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Physicians Are Frustrated by the Doc Fix Drama, but Will They Flee Medicare?

By Jane Norman, CQ HealthBeat Associate Editor

June 18, 2010 -- Past studies and surveys haven't found that the continuing turmoil over Medicare physician reimbursements affects patients' access to care, but some doctors say this topsy-turvy year has been a game-changer.

The Senate on Friday passed by voice vote a six-month postponement of a scheduled 21 percent cut in physicians' Medicare pay. Payments instead would be increased by 2.2 percent.

However, the House will not be in session until June 22 to take action, and Medicare announced it will begin processing claims dating back to June 1 that include the pay cut. And if the House accepts the Senate language, it would resolve the problem only temporarily. The Senate measure would expire Nov. 30, kicking action on the increasingly troublesome "doc fix" until after the November midterm elections.

The latest episode marked the third time this year that Congress didn't act before the payment cuts went into effect. Doctors say the legislative scrambling has brought an unprecedented level of uncertainty and frustration into their practices.

Susan Bailey, president of the Texas Medical Society and an allergist, said she saw a Medicare patient on Friday morning who told her it took a year to find a primary care doctor who was accepting new Medicare patients. "I hear that story all the time," Bailey said.

Officials at the society pointed to a May article in the Houston Chronicle that said 100 to 200 doctors a year in Texas are opting out of the program. Prior to 2007, just a handful of doctors would leave annually, the Chronicle said. More than 300 exited Medicare in the last three years including 50 in the first three months of 2010, according to data from the state's Medicare carrier.

"There's no question physicians are leaving Medicare at greater rates" in Texas, said Bailey.

Pam Udall, a spokeswoman for the society, said she spoke with a physician now owed $200,000 by Medicare after the 17-day hold on claims. "There's a lot of discouragement," she said. "Before, we had to fight this yearly. But it's monthly now."

The formula under which physicians are paid is called the sustainable growth rate, or SGR, which attempts to control spending under Medicare Part B physician services. It sets an overall target for spending, and so payment rates are supposed to be adjusted up or down or down ever year, though Congress regularly steps in to prevent cuts. Those legislative fixes, however, are costly—the six-month extension passed by the Senate would cost $6.5 billion.

So far, annual surveys by the Medicare Payment Advisory Commission have not detected major problems in seniors' access to care. Results from the 2009 survey found that most beneficiaries have reliable access to physician services and can easily schedule appointments and find new doctors when needed. Among the 6 percent of patients in the 2009 survey who said they were looking for a new doctor, 22 percent said they had problems finding one who accepted Medicare.

That corresponds to less than 2 percent of the entire Medicare population, but a March MedPAC report acknowledges those problems can be distressing and are often featured in news reports. "It is also important to note that such media accounts typically report similar problems for privately insured individuals," MedPAC said. Some particular markets may have problems of access more than others, the report also noted.

Those looking for a new specialist also reported more problems than those who needed a primary care provider.

The agency, which advises Congress on Medicare policy, is in the field right now conducting its annual survey and should have results available later this year.

In Search of Predictability
In Ohio, Jason Koma, a spokesman for the Ohio State Medical Association, said he doesn't have any hard data on whether physicians are fleeing Medicare in his state, where there are many elderly residents. But he said the level of unhappiness is high. "We have heard from many physicians that because of the continued inaction on this issue that they are no longer taking new Medicare patients or are planning to stop seeing new Medicare patients," said Koma.

Cecil B. Wilson, president of the American Medical Association ( AMA), in a statement blasted congressional inaction on a permanent fix for the reimbursements. "Congress is playing Russian roulette with seniors' health care," said Wilson. "Congress has finally taken its game of brinkmanship too far, as the steep 21 percent cut is now in effect and physicians will be forced to make difficult practice changes to keep their practice doors open."

While Congress almost certainly will avert the cut, it's the uncertainty that's the problem, physicians say.

The AMA recently conducted an online survey of more than 9,000 physicians who accept Medicare patients. It found that one in five are restricting the number of Medicare patients in their practices. Among that group, 85 percent said Medicare payment rates are too low and 78 percent said the ongoing threat of payment cuts makes Medicare an unreliable payer.

Looking at just primary care providers, a third in the AMA survey said they're restricting their number of Medicare payments.

Still, past surveys don't detect that trend. MedPAC in its report noted that the Consumer Assessment of Healthcare Providers and Systems for Medicare FFS, a large survey sponsored by Medicare, has since 2001 consistently found that the share of beneficiaries reporting major problems accessing physician care has remained below 6 percent.

MedPAC, however, has recommended that the survey ask specifically about primary care providers, including physicians, nurse practitioners and physician assistants.

Andrew LaMar, a spokesman for the California Medical Association, said he has no concrete evidence of physician flight among the association's 35,000 members. "I will say what's happened this spring has been tremendously frustrating," he said. The impasse has been particularly hard on doctors in rural areas with high percentages of Medicare patients. If they go out of business or can't accept new patients it's a hardship on beneficiaries who then must drive a distance for care, he said.

"It's not a good time to be undermining credibility and faith in the federal government to execute health care," he added. "I do think there's some dangerous long-term consequences to this."

In Texas, the Chronicle said it found a large share of physicians leaving Medicare are psychiatrists, and the American Psychiatric Association said the turmoil over the pay cut is making it tough for psychiatrists to treat seniors with illnesses such as dementia.

"The administrative hassles and uncertainty associated with the continuing problems with the SGR make it impossible for some physicians to manage their practices effectively and to continue seeing Medicare beneficiaries," said Nicholas Myers, director of government relations.

AARP also joined the chorus of worry. "Finding a physician is already a challenge for our members and older Americans," the group said in a statement. "By allowing these cuts to take effect Congress has only made this challenge more difficult for millions of seniors already in Medicare and those entering the program for the first time.

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