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Stethescope on top of pile of money
In the theory of just getting all the end-of-the-year stuff off of the table in whatever way possible, the White House has included a permanent fix for the perennial problem of Medicare reimbursement rates for physicians, the "doc fix" that plagues Congress and doctors and Medicare beneficiaries every December.

The problem is the "sustainable growth rate" formula Congress passed for Medicare years ago. It was too stingy to be practicable, so every year Congress has to vote to override it and come up with enough money to make the reimbursements adequate. Which it always does, though in recent years it's become just one of many handy hostages for Republicans to take. Not passing the "doc fix" is a big problem because a powerful lobby—physicians—get very exercised and because they have a potent way of fighting back, threatening to stop taking Medicare patients.

According to administration sources, President Obama has included a permanent repeal of the sustainable growth rate in his offer to Boehner on the fiscal cliff, a proposal that has a $245 billion price tag. It adds a few more headaches if it's repealed, because it'll have to be replaced with something.

If the White House does indeed succeed in eliminating the sustainable growth rate, it would presumably need to find $244 billion to pay for the provision. It would also need to settle on a new formula to calculate what Medicare ought to pay doctors for each surgery they perform and medication they prescribe.

MedPac, a non-partisan body that advises Congress on Medicare policy, has its own preferred option. It has recommended that if Congress repeals the sustainable growth rate, it should continue to hold primary care doctor payments steady. At the same time, specialty doctors would see a haircut in their services for three years, and then see their rates freeze as well.

That's a good solution for primary care docs, but the specialists will raise hell about it. But at some point, if real health care savings are going to be realized in this country, physicians are going to have to make some sacrifices, too. Putting that sacrifice mostly on primary doctors, who provide the majority of care, would be backwards. That's why a permanent repeal makes sense, but it might be too complex to try to shoehorn, along with everything else, into some grand ridiculous bargain.

Originally posted to Joan McCarter on Tue Dec 18, 2012 at 12:10 PM PST.

Also republished by Daily Kos.

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Comment Preferences

  •  Tip Jar (21+ / 0-)

    "There’s class warfare, all right, but it’s my class, the rich class, that’s making war, and we’re winning." —Warren Buffett

    by Joan McCarter on Tue Dec 18, 2012 at 12:10:55 PM PST

  •  There's also a shortage (6+ / 0-)
    Recommended by:
    MillieNeon, AlexThorne, willyr, Ottoe, FG, blueoasis

    and an even greater projected shortage of primary care docs in medically underserved areas (those are areas with very high rates of Medicare/caid patients), so making them bear the heaviest burden is very much counterproductive to one of the strategic goals of the ACA.

    Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

    by a gilas girl on Tue Dec 18, 2012 at 12:26:18 PM PST

    •  There is a shortage of physicians who will take (2+ / 0-)
      Recommended by:
      coffeetalk, a gilas girl

      new Medicare patients in my area which is very well served. My primary care physician stopped taking new Medicare patients five years ago and the trend has rapidly accelerated. Physicians who will take Medicaid (Medical here) are impossible to find. I often wonder what physicians will be treating the millions of new Medicaid patents who will have access through the ACA?

      "let's talk about that"

      by VClib on Tue Dec 18, 2012 at 12:47:13 PM PST

      [ Parent ]

    •  My daughter is a specialist and her group has (1+ / 0-)
      Recommended by:
      ferg

      already agreed to take on more Medicare patients. Many other practices are gearing up for this as well. The real issue, she says, will be the lack of primary care doctors and the need to train more physician assistants and nurse practitioners who can fill the breech.

      For Christina's America

      by DWKING on Wed Dec 19, 2012 at 06:10:04 PM PST

      [ Parent ]

  •  If an Idea Is Backward It Becomes the Centerpiece. (0+ / 0-)

    Well I should say "upside-down." 1% vs 99%.

    We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

    by Gooserock on Tue Dec 18, 2012 at 12:45:09 PM PST

  •  This needs a long-term fix for so many reasons (0+ / 0-)

    Not the least of which because it lets politicians of all stripes be dishonest about the long-term projected cost of Medicare.  They can all show long-term projected costs being not so bad under the sustainable growth rate limits when they know there's not a chance in hell that those sustainable growth rate limits will hold.   In other words, they KNOW the numbers are dishonest because they know that they will do a "doc fix."  

    We need an honest way of accounting for what providers will be paid so that we have an honest accounting of what Medicare will cost over the next decade. Then, and only then, can we talk about how to fund it.  

    •  The AMT patch is another stupid artifact (2+ / 0-)
      Recommended by:
      cnt zro, MPociask

      Seriously we need to stop making laws that assume things about future growth rates.

      The laws need to be tied to measured growth rates in prior years...ie base the increase the next year on the observed growth in the prior year.

      And if you do that, tie the funding AND the payout to the same damn rate (so we don't get stuff like the SS payroll cap getting out of sync with the COLA increase)

    •  I agree with you on this (2+ / 0-)
      Recommended by:
      zaka1, MPociask

      The current method using the "doc fix" is ridiculous.  So is trying to resolve the problem in "fiscal cliff" negotiations during a Lame Duck session of Congress.

      Obviously, no one is putting a great deal of thought or planning into this new "fix".  Its just another band-aid that will need fixing later.  This is how we get the highest health care costs per capita in the developed world and the lowest quality of health care.

      Our government does not function properly these days.  Its ridiculous.

      Democratic Leaders must be very clear they stand with the working class of our country. Democrats must hold the line in demanding that deficit reduction is done fairly -- not on the backs of the elderly, the sick, children and the poor.

      by Betty Pinson on Wed Dec 19, 2012 at 06:05:26 PM PST

      [ Parent ]

      •  This (0+ / 0-)

        When "Obamacare" spent MONTHS being negotiated, people said it was "rammed through."  Now they want to make a change to health care that runs into the hundreds of billions of dollars in the last two weeks of the year when everyone is focused on the holidays, and oh yeah, we've had elections to replace many of these jokers?

        What a country.

  •  If you received government-back loans, you take (1+ / 0-)
    Recommended by:
    blueoasis

    ...Medicare patients,to some extent, period. It should be a condition of licensure.

    It probably is just a matter of time before we start importing more physicians as well. We live in a time where downward pressure on wages is the new norm. Besides, there is a limit to what even most non Medicare patients can pay as well. If everyone is broke, soon everyone will be broke.

    "There is nothing more dreadful than the habit of doubt. Doubt separates people. It is a poison that disintegrates friendships and breaks up pleasant relations. It is a thorn that irritates and hurts; it is a sword that kills.".. Buddha

    by sebastianguy99 on Tue Dec 18, 2012 at 12:59:38 PM PST

  •  'Specialists' my a**. I was a Primary Care.. (1+ / 0-)
    Recommended by:
    blueoasis

    ...and my Soc Security is based on the work I did in banking and lending before going to Med School. Never earned a savable dime! Specialists 30 years ago had their ridiculous fees grandfathered into Medicare for their 'procedures'... and also embedded therein is the ZERO payment for thinking or worrying or discussing the patients condition, or treatment. I was the one who had to explain all surgical procedures and healing therefrom...etc. Surgeons were way too busy earning procedure fees!

    Proud to be part of the 21st Century Democratic Majority Party of the 3M's.. Multiracial,Multigender and MiddleClass

    by LOrion on Tue Dec 18, 2012 at 05:48:18 PM PST

  •  One thing being said now re specialist fees (2+ / 0-)
    Recommended by:
    blueoasis, MPociask

    is that technology has rendered very long, complex surgeries more routine and speedier, so that a physician can easily do 2, 3 or 4 in a day, when one might have taken ten hours when the rates were struck. So there is a sense that maybe the fee for some of these should be decreased. One top senior cardiologist did three heart transplants in one day here recently. Not completely planned, the hearts suddenly became available on the same day.

       http://www.ottawacitizen.com/...

    http://ottawaheart.ca/...

    "...stories of past courage can define that ingredient..... But they cannot supply courage itself. For this each man must look into his own soul." JFK Profiles in Courage " Ontario

    by ontario on Tue Dec 18, 2012 at 06:39:23 PM PST

    •  yes ... proceduralists moan about reduced comp (1+ / 0-)
      Recommended by:
      MPociask

      but their "reduced comp" is still 2-4X what  PCP makes.  And they are NOT on call 24/7 like the used to be - unless of course they are being PAID to be on call.  And they have hospitalists helping to manage their patients, so they are more and more surgical/procedural technicians, leaving the conplex cognitive thinking and treatment planning to the primary care and non-proceduralists to manage -- at much lower rates of reimbursement.

      •  cough, cough (1+ / 0-)
        Recommended by:
        westwoodmom04

        There are many varieties of specialists, and not all predominantly do procedures.  The hospitalists have replaced the PCPs in the hospital, not the specialists.  I have never heard of being paid to be on call.  The amount of knowledge required to be up to date in one specialty grows every month, and no one doctor (no PCP) can possibly know enough to provide state of the art care in complex cases.  Indeed the complex cogntivie thinking and treatment planning is usually done by the specialist with the PCP relegated to collecting records from everyone else.   Some say that the PCP treat hypertension, diabetes, COPD, and colds, but refer most of the unusual or complex problems to specialists.  There is no doubt that procedures are valued more than thinking.  It is a constant struggle to determine the relative value of procedures and evaluation and management.  I think the skill required by physicians that predominantly do procedures, and by specialists that don't rely on procedures, is ever increasing, not getting easier.  On the other hand, I'm not sure more is now expected of PCPs, perhaps less and less, thus the increasing role of non-MDs in fulfilling that role.  

        •  Facts (0+ / 0-)

          1.  Hospitalists are internists choosing to practice in the hospital. The same three years post MD training as a general internist. They work shifts and generally make more than primary care internists
          2.  Many hospitals and systems pay for call, be it neurosurgery, ortho surgery, anesthesiology, ob, neurology or whatever, and sometimes in excess of $2000 per 24 hr. period
          3. Remember that the extra three years of traing is on top of four years of premed and four years of med school, so depending on how you count, three years extra training is between 30% and 40% more training, which does not, in and of itself justify 200% to 400% more income
          4. A specialist getting paid large sums certainly has a vested interest in explaining how they are overworked and
          Underpaid
          5. As a physician with experience in all sectors of healthcare, and having been responsible for multiple specialty practices I know a bit about this subject

          •  Agreement (1+ / 0-)
            Recommended by:
            Denver11

            1. What I said
            2. Good to know for future negotiations.  Reflects supply and demand I suppose.
            3. Matter of opinion
            4. I guess you were responding to the idea of specialists (in Canada?, I didn't read the link) complaining about cuts in pay per procedure.  I was responding to PCPs in US complaining about their pay relative to proceduralists.
            5. All physicians know a little bit about this subject.  Agreed.

            •  regarding income differentials (0+ / 0-)

              They are not as pronounced in most other developed nations and are a significant artifact of how insurance payments developed (hospital and procedure based). And until the SGR rules go away, all physician increases need to come from other physician cuts. If we froze high end codes and raised lower end cognitive codes we could see if that changed specialty choice and created a more balanced work force.

          •  There "Facts" Are Not Correct (0+ / 0-)

            My husband works at a large academic medical center, one that is consistently ranked among the top 5 five of the country.  I can tell you that Denver 11 is incorrect in the following way:

            (1) There is no extra payment for taking call at this hospital.  It is part of the physicians'  basic responsibilities.  My husband is on call approximately seventy percent of the time, and does after-hour surgeries approximately once a week, but as many as three to four times a week when on call.  His salary does not reflect any extra pay for taking call, nor would he expect it to.
            (2)  Because his patients are in-patient, my husband goes in to see them every day, including Saturdays and Sundays.  Unless we are on vacation, he does this every single weekend, whether he is on call or not.  There is no extra payment for this; it is part of his commitment to his patients (i.e. his job).
             (3)  I don't think it is appropriate to count college as medical training but the numbers provided above are still incorrect.  My husband did 8 years of training after medical school (6 residency in general surgery and 2 year fellowship in surgical specialty), so more than than twice as much after-medical school training as a pcp (which is 3 years).

            We have friends who are PCPs.  They are also devoted to their patients, but their schedule is much less grueling as they are done when there office hours are over, except to speak to patients over the phone.

            Primary care doctors provided an important service particularly in underserved areas.  With the rise of specialtists, however, they now spend most of their time as gatekeeper, farming patients out to the appropriate specialists.  Much of this work can be done more cheapily by nurse practitioners, and hospitals have greatly increased their use of nurse practitioners as well.

            •  Responses (0+ / 0-)

              1. Your husband may not get paid for call, but many in private practice do. I didn't make the numbers up
              2. If your husband is on call 70% of the time, his institution is probably violating, in spirit if not by law, work hour restrictions.
              3. Can't speak to your husband's rounding and pay, as I don't know whether he is salaried, production based, or a mix of the two.
              4. I will let PCPs describe their own responsibilities, but to equate what many of them do to what mid-levels do severely discounts their additional training, just as you bristled at the discounting of your husband's additional training.

              •  Don't Know Where You Are (0+ / 0-)

                and I expect some of what you say has  some basis in fact from your personal experience, but it is not how academic medical centers work.  To make statements here about the life of "specialists" and say them as if they apply globally is just deceptive to those who aren't in the medical field.

                There are no restrictions on call schedules for attending physicians at academic medical centers (call does not mean he is at the hospital, just that he comes in when there is a surgery or patient issue).  There are restrictions on resident call hours and that is it.  Who do you think makes up the difference for the hours the residents use to work?  The senior doctors who are not subject to the restriction.  He doesn't go without sleep so patient care is not at risk.  He also teaches residents which private practice docs do not.  

                PCP are the first in line to diagnose problems.  Certainly, not all of the care they give can be duplicated by nurse practitioners.  However, it is true that some of the functions formerly performed by PCPs can be performed by nurse practicioners.  This is already happening most places, and indeed, as you reference, nurse practicioners are already part of many PCP practices to help lessen the workload.

                To be fair, nurse practitioners can also perform some of the functions of certain specialists, such as nurse anesthecists.  I don't know why you take this as an insult to doctors, part of thinking about how to lower healthcare costs should be  pushing tasks to the people who can do them in the most cost-efficent but still competent way.  I'm a lawyer, and some of the tasks junior lawyers once did can be done for lower costs by paralegals.  I dont' take that as an insult to my legal training.

                Most doctors work long hours, but I just don't think it is honest to say all doctors work the same schedule.  There are some career choices that carry much heavier work schedules and these are generally surgical specialties.  To deny this across the board just isn't very honest, IMHO.

                •  Reference on call pay (0+ / 0-)

                  MGMA SURVEY

                  As to the rest - as you say, people make choices about specialty, based on a combo of factors including interests, compensation, life style and prestige. My main point is that to the degree possible those factors should not be artificially skewed by historical artifacts of comp models that no longer fit the reality of the healthcare landscape.

                  •  I understand what you are saying (0+ / 0-)

                    but disagree with it.  Medicine is becoming more specialized, not less.  Less and less is remaining in the sphere of the PCP or even the general surgeon, and some of what is remaining can be done by non-doctors (PAs or nurse practicioners).  Compensation differences reflect significantly longer training times, increased risk of the care provided, higher malpractice costs, and longer hours.  A PCP isn't going to cure your cancer or give you a liver transplant although they serve the important purpose of recognizing the condition and referring you to the appropriate specialist.

                    Frankly, I don't think our areas of disagreement are great.  I think PCPs should be paid more, but I don't think specialists should make less or that the differential has no basis in very real fact

      •  Not many doctors (1+ / 0-)
        Recommended by:
        demdoc

        posting.  specialists train three to six years longer than primary care doctors and nobody gets paid for taking call.  Further, much of what is currently done by primary care doctors can be done by nurse practitioners or physician assistants at much lower costs.  Further, patients are often sent to academic medical centers from community ers unnecessarily and under the libby zion laws, the specialist cannot refuse admission.  Doctors' pay has already taken a huge hit over the past decade while malpractice has skyrocketed.  we are already at a tipping point where talented people have few incentives to choose medicine given the cost of medical school, lengthvof residency and declining compensation.  

  •  Nothing like a ‘cliff’. (0+ / 0-)

    Who came up with this “cliff” shit anyway? Did they survey-test different terms to see which one(s) would fuck with people’s heads the most?
    ‘Cliff’.
    Ugh.

  •  How is this going to lower health care costs? (2+ / 0-)
    Recommended by:
    zaka1, MPociask

    That has to be the overall goal of any of these "fixes" - lowering health care costs.

    Democratic Leaders must be very clear they stand with the working class of our country. Democrats must hold the line in demanding that deficit reduction is done fairly -- not on the backs of the elderly, the sick, children and the poor.

    by Betty Pinson on Wed Dec 19, 2012 at 05:53:09 PM PST

    •  Removes a healthcare hostage. (0+ / 0-)

      Political grease.

      Happy little moron, Lucky little man.
      I wish I was a moron, MY GOD, Perhaps I am!
      —Spike Milligan

      by polecat on Wed Dec 19, 2012 at 06:10:30 PM PST

      [ Parent ]

      •  AMA & American Hospital Assn. aren't hostages (0+ / 0-)

        They're very powerful lobbying groups with their own agenda, one that doesn't mesh with lowering health care costs.

        Democratic Leaders must be very clear they stand with the working class of our country. Democrats must hold the line in demanding that deficit reduction is done fairly -- not on the backs of the elderly, the sick, children and the poor.

        by Betty Pinson on Thu Dec 20, 2012 at 06:44:38 AM PST

        [ Parent ]

  •  I been saying for a long time that doctors (1+ / 0-)
    Recommended by:
    MPociask

    are going to have to eat pavement. I've never met any broke specialists so the way I say they'll be okay regardless.

    •  It's stickier than that. For a doc to retire he (1+ / 0-)
      Recommended by:
      demdoc

      needs enough money to pay for his ENTIRE insurancd tail: 7 years.  Not to mention enough money to pay off the student loans.

      Not that easy being a doctor.  Most don't pay off their loans until they're in their 40's.

      Happy little moron, Lucky little man.
      I wish I was a moron, MY GOD, Perhaps I am!
      —Spike Milligan

      by polecat on Wed Dec 19, 2012 at 06:09:33 PM PST

      [ Parent ]

  •  Not worth cutting SS. (0+ / 0-)

    Not at all.  probably would never, ever make it out of conference.

    The liberty of democracy is not safe if people tolerate growth of private power to a point where it becomes stronger than their democratic state itself.---FDR

    by masslib on Wed Dec 19, 2012 at 05:55:28 PM PST

  •  Permanent = 10 years (1+ / 0-)
    Recommended by:
    MPociask

    This so-called "permanent" fix of $245 bn is merely that amount spread over 10 years, through 2022—at which point the permanent becomes the non-existent once again. Also, am I incorrect in recalling that the CBO score for Obamacare (i.e., the fiscal basis on which it was sold) depended in part on counting the decline in M.D. reimbursements as part of the act's projected savings?

    •  The latter is true (2+ / 0-)
      Recommended by:
      hmi, MPociask

      I'm beginning  to have real fears that ACA will not realize the health care costs savings as promised. Too many hostage takers and policymakers want to keep robbing the piggybank to pay for short sighted quick fixes to appease some lobbying group.

      Message to the WH and Congress - as much as they may whine and bawl, health care pacs and lobbying groups have the same number of votes as the rest of us - 1 per person.

      Democratic Leaders must be very clear they stand with the working class of our country. Democrats must hold the line in demanding that deficit reduction is done fairly -- not on the backs of the elderly, the sick, children and the poor.

      by Betty Pinson on Wed Dec 19, 2012 at 06:08:48 PM PST

      [ Parent ]

      •  Alot is going to depend on the patients (0+ / 0-)

        If regular visits with a pcp or nurse practitioner could teach people how to effectively lose weight or help to stop smoking, health care costs will go down.  Even bariatric surgery can be a great money saver.  If people don't want to make lifestyle changes, we're screwed.

  •  Doc fix, amt fix (1+ / 0-)
    Recommended by:
    MPociask

    We have more fixes than you can count yet why does everything work so poorly?

    How about just letting tax rates go up.

    "The real wealth of a nation consists of the contributions of its people and nature." -- Rianne Eisler

    by noofsh on Wed Dec 19, 2012 at 05:58:44 PM PST

  •  Until the cost of Malpractice insurance freezes (1+ / 0-)
    Recommended by:
    demdoc

    don't expect a palatable solution.

    If you freeze what a doc makes, but don't freeze his costs, it's a bad deal.

    Happy little moron, Lucky little man.
    I wish I was a moron, MY GOD, Perhaps I am!
    —Spike Milligan

    by polecat on Wed Dec 19, 2012 at 06:07:00 PM PST

  •  For Pete's Sake! (1+ / 0-)
    Recommended by:
    cnt zro

    Some of the folks who continually bitch about Obama's willingness to give on one issue (chained CPI) ought to read again. He offered that in return for a) stimulus money, b) unemployment extension, c) return of tax rates for >400,000 incomes, d) lots of other great legislation.

    If that was the cost for all the other progressive changes, it would have been a good package. Obama knew Boehner couldn't produce it, though.

    Don't write about one provision but the package.

    In the end, the GOP will look like idiots. Don't help them out of it.

  •  This isn't just docs. It's ancillaries as well. (2+ / 0-)
    Recommended by:
    MPociask, demdoc

    We have a small Physical Therapy practice.  About 20% Medicare.  These doc fix hostage takings have been happening 2x's a year for the last decade.  We could survive the rate cut, but it would cut us to the bone.  As it stands, I work two jobs and run this practice when I'm not with the kids.  My wife works 50 hrs a week to keep this thing going.  Don't know how much more bone we can spare.  Oh, and it is 9:30 at night, and I need to do more paperwork.  That's the real Healthcare system.  Only people getting rich are the insurance companies, and Medicare ain't one of 'em.

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