Medicare Physician Payments

On Monday, reporting on a conference call with aides to Senate Majority Leader Harry Reid, I wrote that there would be a vote this week to eliminate the mandated 21.5 percent reduction in Medicare reimbursement to physicians that is scheduled to go into effect on 1 January 2010, along with the system that currently determines physician reimbursement levels.

The aides sounded confident that the bill, which needed 60 votes to succeed, would sail through and said a new system would be forthcoming in a health care reform bill.

That didn't happen. On Wednesday, the measure (S.1776) was defeated in a roll call vote 53 – 47. Twelve Democrats and one independent voted against the bill because its cost - $247 billion over 10 years – was not funded.

That got me wondering how much in dollar figures physicians are reimbursed by Medicare. Good luck finding it online. I couldn't – undoubtedly because there are thousands of code numbers for procedures and treatment by which doctors bill Medicare.

But what I do have in my personal possession are three years of records from my tenure so far as a Medicare beneficiary listing charges, reimbursement to the doctor through Medicare Part B and what was covered by my Medigap (supplemental) policy.

Here is an example of one charge from a visit at this time last year when I saw the physician's assistant.

“Medical Visit” was charged by the doctor at $104. The Medicare Approved amount for that service is $59.85 of which it paid 80 percent or $47.88. My Medigap policy paid the remaining 20 percent of the Medicare Approved amount or $11.97.

So the total paid for a $104 visit was $59.85 or about 57 percent of what was billed, and the physician eats the difference.

Physician's assistants are professionally licensed to practice medicine under a physician's supervision. They hold advanced degrees from accredited PA programs and can perform examinations and procedures, diagnose illnesses, order treatment, prescribe medications, refer patients to specialists and assist in surgery.

On the day of the example billing, my physician's assistant conducted a basic physical exam and, because I have had a basal cell carcinoma, checked my body for any new indications of skin cancer. She adjusted my one prescription drug, checked my breasts for lumps, drew blood for a couple of tests (which are billed separately by the diagnostic clinic) and administered my annual flu shot. She also answered a few questions I had with no sense of rushing me through the visit. We spent about 45 minutes together.

$104 is more than reasonable for what we accomplished in that time and although my doctor accepts what Medicare pays, $59.85 doesn't seem fair to me. Nevertheless, unless the Senate finds another way to stop the 21.5 percent reduction in Medicare reimbursements, next year my doctor's office will be paid only $47.28 for the same visit, give or take a few cents.

Medicare determines the amount of physician reimbursement (under Part B) with a system called Sustainable Growth Rate (SGR) by which annual and cumulative spending targets are set. If spending exceeds the target, physician reimbursements for the next year are calculated downward. With the increasing costs of medical care, targets have been missed for the past several years so Congress, each year, has overridden the decrease and for 2009, allowed a 1.1 percent increase.

With the defeat on Wednesday of S.1776, the 21.5 percent reimbursement reduction is scheduled to go into effect on 1 January. After the failed vote, Senator Reid said he expects to go with another one-year override, but after this vote, can we be sure? And it doesn't solve the long-term problem.

An increasing number of physicians do not accept new Medicare patients. If messages from TGB readers are any indication, each year some doctors “fire” their Medicare patients leaving all of us – doctors in regard to their fees and patients in regard to continuing care – in uneasy anticipation of waiting for a shoe to drop.

These issues become more critical when you remember that those 78 million baby boomers start becoming eligible for Medicare in little more than a year, 2011.

S.1776 was defeated because enough senators balked at the $247 billion cost over 10 years. But let's put that number in some perspective. As of July, the bailouts, bank rescues and other corporate aid programs have cost taxpayers $2 trillion dollars – and that's only in one year, not 10. Some experts estimate that the cost will spiral to $23 trillion before it's done.

Currently, the Afghan war is costing roughly $4 billion a month. Now there's an idea: get us out of Afghanistan and the $247 billion cost of maintaining Medicare reimbursements to physicians could be paid for in a little more than five years – half the time covered by the projected $247 billion cost.

Okay, I know it's not that simple, but it could be done if Congress and the administration really believed they work for the people. Trillions of dollars for banks that brought the country to its knees and not a penny so far for the rest of us. That must change. I want my doctor to be paid fairly for her work and I don't think $59.85 is enough.

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The PBS series Life (Part 2) hosted by Robert Lipsyte tackles ageism this week. Here is a short clip:

You can watch the entire episode here.

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At The Elder Storytelling Place today, Jeanne Waite Follet: Followup to My Glasses are Missing (see also yesterday).

Comments

[Alan G]

This is an issue of major concern of mine and has been for a number of years as I have monitored the reductions in payments to physicians since going on Medicare in 2005.

Last year, out of curiosity, I called several of the local Baptist Health Clinics in my area seeing if they had an open enrollment for Medicare patients. None of them did. They told me to call the Main Baptist Hospital in our city and they had a list of doctors accepting Medicare patients. Bottom line - you don't have a choice with regard to doctor or location. You would have to take what's available.

In addition, I also found out that if you were of a mind to help bridge that difference by paying a reasonable amount out-of-pocket to your doctor or his clinic, the doctors who operate under Medicare are not allowed to receive anymore than the billed amount and remain a part of the Medicare program.

I find myself personally hard-pressed to see how this is going to have a happy ending at this point....

[NancyB]

Why are we surprised it did not pass. It just demonstrates that the Senate is clueless on reality. Perhaps we should stript them of their health insurance, parking, etc. And stop pay raises for them. After all, money needs to be appropriated where it is needed they say...I don't think its needed to cover benefits for Congress given their track record.

Here is the kicker Ronni, 151 members of Congress are on Medicare. They are listed on Cong. Andrew Weiner site as well as my blog. And these are the same members of Congress that oppose the public option. I know this doesn't help the Senate vote but wonder if we could find out who in Senate is on Medicare...of course these people are supplemented by the Federal health insurance given members of Congress....still, might be interesting

[francine hardaway]

Well, it's not as simple as all that. Medical practices have been dealing with medicare for 40 years and have developed billing practices around it. My husband was a physician, and they jacked up their billable rate so they could stay within the guidelines. Every time Medicare lowers reimbursements, physicians raise rates.

CMS watches whether Medicare patients have access to care, and if docs stop taking Medicare, they adjust accordingly. So far, there's been no measurable lack of access (beyond the universal shortage of primary care docs) according to their studies. And that's because Medicare pays on time, which is very important if you are running a medical practice. You need the government's cash flow as part of your mix of patients.

[Rain]

Obama set the criteria that nothing they do can add to the debt. He also set the method which was cut $500 billion from Medicare reimbursements. It's not that they could not switch the money from a war we could leave, it's that they don't want to and our debt is growing so fast that they will want to put some of whatever they save from those wars into paying it down. The whole health care situation is a mess and unless the government is willing to make it more competitive through a real public option, bargain for lower prices on drugs, do some price controls on doctors for all patients (something Republicans will yell about), get more trained doctors, it won't get better in our lifetime which may end up shorter for us and the youth because of our medical system which is NOT the best in the world. Worse Congress (not all but too many) and the president don't want to keep the costs down to insurance corporations because of the way it makes the stock market look. They talk one way but manage to operate another to keep those profits up.

And on physicians' assistants, it varies in different states how much training they must have but it definitely is not what a doctor has even though they do a lot of what doctors do and it's not (in our state) what a registered nurse would have). I would guess some of them are quite good and get extra training and some are not that great at it. Supposedly they operate under the doctor's supervision but the doctor is not in the office with them, doesn't observe what they do and depends on their notes. I am sure there are things they can do fine but there are others that to keep costs down that maybe our pharmacist could do as well. We pay the fees but we have no say on what we will get for care.

[janinsanfran]

Couple of comments: I've been asking around about the Medicare situation for months because here in San Francisco you hear about the difficulties of finding a doc who will accept Medicare pretty frequently. I keep hearing what francine says above: unlike the private insurers, at least Medicare pays on time. For the smaller medical practices, the worst thing about the current system is insurers who question every charge and try to string out doctors and hospitals for over a year, whereupon they can refuse to pay at all. Medicare rates may be low,but something gets paid.

I have been surprised by the number of folks who report this.

Also -- got to stick up for the physician's assistants, at least here in California. A friend of mine is one and she does neurosurgery! She did a conventional surgical residency at Beth Israel hospital in New York City. That is, her training was just like the doctors; she just started when she was older and gets paid less while working under a regular doctor. Interestingly, the politician who is the leader of the California State Assembly (lower legislative house) is a P.A. also. Training up folks, mostly women, to be "almost doctors" was something that came out of the Vietnam experience with military aides, during a last round of health care cost cutting.

[Ronni Bennett]

Rain...

I don't know about your state, but I must speak up for physicians' assistants.

Mine holds the same medical degree all physicians take, she just never went beyond that initial degree. She is highly qualified, particularly for a general practice and if she runs into anything she can't handle, the physician she works is called in.

There are about 70,000 PAs in the U.S. and the numbers are growing. This is going to be very important to elders as the number of old people increases.

Contrary to the impression we are left with from medical TV programs, most people don't have mysterious medical problems and if they become complex, even an internist would pass us on to a specialist.

Oh, I just saw janinsanfran's comment above - interesting about the genesis of PAs in Vietnam...

[Steven]

Do you happen to know the names of the Democratic Senators that voted against S.1776? I've been looking and can't find the names so far. But, when I do, they will receive my thoughts on the matter of their vote.

[Ronni Bennett]

Steven...

You can find the roll call vote here.

[Mage B]

I asked my doctor, and she said she took Medicare. That's a start. Now I have to figure out how to sign up for it. Where is there someone who will tell me what I need to do and what the pitfalls are. I'm not even to the state most of you are, I'm still crawling in the basement.

[Darlene]

All of this could have been avoided with the single payer system. Sad that it wasn't even considered.

[Ronni Bennett]

Mage...

Here's the place to start at the Medicare website.

[JSW]

I agree this is not a simple problem. But Medicare is no different from health plans for people under 65.

The difference between what my doctor charges and what the insurance company says is the reasonable and customary charge is large. In my area, many doctors don't accept insurance payments and will not file a claim with the insurance company. The patient is required by the doctor to pay the full bill at the end of the doctor visit. The patient then files a claim with the insurance company. The patient absorbs the difference between what the doctor charged and the insurance company paid.

[Rain]

Every state has different requirements for what a physician's assistant must have for training. I had looked up Oregon's when I began to see the PAs being so prevalent. I have no idea about other states. and I would guess each individual clinic would vary for their requirements even in a state but there would be the minimum that they could not have beneath. Personally I think we need to get more doctors trained but the AMA blocks a lot of that to keep their fees high or so I have been told.

[Rain]

I should add that I did that research a few years back after I had had a case of poison oak that went systemic, saw a PA who gave me a prescription for a steroid which turned out to be insufficient in time for my problem and according to what I researched online later. The dermatologist in that clinic might have done the same thing for all I know but it made me curious how much training the PA had before diagnosing my situation.

[Nan]

Mage, for you and others who need help initially navigating the Medicare system, each state should have a State Health Insurance Assistance Program (SHIP)that does free counseling and assistance. You can find yours on the Medicare Site or by doing an Internet search for SHIP counselors.

As for physicians assistance, my SIL is going through training in a different state. The initial year he attends the same classes as the other med students. So far he is very comfortable with what he is learning. We do use the PA's in our clinic for routine matters, and there's never been a problem with stepping up to a doctor if the situation warrants.

[John]

Health care is one big mess. Wall street bail out is a big mess. The economy is a big mess. Many Americans are broke, in debt, and barely scraping by--with little hope for major improvement. Baby boomers are not prepared for retirement and a slow motion train wreck of sorts is about to unfold. Is government the solution? This should be an interesting next 20 years.

[r]

It's too bad that the single payer option wasn't even seriously considered. It would have solved to many problems.

[joared]

Almost thirty years ago I encountered my first P.A. in a State between Calif. and Colo. as my dtr and I were driving cross country. She became ill with a high rising temperature so we had to stop on a weekend in some little town to spend the night, or longer if need be. I couldn't find a Dr., no hospital, but was finally referred to a clinic luckily open a few short hours that Sat. afternoon that would be staffed only by a P.A. I was told. I was very impressed with the care the P.A. provided though initially I was quite apprehensive since I hadn't heard of P.A.s then.

I have since encountered other P.A.s in situations other than as a patient and have found some to be superior to seeing the doctor.
For a few others that would not be the case.

Many medical disciplines have created lower level professional categories where there is a shortage of the primary professional as with doctors, nurses, rehabilitation therapies. As with the primary professional, their capabilities and knowledge can vary considerably just as the State's requirements in which they practice may differ. These lower level professionals are utilized increasingly to meet needs and also because they can be paid less making them more cost effective and even income producing for some medical practices. They can be a boon for the professional whose practice they work for and for the patients -- a potential asset to health care if used properly, as intended and their training requirements have been demanding enough.

They can also be subject to pressure by their professional and/or business supervisor/company owner for exploitation by having them perform treatments for which they lack the necessary more advanced knowledge and training. The lines on that and interpretation are sometimes blurred. Unfortunately, some bosses and/or underlings are more susceptible and willing to cross some of these lines. Others simply don't realize their limitations and what they don't know so may unwittingly tackle problems beyond their ken. Others are just more interested in making more money, keeping their job or both. Yes, it would be unlawful but not uncommon for some to disregard the ethics, morality and expected practices requirements. Ideally they would be found out sooner, or later.

National professional medical organizations do press for uniform requirements for all these different level groups to legally practice to be standardized across the U.S. Personally, I would want to be assured that the P.A. I might see had to meet a highest training standard and licensing that would be uniform in every State whether they're a P.A.,or in therapies an Asst., Aide, or whatever other designated term is used.

Nursing is a good example of care once assigned to only Registered Nurses being relegated to what we have in California called Licensed Vocational Nurses. I've seen first hand both the pros and cons of that for the patients in different types of medical settings as I have with other groups utilizing these lower level professional groups.

[Judy W]

I live in a rural area & have a PA...I feel well cared for ....