House averts ‘fiscal cliff,’ forestalls 26.5% Medicare physician payment cut

Andrew Alan Nierenberg, MD

When reimbursements fall below costs, physicians lose money for every patient they take care of. To ensure that practices stay solvent, 17% of physicians and 31% of primary care doctors limit the proportion of patients covered by Medicare even without the draconian cuts that were just narrowly averted. But the instability and "ongoing threat of future payment cuts" are another factor according to an AMA May 2010 survey of 9,000 physicians. To balance the budget on the backs of physicians and annually threaten to enact further decreases in reimbursement will result in decreased access to physicians for seniors. Congress needs to find a reasonable long-term solution.

Catherine G. Cohen

Congress’ last-minute action to avert the drastic Medicare physician pay cut caused by the sustainable growth rate formula highlights the need for permanent reforms. This recurring threat of SGR cuts and late action by Congress creates instability for Medicare providers that ultimately threatens beneficiaries’ access to quality care. The American Academy of Ophthalmology will push for the new Congress to act quickly to develop a permanent solution to the faulty SGR formula.

Jack M. Bert, MD

The United States represents 4.5% of the world population, yet of the $6.1 trillion spent on medical care annually in the world today, we spend 33% of the total on ourselves. However, physician related income and expenses only represent approximately 10% to 14% of the funds spent on medical care in the U.S. Congress continues "kicking the can" down the road once again without any suggestions regarding meaningful logical reform to Medicare and health care expenses. The $16 trillion deficit will continue to rise without any attention paid to entitlement programs.

As the Oklahoma senator Tom Coburn said on "Face the Nation" this past weekend, every American citizen is in debt $51,000 representing the U.S. government debt, and every Greek citizen is in debt $36,000. So what does that tell us?

Jeffrey R. Starke, MD

The federal government did the only thing it seems to be good at these days, which is crisis management. In fact, virtually none of the problems were solved, just the inevitable was delayed. It punted on raising the debt ceiling and sequestration, and did nothing to fundamentally restructure what is a broken financial system. If nothing else changes, the effect on health care will be catastrophic.

In the short run, Medicare reimbursements to physicians were not cut by 27%. However, none of the financial reforms and restructuring that are needed to make the Affordable Care Act truly transformational to American health care were addressed. My analogy is with quality and safety in health care. For decades, we in health care just put bandages on safety problems to get through the day. Now, we are trying to restructure systems and processes to fundamentally improve the system, avoid the problems, and make it as safe as possible. Our government needs to do the same thing, restructuring the financial system and processes to avoid fiscal cliffs and debt ceilings while ensuring that essential services are maintained.

The problem will not be solved by the expression of extreme “principles” on either side of US political philosophy, but must be solved by compromise and avoidance of the fear to try a new approach. As with medicine, true change in fiscal policy will require courage and leadership, two qualities that have been almost totally lacking in Washington and state capitals all over the country.

Paul A. Volberding, MD

We are glad to see some evidence that the Senate and House have begun to work together in addressing the nation's economy. While getting the tax agreement in place is important, the medical system will need to watch the next steps with real vigilance as the possible spending cuts may yet be a huge challenge to our ability to provide care. We do recognize that discussions on medical spending are coming soon and it will be important to do all we can to ensure as close to universal care access while making tough decisions on how we can participate in sensible cost controls.

 

Richard F. Jacobs, MD

Although the fiscal cliff votes in the US Congress will avert higher taxes for many Americans, the issues related to the debt ceiling and future cost cuts have only been pushed down stream.  For those of us who take care of children, who depend on NIH, other extramural funding, and other federal programs for our missions, this is not a solution.  It is not a time to celebrate!  From graduate medical education support to research support to continued help for children, the current legislative crisis is not over.  It may give many of us a “sigh of relief” for the short term, but we will be back on the battle lines soon as the contentious nature of our current government continues to lead to sleepless nights and stress over the future of our profession and missions.

Richard O. Dolinar, MD

A number of years ago, I was having breakfast at a conference of State legislators. Seated at my table were legislators from around the country. The youngest woman at the table had just recently been elected and was finding the experience to be challenging. Each year the legislators are swamped with hundreds of bills trying to become law. There just is not enough time to thoroughly read each one and decide whether it should become law. She asked for advice from the more seasoned legislators at the table, “How do you do it? Given the time constraints, how are you able to assess each one and vote on it appropriately?” One spoke up immediately and the others nodded in agreement as he answered, “You simply vote yes or no and then go on to the next one.”

That response has always haunted me up to the present. He seemed to be telling the truth, but how preposterous, if he was. Is this how laws are really passed? After watching Congress pass legislation involving the fiscal cliff it would appear to be so. The Senate received the 154 page Bill at 1:36 am and then immediately began voting on it 3 minutes later! After passage in the Senate it was then rushed to the House and was passed a few hours later without going through the customary 48 hour period for public viewing prior to voting on it.

The result? A law that not only contained pork for Puerto Rican rum makers and NASCAR but also increased both taxes and spending while simultaneously “kicking the can down the road” another 2 months to the next budget battle involving the debt ceiling.

Many are quite concerned about our country’s financial future. Currently, out of every dollar spent at the Federal level, over 40 cents of it is borrowed. The US now carries more debt per capita than Greece. This does not bode well for future Medicare physician reimbursements.

Given this reality, perhaps the best we can hope for, individually, is that we die in debt; to do so means that we spent more than we earned. In other words, we won!