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Medicare Physician Payments

Posted Oct 23 2009 10:02pm

category_bug_politics.gif On Monday, reporting on a conference call with aides to Senate Majority Leader Harry Reid, I wrote that there would be a vote this week to eliminate the mandated 21.5 percent reduction in Medicare reimbursement to physicians that is scheduled to go into effect on 1 January 2010, along with the system that currently determines physician reimbursement levels.

The aides sounded confident that the bill, which needed 60 votes to succeed, would sail through and said a new system would be forthcoming in a health care reform bill.

That didn't happen. On Wednesday, the measure (S.1776) was defeated in a roll call vote 53 – 47. Twelve Democrats and one independent voted against the bill because its cost - $247 billion over 10 years – was not funded.

That got me wondering how much in dollar figures physicians are reimbursed by Medicare. Good luck finding it online. I couldn't – undoubtedly because there are thousands of code numbers for procedures and treatment by which doctors bill Medicare.

But what I do have in my personal possession are three years of records from my tenure so far as a Medicare beneficiary listing charges, reimbursement to the doctor through Medicare Part B and what was covered by my Medigap (supplemental) policy.

Here is an example of one charge from a visit at this time last year when I saw the physician's assistant.

“Medical Visit” was charged by the doctor at $104. The Medicare Approved amount for that service is $59.85 of which it paid 80 percent or $47.88. My Medigap policy paid the remaining 20 percent of the Medicare Approved amount or $11.97.

So the total paid for a $104 visit was $59.85 or about 57 percent of what was billed, and the physician eats the difference.

Physician's assistants are professionally licensed to practice medicine under a physician's supervision. They hold advanced degrees from accredited PA programs and can perform examinations and procedures, diagnose illnesses, order treatment, prescribe medications, refer patients to specialists and assist in surgery.

On the day of the example billing, my physician's assistant conducted a basic physical exam and, because I have had a basal cell carcinoma, checked my body for any new indications of skin cancer. She adjusted my one prescription drug, checked my breasts for lumps, drew blood for a couple of tests (which are billed separately by the diagnostic clinic) and administered my annual flu shot. She also answered a few questions I had with no sense of rushing me through the visit. We spent about 45 minutes together.

$104 is more than reasonable for what we accomplished in that time and although my doctor accepts what Medicare pays, $59.85 doesn't seem fair to me. Nevertheless, unless the Senate finds another way to stop the 21.5 percent reduction in Medicare reimbursements, next year my doctor's office will be paid only $47.28 for the same visit, give or take a few cents.

Medicare determines the amount of physician reimbursement (under Part B) with a system called Sustainable Growth Rate (SGR) by which annual and cumulative spending targets are set. If spending exceeds the target, physician reimbursements for the next year are calculated downward. With the increasing costs of medical care, targets have been missed for the past several years so Congress, each year, has overridden the decrease and for 2009, allowed a 1.1 percent increase.

With the defeat on Wednesday of S.1776, the 21.5 percent reimbursement reduction is scheduled to go into effect on 1 January. After the failed vote, Senator Reid said he expects to go with another one-year override, but after this vote, can we be sure? And it doesn't solve the long-term problem.

An increasing number of physicians do not accept new Medicare patients. If messages from TGB readers are any indication, each year some doctors “fire” their Medicare patients leaving all of us – doctors in regard to their fees and patients in regard to continuing care – in uneasy anticipation of waiting for a shoe to drop.

These issues become more critical when you remember that those 78 million baby boomers start becoming eligible for Medicare in little more than a year, 2011.

S.1776 was defeated because enough senators balked at the $247 billion cost over 10 years. But let's put that number in some perspective. As of July, the bailouts, bank rescues and other corporate aid programs have cost taxpayers $2 trillion dollars – and that's only in one year, not 10. Some experts estimate that the cost will spiral to $23 trillion before it's done.

Currently, the Afghan war is costing roughly $4 billion a month. Now there's an idea: get us out of Afghanistan and the $247 billion cost of maintaining Medicare reimbursements to physicians could be paid for in a little more than five years – half the time covered by the projected $247 billion cost.

Okay, I know it's not that simple, but it could be done if Congress and the administration really believed they work for the people. Trillions of dollars for banks that brought the country to its knees and not a penny so far for the rest of us. That must change. I want my doctor to be paid fairly for her work and I don't think $59.85 is enough.

The PBS series Life (Part 2) hosted by Robert Lipsyte tackles ageism this week. Here is a short clip:

You can watch the entire episode here.

At The Elder Storytelling Place today, Jeanne Waite Follet: Followup to My Glasses are Missing (see also yesterday ).

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