Dem Plan Would Hit Specialists To Pay Primary Doctors More
By DAVID HOGBERG, INVESTOR'S BUSINESS DAILY
Amid big fights over Medicare cuts and whether to squeeze drugmakers
further, doctor payments could become another obstacle to a sweeping health
overhaul.
Senate Finance Committee Chairman Max Baucus' proposal would change how
Medicare pays for primary-care services, pitting primary-care physicians
against specialists.
Much research shows that primary-care physicians - internists, family
practitioners, geriatricians, and pediatricians - often provide quality care
that is less expensive. But they are increasingly scarce.
There are 6,080 primary-care Health Professional Shortage Areas where the
population to primary-care physician ratio is at least 3,500 to 1, says the
Health Resources and Services Administration.
There may be a shortage of 46,000 primary-care physicians by 2025, according
to a recent study by the Association of American Medical Colleges.
So the Baucus bill gives physicians a 10% bonus on primary-care services
under Medicare. To qualify, physicians must work in an HPSA and 60% of their
services must be primary-care services.
Not So Special Now
About half of the funding for the bonuses comes from across-the-board cuts
in the fees Medicare pays for nonprimary care.
Specialists, naturally, oppose this course of treatment. The Alliance of
Specialty Medicine sent a letter to Baucus saying that its members could not
"support your manager's amendment that would provide additional payments to
primary-care physicians at the expense of specialists ... we support (the
Kyl Amendment) and other proposals to ensure that any primary-care bonuses
are not at the expense of specialty care."
The Alliance represents 10 medical specialty groups, including the American
Association of Neurological Surgeons, American Urological Association, and
the Society for Cardiovascular Angiography and Interventions.
The American Medical Association also criticized the Baucus approach.
But primary-care groups are applauding the bill.
"By providing a 10% bonus for primary-care services over the next five
years, this legislation begins to rebalance a system that has seen the
number of subspecialists skyrocket and the compensation for primary medical
care fall precipitously," the American Academy of Family Physicians said in
a press release.
Many lawmakers and doctors say they favor higher payments to primary-care
doctors, but not at the expense of specialists.
"The bonus is appropriate. You're going to need more and more primary-care
physicians if legislation passes that gives insurance to millions of
uninsured," said Rep. Phil Gingrey, R-Ga. But Gingrey, an OB-GYN before
coming to Congress, worried about "the cuts to the specialists. We want
young physicians going into the specialties, and that will take a blow under
this bill."
"I would much rather not see us have this internal war and struggle between
doctors' groups," said Dr. Ted Epperly, a family physician in Boise, Idaho,
and president of the American Academy of Family Physicians. "There's enough
money in the system to increase primary care - let's take a look at the
entire Medicare system, not just that part that pays physicians."
Paying For Bonuses
Sen. Jon Kyl, R-Ariz., plans to offer an amendment to scrap the lower
payments on specialists. Instead, it would get rid of planned federal
funding for health care co-operatives. Those co-ops are Baucus' attempt to
provide a politically palatable alternative to a government-run insurance
program.
The battle over paying for the primary-care bonuses will be key, creating or
soothing opposition to the provision and even the overall bill.
"We need to be fiscally responsible, so we have to find a way to pay for
it," said Sen. Ben Cardin, D-Md. "But we have to do something to encourage
more professionals in primary care."
The primary-care shortage can be traced to salaries. Median salaries for
primary-care physicians range $140,000-$209,000, according to Modern
Physician. Specialists earn $174,000-$600,000.
Some physicians don't think the bonus is sufficient.
"You're talking about newly trained doctors graduating with $200,000 in
medical school debt," said Dr. Margaret Lewin, an internist and medical
director of Cinergy Health in New York. "To attract those young doctors into
(HPSAs) with that kind of a bonus and without loan relief - it's not going
to work."
Dr. Kevin Pho, an internist who maintains the popular medical blog,
KevinMD.com, suggests the problem goes beyond financial.
"Money aside, there has to be more done to improve the work environment for
primary-care doctors," he said. "The paperwork requirement is onerous, and
doctors find frustrating the restrictions both Medicare and insurance
companies impose on the doctor-patient relationship."
Lower primary-care pay is linked to Medicare's fee schedule, which initially
paid well for procedures, often performed by specialists, but less well for
consultation, which tends to be the purview of primary-care physicians.
"When the fee schedule was set up, it compensated well for procedures but
not for sitting and talking to the patient," said Dr. Alieta Eck, an
internist in Zarephath, N.J. "Before I lay hands on a patient, I should know
what's the matter, but Medicare doesn't compensate me for that."
Dr. Lewin concurs: "I believe passionately in the need to have primary care
at the center of health care, to have primary-care physicians coordinating
the care provided by specialists. But that coordination is time-consuming,
and we don't get paid for it."
Dr. Eck dismissed Baucus' primary-care proposal as "nonsense."
"It makes me feel like a marionette," she said. "Politicians and bureaucrats
are just pulling me this way and that, and trying to make me behave the way
they want. Why don't they just pay me a reasonable amount for what I do and
not a reward for being a good doctor 'by the numbers'?" |
