The physician organizational leadership crisis – and growing physician disenchantment with the AMA – reminds me of Robert Browning’s poem The Pied Piper of Hamelin City,
And out of the houses, the rats came tumbling,
Great rats, small rats, lean rats, brawny rats,
Brown rats, black rats, gray rats, tawny rats,
Grave old plodders, gay young friskers,
Fathers, mothers, uncles, cousins,
Cocking tails and pricking whiskers,
Families by tens and dozens,
Brothers, uncles, husbands, wives -
Followed the Piper for their lives.
A Diverse Bunch
Not that doctors are rats, but we’re a diverse bunch, and many of us looking for a Pied Piper besides the AMA. If I were to rewrite the Browning verse, it would read,
And out of the House of Medicine, the docs came tumbling,
Group docs, solo docs, happy docs, sad docs,
Specialty docs, primary docs,
Town docs, gown docs,
Grave old conservatives,
Pricking young progressives,
Independent docs, employed docs,
Hospitalist docs, locum docs.
Cocky thriving specialists,
Struggling surviving generalists –
And all of their wives,
Looking for a substitute for the AMA for their lives.
My Point
My point is: it is hard for the AMA to be everything to everybody,
which may have led to its undoing. The AMA may be too democratic, a formula for paralysis through over-analysis. The AMA has tried to be everything to everybody, and too often it has ended by being nothing to nobody. The AMA can not simultaneously represent the professional and financial interests of academic medicine, specialty doctors, primary care doctors, HMO doctors, government doctors, and left and right wing doctors.
A completely open democracy – with a voice and a veto for everyone – sooner or later disappoints everyone, which may be why the membership of the AMA, and the percentage of actively practicing physicians belonging, has dropped to 15% to 20%. Nobody knows for sure the exact percentage.
In these times of heated debate on how the system ought to be reformed, the low number of doctors belonging to the AMA, and the feeling of a majority of doctors that the AMA does not represent them, poses a political problem.
Who represents medicine at the reform table? The public and other health care stakeholders may think the AMA stands for all doctors, but what if the AMA does not.
Into this leadership vacuum have moved state and local medical societies, which are closer to grassroots doctors and to which perhaps 650.000 of America’s 825,000 doctors belong, and which fall under the umbrella of the Physicians’ Foundation, an organization created in 2003 as the result of a lawsuit against the nation’s major HMOs, and Sermo, a social networking site with 100,000 members, where licensed doctors can exchange unbridled, unfettered, and sometimes divided and uncoherent views of what’s right and wrong with the system. I should also mention Physicians for a National Health Program, an organization of 14,000 physicians, medical students, and health professionals, advocating for a single-payer national health insurance program.
As yet, unfortunately, there is no Pied Piper.
Sunday, July 5, 2009
Obam's E-Based Health Reform Push
Prelude: What follows is from my book Obama-Doctors, and Health Reform: A Doctor Assesses Odds for Success, now available on Amazon.com
As we ponder modern politics, it is becoming increasingly evident that the Internet will offer yet another opportunity for a great leap in communications, bringing a customized one-on-one dialogue into the home of each voter. Instead of the one-size-fits-all television campaigns that dominate our politics, the Internet in general – and e-mail in particular – will make possible a conversation between each voter and each candidate about issues and ideas. The interactivity of the Web means the end to “I talk, you listen” politics, and the beginning of a two-way discussion as the basis of political communication. Some feel this is long overdue.
Dick Morris, Power Plays: Win or Lose – How History’s Great Political Leaders Play the Game, Regan Books, 2002
As part of the administration’s efforts to tee off a movement toward legislative action on health care, it also set up a new Web site, healthreform.gov.
Kate Phillips, “White House Plans Regional Health Care Forum,” New York Times, March 5, 2009
The world is moving on Internet time. This reality has seemingly dawned on the whole world at once. It is the factor leading to the wide-spread belief that a interoperable , all-purpose, all-reaching, all-the-time available, on-line system holds the key to improving access and quality of our health care system.
President Obama and his advisors believe this. And for good reason. The Internet is an efficient, instantaneous, and inexpensive way of reaching millions with a click on the keyboard.
One tactic Obama used successfully to win the presidency was mobilizing support and money over the Internet. He raised a record $750 million and kept e-mail addresses of millions who contributed to this campaign over a two year period. Now Obama has became an e-health reform organizer, an extension of his knowledge gained from Internet fundraising and his community organizes efforts. This includes you, the patient, who can access the Obama administration’s multiple website, to see his thoughts for the day and his progress on multiple health care fronts.
Current E-Reform Efforts
President Obama is an engaged in an extensive Internet campaign promising to provide universal coverage by the end of his first term. The dimensions of this e-campaign are becoming evident and include.
1. The Obama-Biden website which says.
- Obama will make affordable and accessible health care for all
- Obama will lower health premiums by $2500 per year per family
- Obama will promote public health
In addition, the web site asks for comments (it claims to already have over 10,000 citizens suggesting and offering free access clicks to Obama videos on health care.)
2. Regular Obama Facebooks, with videos featuring Obama talking health care
basic promises.
3. Virtual Online Townhalls – On March 25, President Obama held what promises to be first of a series of virtual townhalls. In this first online townhall, he responded directly to six questions winnowed from more than 100.000 submitted directed by emails from citizens. The media dutifully televised the event. It also appeared on online video, and was broadcast it to the nation on mainstream and cable television.
Clicking Away
Through these instantly accessible e-sites, Obama can efficiently click away again and again at his basic promises and premises.
- Savings through prevention, EMRs, chronic disease management, medical homes
- Expanding coverage through private and government-run health plans
- Making large businesses cover employees or pay a fine
- Mandating that health plans accept those with pre-existing illnesses
- Having government negotiate Medicare drug prices
- Reforming health care as an integral part of his economic salvage plan
Prospects for Success
Given his election margin (53% vs. 47%), large Democratic majorities in the House and Senate, his successful Internet deployment during the presidential run, his cache of millions of email addresses from supporters, the presence of personal computers in 80% of American homes, and his promise of $2500 premium savings for the typical American family, Obama’s electronic mobilizing tactics for health reform may succeed.
President Obama has a simultaneous top-down , i.e. daily dominating the national radio, mainstream and cable television, and Internet media, and a bottom-up strategy, i.e, while at the same time soliciting and responding to hundreds of thousands, indeed, millions of emails.
In his book Power Plays, Dick Morris asks and answers, ”Will the new techniques and strategies improve our political process? Likely they will. Each development seems to move in the same direction – greater direct democracy and more public participation. Certainly the Internet and the two-way political dialogue it fosters will tend to make our democracy more direct and citizen involvement more consuming.”
As with any political development, there may be a darker side. Rush Limbaugh, the conservative radio talk show host, believes the Obama daily dominance of all media has Orwellian, Big Brother overtones, and may lead to totalitarian tyranny of our minds. I would not go that far. I give President Obama his due. It is a brilliant ongoing political communication strategy, transforms politics, and will have to be countered by his political opponents.
I would not bet against significant incremental health reform. What might prevent Obama-style health reform are the economy, the soaring federal budget deficit, and the Department of Health and Human Services current $708 billion budget, 25% of federal spending and Medicare on brink of bankruptcy, but Obama is not one to let billions, even trillions of dollars, stand in his way. He will persist, and he will let the government printing presses roll.
Summary
Barack Obama is our first Internet President, which is altogether without precedent. The President uses the Web to issue a daily report and to mobilize wider political support. That e-tools help his agenda is evident. For Obama, Internet politics is good. For all of us that fact has to be understood. Obama Internet supporters helped get him where he is today and elevated him above the ordinary political fray. For Obama the Internet was the little Engine that could. Say about Obama’s Internet strategy what you will. Say that it’s shows the mark of remarkable political skill. Say that it smacks of George Orwell’s Big Brother. Say that it brings all media under one giant cover. Say what you will: The Internet is now routine grist for the political and health care mill.
As we ponder modern politics, it is becoming increasingly evident that the Internet will offer yet another opportunity for a great leap in communications, bringing a customized one-on-one dialogue into the home of each voter. Instead of the one-size-fits-all television campaigns that dominate our politics, the Internet in general – and e-mail in particular – will make possible a conversation between each voter and each candidate about issues and ideas. The interactivity of the Web means the end to “I talk, you listen” politics, and the beginning of a two-way discussion as the basis of political communication. Some feel this is long overdue.
Dick Morris, Power Plays: Win or Lose – How History’s Great Political Leaders Play the Game, Regan Books, 2002
As part of the administration’s efforts to tee off a movement toward legislative action on health care, it also set up a new Web site, healthreform.gov.
Kate Phillips, “White House Plans Regional Health Care Forum,” New York Times, March 5, 2009
The world is moving on Internet time. This reality has seemingly dawned on the whole world at once. It is the factor leading to the wide-spread belief that a interoperable , all-purpose, all-reaching, all-the-time available, on-line system holds the key to improving access and quality of our health care system.
President Obama and his advisors believe this. And for good reason. The Internet is an efficient, instantaneous, and inexpensive way of reaching millions with a click on the keyboard.
One tactic Obama used successfully to win the presidency was mobilizing support and money over the Internet. He raised a record $750 million and kept e-mail addresses of millions who contributed to this campaign over a two year period. Now Obama has became an e-health reform organizer, an extension of his knowledge gained from Internet fundraising and his community organizes efforts. This includes you, the patient, who can access the Obama administration’s multiple website, to see his thoughts for the day and his progress on multiple health care fronts.
Current E-Reform Efforts
President Obama is an engaged in an extensive Internet campaign promising to provide universal coverage by the end of his first term. The dimensions of this e-campaign are becoming evident and include.
1. The Obama-Biden website which says.
- Obama will make affordable and accessible health care for all
- Obama will lower health premiums by $2500 per year per family
- Obama will promote public health
In addition, the web site asks for comments (it claims to already have over 10,000 citizens suggesting and offering free access clicks to Obama videos on health care.)
2. Regular Obama Facebooks, with videos featuring Obama talking health care
basic promises.
3. Virtual Online Townhalls – On March 25, President Obama held what promises to be first of a series of virtual townhalls. In this first online townhall, he responded directly to six questions winnowed from more than 100.000 submitted directed by emails from citizens. The media dutifully televised the event. It also appeared on online video, and was broadcast it to the nation on mainstream and cable television.
Clicking Away
Through these instantly accessible e-sites, Obama can efficiently click away again and again at his basic promises and premises.
- Savings through prevention, EMRs, chronic disease management, medical homes
- Expanding coverage through private and government-run health plans
- Making large businesses cover employees or pay a fine
- Mandating that health plans accept those with pre-existing illnesses
- Having government negotiate Medicare drug prices
- Reforming health care as an integral part of his economic salvage plan
Prospects for Success
Given his election margin (53% vs. 47%), large Democratic majorities in the House and Senate, his successful Internet deployment during the presidential run, his cache of millions of email addresses from supporters, the presence of personal computers in 80% of American homes, and his promise of $2500 premium savings for the typical American family, Obama’s electronic mobilizing tactics for health reform may succeed.
President Obama has a simultaneous top-down , i.e. daily dominating the national radio, mainstream and cable television, and Internet media, and a bottom-up strategy, i.e, while at the same time soliciting and responding to hundreds of thousands, indeed, millions of emails.
In his book Power Plays, Dick Morris asks and answers, ”Will the new techniques and strategies improve our political process? Likely they will. Each development seems to move in the same direction – greater direct democracy and more public participation. Certainly the Internet and the two-way political dialogue it fosters will tend to make our democracy more direct and citizen involvement more consuming.”
As with any political development, there may be a darker side. Rush Limbaugh, the conservative radio talk show host, believes the Obama daily dominance of all media has Orwellian, Big Brother overtones, and may lead to totalitarian tyranny of our minds. I would not go that far. I give President Obama his due. It is a brilliant ongoing political communication strategy, transforms politics, and will have to be countered by his political opponents.
I would not bet against significant incremental health reform. What might prevent Obama-style health reform are the economy, the soaring federal budget deficit, and the Department of Health and Human Services current $708 billion budget, 25% of federal spending and Medicare on brink of bankruptcy, but Obama is not one to let billions, even trillions of dollars, stand in his way. He will persist, and he will let the government printing presses roll.
Summary
Barack Obama is our first Internet President, which is altogether without precedent. The President uses the Web to issue a daily report and to mobilize wider political support. That e-tools help his agenda is evident. For Obama, Internet politics is good. For all of us that fact has to be understood. Obama Internet supporters helped get him where he is today and elevated him above the ordinary political fray. For Obama the Internet was the little Engine that could. Say about Obama’s Internet strategy what you will. Say that it’s shows the mark of remarkable political skill. Say that it smacks of George Orwell’s Big Brother. Say that it brings all media under one giant cover. Say what you will: The Internet is now routine grist for the political and health care mill.
Saturday, July 4, 2009
Is The Devil in the Details?
As the health reform debate roars on, and Independence day has arrived without any detailed reform bill, these questions arise. Is the devil in the details? Or is the devil in failing to pass a reform bill because of lack of details?
I raise this question because the July 4 edition of Politico reports a health care insider of saying the following about an Obama phone call to Democratic lawmakers before embarking on his Russia trip,”Obama made a very firm pitch that they need to get the bills out of the House and Senate, and we’ll worry about the details in September.”
In other words, to quote the “Come September” song lyrics, “Everything wrong gonna be alright come September.” In September, presumably, we’ll worry about Details. How much is this Thing going to cost? Will the government run a Thing called the Public Plan? How much will the bill dictate terms of the Doctor-Payment engagement, and who gets what and for how much? These are just details, of course.
Obama may be right. As the famous bank robber, Willie Sutton, remarked, “Success in any endeavour requires a single-minded attention to detail and total concentration.” Here that single minded attention seems to be getting the Thing passed and worrying about details later.
But unfortunately, as Alfred North Whitehead, the English philosopher, noted, “We think in generalities, but we live in details.” In general, it would be great to pass a reform bill, but we and future generations will have to live with the details.
Should we not sweat the details? Should we not worry about someone who can’t be bothered with details? Anyway, are details all that important as long as we do the Right Thing and get the Right Thing done?
Details, details. We’ll bother about them come September. After September, we'll worry about how much Independence remains for doctors and patients. But not this Independence Day, when we celebrate the Past.
I raise this question because the July 4 edition of Politico reports a health care insider of saying the following about an Obama phone call to Democratic lawmakers before embarking on his Russia trip,”Obama made a very firm pitch that they need to get the bills out of the House and Senate, and we’ll worry about the details in September.”
In other words, to quote the “Come September” song lyrics, “Everything wrong gonna be alright come September.” In September, presumably, we’ll worry about Details. How much is this Thing going to cost? Will the government run a Thing called the Public Plan? How much will the bill dictate terms of the Doctor-Payment engagement, and who gets what and for how much? These are just details, of course.
Obama may be right. As the famous bank robber, Willie Sutton, remarked, “Success in any endeavour requires a single-minded attention to detail and total concentration.” Here that single minded attention seems to be getting the Thing passed and worrying about details later.
But unfortunately, as Alfred North Whitehead, the English philosopher, noted, “We think in generalities, but we live in details.” In general, it would be great to pass a reform bill, but we and future generations will have to live with the details.
Should we not sweat the details? Should we not worry about someone who can’t be bothered with details? Anyway, are details all that important as long as we do the Right Thing and get the Right Thing done?
Details, details. We’ll bother about them come September. After September, we'll worry about how much Independence remains for doctors and patients. But not this Independence Day, when we celebrate the Past.
Friday, July 3, 2009
Obama Dilemma
The Obama Dilemma – how to implement a single payer health system without harming the single greatest employer of American – is vividly on display in the July 2 amd 3 news.
Overall, the health care sector—from physicians' offices, to residential mental health homes, to blood and organ banks—reported 20,800 payroll additions in June, and 127,300 new jobs in the first half of 2009, preliminary data show. In the first half of 2008, the health care sector grew 179,400 new jobs, and averaged about 30,000 new jobs per month.
The fastest area of job growth in the health care sector continues to be in the ambulatory healthcare services, which reported 12,400 new jobs in June, and 83,700 new jobs in the first half of 2009, preliminary data show.
This health care job growth creates a dilemma for President Obama. Obama, you see, has promised to save the economy by spending $330 billion to make the health system more “efficient,” that is, by making the system more “rational” by paying less to hospitals and doctors, and to health plans and drug companies, who collectively employ millions of people. The health care industry is, in fact, the the biggest and only growth sector in the American economy. You can slow its growth, but it will come at the cost of jobs.
Peter Goodman, “Joblessness Hits 9.5%, Deflating Recovery Hopes, Administration Defends, Stimulus Spending as Still Sufficient, Recovery Hopes Deflate as Jobless Rate Hits 9.5% “July 3, New York Times
For another month, manufacturing jobs disappeared, dipping by 136,000, while contraction jobs shrank by 79,000 and retail by 21,000. Health care remained a rare bright spot, adding 21,000.
Martin Kettle, “Obama’s Future Depends Upon His Nation’s Health,”July 3, The Guardian
Be in no doubt, though, that the fate of his reform plan will define the fate of his presidency. It will do so because of two overwhelming reasons. First, because the US healthcare system is so huge. And second, because it has defied the efforts of all those who have tried to reform it in the past. It will be healthcare – not Iraq, Iran, nuclear weapons, climate change, the budget, or even the banks – that frames the verdict on the Obama administration.
Will Wilkinson, “Demcoratic Health Care Vs. Democracy,” July 3, The Week
President Obama has confessed that he'd aim for a Canadian-style, single-payer health-care system if he were "starting from scratch." Of course, nobody gets to start from scratch. We've always got to start from here.
The fact that American voters have repeatedly resisted a move to any system of universal health care underscores for many liberals the danger of leaving the protection of basic rights to the discretion of the democratic public. And so, in one of the profound ironies of American politics, even the Democratic Party abjures the fundamental democratic responsibility of honest persuasion when it comes to nailing down its contested vision of our basic rights.
Nobody gets to start from scratch. And that means sometimes things that shouldn't be on the table are on it. If so, how do we take them off? Not by lying to one another. The worth of trust and cost of mutual hostility are too high. Our democratic burden is to help others see what we think we see. And if we fail, we keep trying. We might try this sometime. Maybe, then, we could find a way to trust one another enough to create a health-care system that really delivers for everybody. Until then, we'll get the system we deserve.
The good news for Obama is: the American people want "reform" - lower prices and wider access. The bad news is that they don't want reform if it interfers with their own private plan, which covers 70% or so of Americans, if it narrows, access to providers and technnologies, and if it interferes with their conservative values - smaller government, lower taxes, freedom to choose, and equal opportunity but not necessarily equal uniform access and results for all.
Overall, the health care sector—from physicians' offices, to residential mental health homes, to blood and organ banks—reported 20,800 payroll additions in June, and 127,300 new jobs in the first half of 2009, preliminary data show. In the first half of 2008, the health care sector grew 179,400 new jobs, and averaged about 30,000 new jobs per month.
The fastest area of job growth in the health care sector continues to be in the ambulatory healthcare services, which reported 12,400 new jobs in June, and 83,700 new jobs in the first half of 2009, preliminary data show.
This health care job growth creates a dilemma for President Obama. Obama, you see, has promised to save the economy by spending $330 billion to make the health system more “efficient,” that is, by making the system more “rational” by paying less to hospitals and doctors, and to health plans and drug companies, who collectively employ millions of people. The health care industry is, in fact, the the biggest and only growth sector in the American economy. You can slow its growth, but it will come at the cost of jobs.
Peter Goodman, “Joblessness Hits 9.5%, Deflating Recovery Hopes, Administration Defends, Stimulus Spending as Still Sufficient, Recovery Hopes Deflate as Jobless Rate Hits 9.5% “July 3, New York Times
For another month, manufacturing jobs disappeared, dipping by 136,000, while contraction jobs shrank by 79,000 and retail by 21,000. Health care remained a rare bright spot, adding 21,000.
Martin Kettle, “Obama’s Future Depends Upon His Nation’s Health,”July 3, The Guardian
Be in no doubt, though, that the fate of his reform plan will define the fate of his presidency. It will do so because of two overwhelming reasons. First, because the US healthcare system is so huge. And second, because it has defied the efforts of all those who have tried to reform it in the past. It will be healthcare – not Iraq, Iran, nuclear weapons, climate change, the budget, or even the banks – that frames the verdict on the Obama administration.
Will Wilkinson, “Demcoratic Health Care Vs. Democracy,” July 3, The Week
President Obama has confessed that he'd aim for a Canadian-style, single-payer health-care system if he were "starting from scratch." Of course, nobody gets to start from scratch. We've always got to start from here.
The fact that American voters have repeatedly resisted a move to any system of universal health care underscores for many liberals the danger of leaving the protection of basic rights to the discretion of the democratic public. And so, in one of the profound ironies of American politics, even the Democratic Party abjures the fundamental democratic responsibility of honest persuasion when it comes to nailing down its contested vision of our basic rights.
Nobody gets to start from scratch. And that means sometimes things that shouldn't be on the table are on it. If so, how do we take them off? Not by lying to one another. The worth of trust and cost of mutual hostility are too high. Our democratic burden is to help others see what we think we see. And if we fail, we keep trying. We might try this sometime. Maybe, then, we could find a way to trust one another enough to create a health-care system that really delivers for everybody. Until then, we'll get the system we deserve.
The good news for Obama is: the American people want "reform" - lower prices and wider access. The bad news is that they don't want reform if it interfers with their own private plan, which covers 70% or so of Americans, if it narrows, access to providers and technnologies, and if it interferes with their conservative values - smaller government, lower taxes, freedom to choose, and equal opportunity but not necessarily equal uniform access and results for all.
Thursday, July 2, 2009
Ahead of Obama Reversal Curse
July 2 - Two days ago, I blogged that Obama was reversing himself on a number of campaign promises. The Wall Street Journal agrees. In an article today, “Obama Moderates Health-Care Stance,” Laura Meckler had this to say
WASHINGTON -- President Barack Obama, after picking fights with rivals over health care during the election campaign, is signaling flexibility on many of his previous stances as he tries to put a health-care deal together.
As a candidate, Mr. Obama criticized Democratic opponent Hillary Clinton for proposing that all Americans be required to get health insurance. Now he says he is open to the idea.
He ran some 47,000 TV ads criticizing Republican candidate John McCain for wanting to tax employee health benefits and cut Medicare spending. Mr. Obama has now signaled openness to taxing such benefits, and has proposed his own Medicare cuts.
In addition, the White House isn't ruling out the possibility that families earning less than $250,000 a year might see higher taxes if they have generous health benefits that become subject to new taxes. During the campaign, Mr. Obama had vowed not to raise taxes on any families earning less than $250,000.
Asked about the shift in positions, White House spokesman Reid Cherlin said the president would prefer that Congress adopt his health-care plan. But "there is recognition across the board that we can't wait another year to get this done," he said.
I suppose the lesson here is that President Obama will do almost anything to get his health care bill passed this year. The health bill is, after all, the biggest pillar of his domestic policy. Like Garrison Keillor's Norwegian farmer in Lake Woebegone, President Obama will do what needs to be done.
WASHINGTON -- President Barack Obama, after picking fights with rivals over health care during the election campaign, is signaling flexibility on many of his previous stances as he tries to put a health-care deal together.
As a candidate, Mr. Obama criticized Democratic opponent Hillary Clinton for proposing that all Americans be required to get health insurance. Now he says he is open to the idea.
He ran some 47,000 TV ads criticizing Republican candidate John McCain for wanting to tax employee health benefits and cut Medicare spending. Mr. Obama has now signaled openness to taxing such benefits, and has proposed his own Medicare cuts.
In addition, the White House isn't ruling out the possibility that families earning less than $250,000 a year might see higher taxes if they have generous health benefits that become subject to new taxes. During the campaign, Mr. Obama had vowed not to raise taxes on any families earning less than $250,000.
Asked about the shift in positions, White House spokesman Reid Cherlin said the president would prefer that Congress adopt his health-care plan. But "there is recognition across the board that we can't wait another year to get this done," he said.
I suppose the lesson here is that President Obama will do almost anything to get his health care bill passed this year. The health bill is, after all, the biggest pillar of his domestic policy. Like Garrison Keillor's Norwegian farmer in Lake Woebegone, President Obama will do what needs to be done.
Physician Fees: Government Giveth, Government Taketh Away, Another Untold Story
Physicians are different from other professionals by virtue of the ground rules of contemporary medicine…Physicians rarely set their own fees are dictated to them by Medicare, Medicaid, HMOs, PPOs, and other third party payers. The money reimbursed to them for services rendered may have little or no relation to to their cost of doing business. What can be more aggravating is that sometimes third party payers also dictate what physicians can and can’t do for their patients, by declining to pay for services that physicians may believe patients need.
Merritt, Hawkins & Associates, Guide to Physician Recruiting, 2007
By and large, the public is completely unaware that Medicare sets the fees for which it will pay doctors, and the health plans follow suite. Doctors are at the mercy of payers.
I thought of this
the other day when I received an itemized statement of what Medicare and Blue Cross Blue Shield paid for work done on me after my visit to a cardiologist. For 5 services, Medicare was billed $1012.02, Medicare paid $211.97, and Blue Cross/Blue Shield plan paid $53.00. The cardiologists billed $1012.92, and Medicare/Blue Cross Blue Shield combined paid $264.97, a reduction of $747.05 – a discount of 738%.
These figures are arrived at based on codes in an arcane process developed by Medicare and something called RUC (Reimbursement Update Committee) . The process is arbitrary, secretive, and byzantine and usually has nothing to do with the cost of doing business.
Now we have new news. Starting in January, 2009, Medicare will up pay to family physicians, internists, and geriatric specialists by 6-8% and cut overall fees to cardiologists by 11% with reductions of 42% for echocardiograms and 24% less for cardiac caths, ,overall fees to radiologists by 20% CT and MRI scans by radiologists .
The good news here is that the Obama administration is making moves to increase pay for primary care and in addition, has $500 million more in funds in the stimulus package to train more primary care doctors. If you’re a specialist, the bad news is the Centers for Medicare and Medicaid Services has decided trim pay for cardiologists and radiologists to keep the overall physician reimbursement pie neutral.
There is probably no rhyme or reason for the magnitude of the cuts, other than the fact that the number of cardiac and imaging procedures are increasing faster than the government would like. The next shoe to drop will likely be for Medicare refusing to pay for procedures that it deems “inappropriate,” or not as “effective” compared to some other procedure or conservative clinical approach.
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