President's Page

President's Page
May 2008

What in God's Name am I doing?
22nd Annual Conference of Professions

By William J. Walton, MD
2008 DCMS President

Do you know what the SGR is? Try the following quiz.
The SGR is:

1. A formula for the degradation of nuclear particles in the WDC black hole
2. An actuarial analysis of the aging of whales in the depths of the Pacific Ocean
3. The geometric brain analysis of Tiger Woods’ caddy
4. Your pay formula

If you answered No. 4, you are correct! However, the other three answers make just as much sense.

The SGR formula is the Sustainable Growth Rate formula devised by our great and wise Congress to calculate Medicare payment to physicians. It was intended to keep Medicare costs under control by limiting total payments to physicians to a zero sum, no matter the reality of Medicare patient demographics or physician practice costs.

What this means is that, over the years, as more people reach Medicare age and more people become disabled, physicians get paid proportionately less and less per service provided. It also means that as medicine becomes more complex and demands more physician expertise and time, Medicare pays less and less for physicians’ time and skill. This makes no sense. No one thinks it makes sense. Each US congressman and senator admits it makes no sense. The president thinks it makes no sense. But as a collective body, our US government continues to live by this nonsense, to the grief of our patients and to the detriment of our medical practices.

Each year, Medicare gets ready to enforce the SGR formula, and each year our Congress dallies and postures and dances and fiddles as the year drags on and December approaches. Then at the 11th hour, under pressure from organized medicine (AMA, TMA and specialty societies), Congress delays implementation of the SGR formula and gives physicians a token pay raise. Since 2001, the raise has not kept pace with inflation, and physicians have been more and more strapped to meet expenses. Last December, we faced an SGR formula Medicare payment cut of 10%! Congress delayed the cut and gave us a temporary raise of 0.5%. Wow! But something different happened—Congress delayed the implementation of the formula for only 6 months. That means the dance will happen again this summer.

Each year, more of us limit or drop Medicare participation. Many physicians limit the admission of new Medicare patients into their practices. Many have stopped seeing Medicare patients altogether. And many more will have to stop if the trends continue.

One of my closest colleagues, another family physician, has stopped seeing Medicare patients. He did this not only because they pay less than do younger patients, but they are more complex and take more time. Just the physical part of getting into the office, filling out forms, answering questions more slowly and, as is often the case with older people, inserting a life story with each question, lengthens the visit time. I love my Medicare patients, but I have to admit, my friend is right.

On one recent afternoon, I saw in sequence three Medicare patients. Two used walkers and were accompanied by a relative. As we doctors well know, the relative also has to insert history and a discussion always ensues; more time passes. All three patients had medication lists of 8–12 pharmaceuticals; each must be considered. These three patients had an average of 6 or 7 problems that required attention. We had a great time together as we laughed and hugged. It took 1½ hours to see these three patients, and I then was behind schedule for the rest of the afternoon. Meanwhile, across the street, my good friend, who is an excellent and respected physician, probably was seeing 6 or 7 private pay patients, all of whom “reimburse” at a better rate.

All physicians face the dilemma balancing our desire to practice good medicine while serving our “public” with the need to survive in the business of medical practice. Even if you do not see Medicare patients, the SGR deeply affects you. Medicare is by far the greatest payor in the “industry.” (This is a term I hate. I used to be a physician in the profession of medicine; now some make me a provider in the medical industry.) Medicare sets the benchmark for all other payors, so even if you accept only private plans, you are affected.

Another egregious insult to doctors is not well known. Year after year, hospitals, nursing homes and Medicare Advantage plans get hefty increases in reimbursement while we endure inflationary practice cost and inadequate reimbursement. Who cares for patients—corporations or individual physicians?

Come this summer, Congress again will face the Medicare mess. Congress again may fail to think creatively to solve the mess and delay a decision, leaving us to bleed slowly to death; this is the worst outcome. If Congress fails to react, physician fee payments will be cut 10%. This is a better outcome because then a true crisis will occur before the November election. Physicians will be forced to drop Medicare patients in large numbers, our citizens will be outraged, and something will have to be done to fix Medicare.

The best solution to our crisis is within reach. We all need to put pressure on Congress, educate our patients and band together. Our TMA and AMA are making great efforts on our behalf.

Two Texas congressmen are our champions on this issue. Senator John Cornyn has submitted a bill titled “Ensuring the Future Physician Workforce Act of 2008.” It provides positive physician updates for 2008 and 2009, and eliminates the SGR beginning in 2010. The SGR would be replaced by the Medicare Economic Index (MEI), a more reasonable indicator of practice costs. In the House, Congressman Michael Burgess, MD, has been a tireless champion for sanity in Medicare; his bill is similar to Senator Cornyn’s. Both bills have numerous provisions, most of which the TMA favors. These two need our support.

Here’s another quiz. You should do the following to help fix the SGR problem, except:

1. Nothing; it’s someone else’s problem.
2. Call your congressional representatives and mention Congressman Michael Burgess, MD, and Senator John Cornyn.
3. Call Senator Kay Bailey Hutchison at 202-224-5922 and Senator John Cornyn at 202-224-2934 with your
opinion.
4. Get patient education materials from the TMA website at www.texmed.org. Select Governmental Affairs from the menu on the left, and then click on US Congress. At the bottom of the page is a variety of resources.
5. Read President Hinchey’s Texas Medicare Manifesto on that same US Congress page at www.texmed.org.

I know you all got the answer to that one. Right?!

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