNER: Doctors say the fact that Medicare payments haven't kept up with medical inflation is keeping medical students from pursuing specialties that take a long time to train for.

For example, nearly a third of training positions in cardiothoracic surgery have gone unfilled for the past several years. Frederick Grover, president of the Society for Thoracic Surgery, says that's in no small part due to declining Medicare payments.

FREDERICK GROVER (Society for Thoracic Surgery): It's massive, which really has to impact young people when they look into long training, debt already on board, and pretty hard work.

ROVNER: But if Congress is going to give doctors more money, lawmakers want something in return: better quality care. Specifically, says Montana Democratic Senator Max Baucus, Congress wants to give increases only to doctors who agree to provide data on the actual care they provide.

Senator MAX BAUCUS (Democrat, Montana): And it's important, generally, to encourage quality by linking compensation to quality; that is to say, docs who report certain quality measures to show that they're giving even better quality care get a little additional compensation.

ROVNER: Doctors, however, have resisted most of the proposals offered by lawmakers so far. Cardiologist Steve Nissen says it's not that doctor's object to getting paid based on quality…

Dr. NISSEN: We are absolutely in favor of pay for performance, which is the term that's used for this idea of reimbursement in exchange for quality. We think it's a great idea.

ROVNER: Rather, Nissen says, it's that most of the proposals offered so far are based on Medicare claims data. And he says that could lead to problems. Take, for example, a patient who goes to a local hospital with a heart attack. That hospital tests the patient's cholesterol, decides he needs more advanced care, and sends him onto another facility.

Mr. NISSEN: And along with them comes their record. And we look at it and we see their cholesterol has been checked. We don't want to repeat the test. That's not cost-effective. So we don't repeat it. When that claim then goes to Medicare, they say, ah, you didn't measure the cholesterol. And you get dinged.

ROVNER: Doctors also have another problem compared to other health providers like hospitals or nursing homes, says health researcher Paul Ginsburg.

Mr. GINSBURG: The fact that they're dealing with fewer patients and it's always the issue of my patients are sicker than other physicians' patients and I'm going to look bad because of that.

ROVNER: But Congress is far from having to address that problem. So far, it's just looking at some basic reporting requirements. But even those are encountering resistance from physician groups, leaving open to possibility that the issue could linger on after the election or even into next year.

Julie Rovner, NPR News, Washington.

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