SGR stealthily undermines care -- what will physicians do about it?

There's an old folk myth that says a frog thrown in boiling water will quickly jump out. But a frog in a pan of cold water that is gradually heated will doze happily and cook to death, without ever waking up.

Medicare beneficiaries are not frogs -- but the frog-boiling analogy resonates.

There are certainly valid reasons for the federal government's concern about the cost of the Medicare program: our increasing life expectancy, the impact from baby boomers and ever more expensive diagnostic procedures and therapies. Adding to the pressure on Washington is the taxpayer expectation that after a lifetime of paying into the system, the Medicare program will provide virtually unlimited, American-style (read: no waiting), excellent health care.

The government faces these choices: increase taxes, decrease benefits or increase efficiency.

Increasing efficiency is a great idea, but pay-for-performance is not going to do it. The necessary adoption of appropriate information technology that could help requires a huge investment in both time and money -- investments that not many individual doctors are able to make.

Since the government is unwilling to raise taxes, that leaves decreasing benefits as the remaining option.

And that is how we came to have the sustainable growth rate, the formula that bases payment for physician services on the number of cars produced, ears of corn harvested, pizzas sold and so on.

So how does the SGR boil the frog?

With the decreased, and decreasing, Medicare reimbursement rates, medical students are avoiding the specialties that are heavily dependent on the low reimbursement Medicare E&M services -- general internal medicine and family practice. Already in some areas of America, patients are waiting for a 10-minute-or-less appointment for follow-up on their diabetes, hypertension, heart disease or other chronic illness.

So what should we do about the SGR and our relationship with Medicare?

For the past several years, physicians have been begging for reimbursement increases that are consistent with the increase in the cost of living. We have been phenomenally unsuccessful. The government cites the almost universal acceptance of Medicare assignment as clear evidence that the sky is not falling; that there is no access-to-care crisis. Meanwhile, we have been pacified with increases that are significantly less than the increase in our expenses -- and less than what other components of health care receive.

So the question that I ask our colleagues, including today's medical students, is: What should we do? What should we ask our professional organizations to do, and how should we suggest that it be accomplished?

How can we protect access to good, perhaps even excellent, health care for the expanding Medicare population?

How can we save the frog?

Melvyn Sterling, MD, Orange, Calif.

Editor's note: Dr. Sterling is a California delegate to the AMA House of Delegates and a member of the AMA Council on Science and Public Health.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2006/07/10/edlt0710.htm.