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Friday, August 28, 2009

Cardiologists Crying Foul Over Medicare Cuts Hurt Obama Revamp


Well, this news is about President Obama,

An Obama administration plan to cut Medicare payments to heart and cancer doctors by $1.4 billion next year is generating a backlash that’s undermining the president’s health-care overhaul.

While President Barack Obama and members of Congress have spent August debating health insurance and medical costs at public forums, specialists are waging what one advocate calls a “tooth and nail” fight against a separate initiative to boost the pay of family doctors, and cut fees for cardiologists and oncologists. The specialists, in newspaper columns and meetings with lawmakers, say patients will lose access to life-saving care, from pacemakers to chemotherapy.

The proposal by Medicare, the government insurer for the elderly and disabled, is an effort by Obama to focus U.S. medicine on preventive care. The fight by physicians who work with the most expensive patients is weakening support for Obama’s broader goal, legislation to remake the health system, said Mark B. McClellan, 46, a former Medicare chief.

“If you can make the health-care debate all about moving slices of the pie around, it’s very easy to generate opposition and very easy to get derailed,” said McClellan, a physician and analyst at the Brookings Institution, a policy research center in Washington, in an interview.

Obama and his allies in Congress are pushing to extend coverage to the 46 million Americans without health insurance, at a potential cost of $1 trillion over a decade. The separate Medicare proposal, announced July 1, slashes projected spending for care by cardiologists and oncologists by more than 10 percent each, while paying family doctors 8 percent more and nurses an additional 7 percent.

Tooth and Nail

“Our 37,000 members are fighting tooth and nail on these other issues rather than fighting thoughtfully for expanding access,” said Jack Lewin, 63, chief executive officer of the Washington-based American College of Cardiology.

The cuts could have the unintended consequence of rationing care, especially in rural regions with a large number of Medicare patients, doctors said. In other areas, specialists may decide to pull out of Medicare, or ask patients to make up the difference with higher out-of-pocket payments, said Alfred Bove, president of the American College of Cardiology.

“A fair number of cardiologists are looking at the accounting and saying ‘we can’t afford it,’” Bove said in a telephone interview.

Some oncologists in rural areas may stop offering chemotherapy in the office, forcing patients to travel to more- distant hospitals, said Allen S. Lichter, 63, CEO of the 27,000- member American Society of Clinical Oncology in Alexandria, Virginia.

Cuts ‘Impossible’

The cuts would be “impossible” for some small-town cardiologists who rely on Medicare patients, said Zia Roshandel, a heart doctor in Culpeper, Virginia. The town of 10,000 people is about 60 miles southwest of Washington.

Roshandel and two partners see perhaps 50 patients a day at his practice, the local hospital and a community clinic for the indigent, the 40-year-old said in a telephone interview. Medicare accounts for two-thirds of their clientele, he said.

Already squeezed by government and private insurers, Roshandel said he has cut office hours, forgone paychecks and shifted his 12 workers to a high-deductible insurance plan over the past two years. The latest proposal would push him out of private practice altogether, most likely to a hospital in a larger community less reliant on Medicare, he said.

‘Close the Office’

If the proposal stands, “the bottom line is I’m going to close the office,” he said. “This is impossible for me to survive. If my partners and I don’t get a salary and run it for free, maybe then we can survive.”

Medicare would reduce reimbursements for some of Roshandel’s most common procedures, raising the amount patients will need to pay up front, he said. The government would cut the $251 it pays for an echocardiogram, a sonogram of the heart, by 40 percent, he said. The rate for a cardiac catheterization, another test, would drop by a third to $249.

Those reductions include an additional across-the-board cut of 22 percent for all physicians mandated by federal budget rules. Legislation passed by three committees in the House last month would eliminate that cut, at a cost of $200 billion to U.S. taxpayers. Even so, if Medicare goes ahead with its tilt toward primary care, cardiologists will suffer, Roshandel said.

The Obama administration’s plan to raise payment for primary care doctors is intended to encourage more doctors to go into that field of medicine. Some 65 million people already live in areas considered by the U.S. Health and Human Services Department to have too few primary care doctors, with less than one practitioner for every 2,000 people, according to department figures as of March 31.

Outnumbered by Specialists

The U.S. has 250,000 primary-care doctors and nurses and about three times as many specialists, said Atul Grover, 39, chief advocacy officer for the Association of American Medical Colleges, a Washington group. The number of medical school graduates in the U.S. entering family medicine fell more than a quarter from 2002 to 2007, according to a study last year by the group and the American Medical Association.

With the number of Americans older than 65 soaring, specialists will be in short supply, Grover said. The Census Bureau projects 81.2 million people in the U.S. will be 65 or older in 2040, from 40.2 million in 2010.

‘Silver Tsunami’

“That silver tsunami that represents the baby boomers hitting Medicare age is coming,” Grover said in a telephone interview, referring to the U.S. generation born from 1946 through 1964. “In the next 20 years, we are going to face a physician shortage really across the board.”

Medicare, which covers 45 million people, is expected to spend $503.1 billion this year, accounting for one of every five dollars spent on U.S. health care, the Centers for Medicare and Medicaid Services estimated in February. Spending will reach $931.9 billion in 2018, the agency said.

Without changes, the system is guaranteed “to basically break the federal budget,” Obama said at a White House news conference July 22.

The reimbursements, though, are still a proposal, and may change before a final schedule is adopted Nov. 1, said Ellen Griffith, a spokeswoman for the Centers for Medicare and Medicaid Services, in an e-mail. “All comments that are submitted during the comment period will be given careful consideration,” she said.

Reid Cherlin, an assistant White House press secretary, said the administration would have no comment “since it concerns a pending regulation.”

Focus on Results

McClellan, who ran Medicare while George W. Bush was president, said the ultimate solution requires changing how doctors are paid to focus more on results rather than on the number of patient visits.

“My hope is that they’ll resolve it in a way that doesn’t just move the deck chairs around in a Medicare payment system that’s clearly sinking,” he said. “This gets resolved by changing the way that Medicare pays so that both the specialists and the generalists get paid more when they work together and deliver better care.”

McClellan cited Medicare pilot programs in which doctors have formed “accountable care organizations” allowing them to better coordinate patient care. The ACC, the cardiologist group, has pitched another alternative that would use lower co-pays to steer patients to better-performing doctors and give bonuses to physicians and hospitals that cut wasteful spending.

Tensions Rising

Tensions are rising among doctors, said Ted Epperly, 55, president of the American Academy of Family Physicians in Leawood, Kansas, in a telephone interview. Epperly runs a family practice in Boise, Idaho, and teaches at the University of Washington School of Medicine in Seattle.

Specialist colleagues have implied his support for the Medicare changes may cost his students, he said.

While family-care students typically spend parts of their three-year residencies training with specialists, “What I’ve heard is ‘maybe we just won’t have time any longer to teach your residents,’” Epperly said.

The ACC is offering a sample letter to patients, asking them to write Congress. “I am concerned that my physician may no longer be able to treat me or other Medicare patients,” the letter says. The campaign has extended to fliers, posters and even the on-hold message the group plays for callers to its Washington office, which asks the public to fight “drastic pay cuts for cardiology.”

The arguments have a familiar ring, McClellan said.

“The usual way that you try to scuttle a health-care reform proposal is by saying whatever it is going to reduce your access to the care that you need,” he said.

Three Years Earlier

Cancer specialists made similar warnings three years ago when reimbursement was cut for the drugs they used, said Nancy M. Kane, a professor at the Harvard School of Public Health in Boston and member of the Medicare Payment Advisory Commission, a panel of outside advisers to Congress.

“As far as I know we have not seen a drop in the number of oncologists since then,” Kane said. “People are not screaming that they don’t have access to oncologists.”

The pay shift would help right a financial imbalance that keeps young physicians out of family care, said Epperly, of the family doctors’ group.

Average total compensation for family doctors ranged from $150,763 to $204,370 a year, according to a 2008 survey by Modern Healthcare magazine. Cardiologists fetched from $332,900 to $561,875. Radiation oncologists, cancer doctors who specialize in radiation therapy, earned $357,000 to $463,293.

“If we don’t invest more in primary care, we won’t have the resources to offer more access,” Epperly said. “Our system is very good at getting people to do what they’re paid to do. That’s why specialists are doing all the things they do, because they’re paid gobs of money.”

To contact the reporters on this story: Alex Nussbaum in New York anussbaum1@bloomberg.net ; Lisa Rapaport in New York at lrapaport1@bloomberg.net .

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