A [now open] letter to Congress re: Proposed Medicare Reimbursement Cuts

I'm not sure that this is entirely in keeping with the theme of this blog, but I will justify it by saying that the health of the healthcare system is of vital interest to all stakeholders including researchers with an interest in clinical trials. The following letter was sent via the ACCP to my senators and congressmen in regards to the Medicare reimbursement cuts that are to be instituted in July of this year. We were solicited via the medical professional society to be a voice in opposition to the cuts....

Dear Sir or Madam-

Physicians' income, especially that of primary care providers, upon whom patients rely most heavily for basic care, has been falling in real dollars (not keeping pace with inflation) for years, and the newest cuts will markedly exacerbate the disconcerting trend that already exists.

Most physicians do not begin earning income in earnest until they are over 30 years old, a significant lost opportunity due to prolonged schooling and training. This compounds the problem of substantial debt burden that recent graduates must bear. Economically speaking, medicine, especially in the essential primary care fields, is no longer an attractive option for many talented students and graduates. From a job satisfaction standpoint, medicine has also become far less attractive due to regulatory burdens, paperwork, lack of adequate time to spend with patients, and fragmentation of care.

This fragmentation of care is in fact at least partially driven by Medicare cuts. When reimbursement to an individual physician is cut, s/he simply "farms out" parcels of the overall care of the patient to other physicians and specialists. This "multi-consultism" militates against any cost savings that might be achieved by cuts in reimbursement to individual physicians. Perhaps more alarming is the fact that care delivery is less comprehensive, more fragmented, and less satisfying to patients and physicians alike, the latter which may feel a "diffusion of responsibilty" regarding patients' care when multiconsultism is employed. Reduced reimbursements also likely drive the excess ordering of laboratory tests and radiographic scans, both in situations where the physician stands to profit from the testing and when s/he does not, in the latter case because the care is being "farmed out" not to another physician, but to the laboratory or radiology suite. The result is that Medicare "cuts" may paradoxically increase overall net healthcare expenditures. Physicians are already squeezed as much as they can tolerate being squeezed. Further cuts are certain to backfire in this and myriad other ways.

A perhaps more insidious, invidious, and pernicious result of reimbursement cuts is that it is driving the talent out of medicine, especially primary care medicine. Were it not for the veritable reimbursement shelter that I experience as a practitioner at an academic medical center, I would surely not be practicing medicine in any traditional way - it is simply not worth it. Hence we have the genesis and proliferation of "concierge practices" where the wealthy pay an annual fee for entry into the practice, only cash payments are accepted, and more traditional service from your physician (e.g., time to talk to him/her in an unhurried fashion) can be expected by patients. Hence we have, as pointed out in a recent New York Times article (http://query.nytimes.com/gst/fullpage.html?res=9C05E6D81E38F93AA25750C0A96E9C8B63&scp=2&sq=dermatology&st=nyt ), the siphoning of medical student talent into specialties such as dermatology and plastic surgery because the lifestyle is more attractive and reimbursement is not a problem since the "clientele" (aka patients) are affluent and pay out-of-pocket. Hence we have the brightest physicians, such as my colleague and close friend Michael C., MD, leaving medicine altogether to work on Wall Street in the financial sector. All of these disturbing trends threaten to undermine what was heretofore (and hopefully still is) one of the best healthcare systems on the planet. I, for one, will not recommend a career in primary care to any medical student who seeks my advice, and to undergraduates contemplating a career in medicine I say "enter medicine only if it is the only field you can invision yourself ever being happy in."

The system is broken, and we as a country cannot endure and thrive if our healthcare expenditures continue to eat up 15+% of our GDP. But cutting the payments to physicians, the very workforce upon which delivery of any care depends, is no longer a viable solution to the problem. Other excesses in the system, such as use of branded pharmaceuticals (e.g., Vytorin or Zetia) when generic alternatives are as good or better, use of expensive scans of unproven benefit (screening CT scans for lung cancer) when cheaper alternatives exist (stoping smoking), excessive and wasteful laboratory testing of unproven benefit (daily laboratory testing on hospital inpatients, wanton ordering of chest x-rays, head CTs, EKGs, and echocardiograms), use of therapeutic modalities of very high cost and modest benefit (AICDs, lung transplantation, back surgery, knee arthroscopy, coated stents, etc.), and provision of futile care at the end of life are better targets for cost savings, limitations on which are far less likely to compromise delivery of generally effective and affordable care for the average citizen.

I urge congress to consider the far-reaching but difficult to measure consequences of further reimbursement cuts before an entire generation of the most talented physicians and potential physicians determines that the financial, lifestyle, and opportunity costs of practicing medicine, especially primary care medicine, are just too much to bear.

Regards,

Scott K Aberegg, MD, MPH, FCCP
Assistant Professor of Medicine
The Ohio State University College of Medicine
Columbus,