New MedPAC physician member offers a rural perspective

Washington -- The Medicare Payment Advisory Commission last month welcomed another physician to the panel. Thomas M. Dean, MD, a board-certified family physician who has practiced in South Dakota for nearly 30 years, says he brings a much-needed rural viewpoint to the body.

The appointment of Dr. Dean, 62, chief of staff at Avera Weskota Memorial Medical Center in Wessington Springs, to a three-year term brings the number of doctors on the panel to six. The group of 17 MedPAC members makes recommendations to Congress on how to set Medicare reimbursement rates. Commission reports often form the starting point for legislation affecting doctors.

AMNews recently spoke with Dr. Dean about his appointment.

Why were you nominated?

I was officially nominated by the National Rural Health Assn. The main reason was that there has been a shortage of rural representation on MedPAC. The authorizing legislation specifies that there should be a balance between rural and urban interests, and the last few years there has really only been one individual out of the 17 that really was tuned into some of the unique rural needs.

What are some of the conditions facing the rural health care system that you hope to bring to the forefront?

The most underlying concern, which isn't uniquely rural, is a real concern about the long-term financial viability of Medicare. We simply have to make the program stable financially. It's terribly important for the whole nation, but even more so for rural areas, because we have a higher proportion of elderly and disabled folks than the urban areas. It's the biggest source of income for many rural hospitals. In our own little hospital here, our utilization runs around 80% to 85% Medicare.

We have a little critical access hospital, and the next closest hospital of any size is about 45 miles away. Our nearest tertiary center is about 125 miles. Sometimes when you're fairly isolated like this and you're dealing with small staffs who have to cover a variety of different disciplines, there are services that need to be available if you're going to provide emergency care and so forth. Yet we don't do them often enough to make them financially viable. If you just look at it on the surface, sometimes it looks like what we're doing is terribly inefficient, and from a purely economic point of view, sometimes it is.

Yet if you're really going to provide the protection for the folks that expect a certain level of service, you need to have those things available. Those are some of the challenges that need to be taken into consideration when some of these [Medicare payment] policies get established. Sometimes we can do a lot of harm by cutting so much that Medicare beneficiaries do not have reasonable access to a range of services, especially emergency, lab and x-ray services.

What is the key to maintaining this level of access?

We need to do what we need to do to maintain the basic infrastructure. We know that we are not going to have a lot of the tertiary services immediately available. But we need to have reasonably easy access to basic primary care services. One of the biggest benefits to rural areas has been the establishment of the critical access hospital system. Ten to 15 years ago, a large number of small rural hospitals were facing bankruptcy simply because they had small volumes and just couldn't generate the income needed to stay open. The critical access program stabilized that.

There are some threats to that system. For instance, with the development of the Medicare Advantage program, many Medicare recipients have been shifted over to private programs. Most of them are not under the same requirements to reimburse the hospitals on a cost-based formula the way traditional Medicare is.

Another threat is the decreasing availability of primary care physicians. We have fewer medical school graduates choosing primary care disciplines. In the rural areas, those are the people that we need.

How could the Medicare payment system be used to address these problems?

We need to look at these things with an open mind and see what works and what doesn't. We're talking about basic entry-level services so we can treat people with pneumonia and heart failure and broken ankles -- the kind of things that are fairly common in these areas. If the access is easy enough, they will get treatment. If they have to drive 50 or 60 miles, they won't do it. They'll put it off and end up being sicker and have poorer outcomes.

Another real concern is pharmacy services in rural areas. Less and less, pharmacists are interested in buying the corner drugstore and operating it themselves. We know that the big chains are never going to come into the kind of communities that I'm in. More and more, the insurance companies are pushing people to use mail-order pharmacies. Yet we still have need for urgent services. If we don't have local pharmacies, we're going to have to figure out some way for people to have access at least to the drugs they need on an emergency basis.

You're a rural health advocate, but you're also a physician. What issues that affect all doctors do you plan to bring up?

The No. 1 issue is to get a better balance of the type of physician manpower that we're producing, because the shortage of primary care physicians is a serious threat.

Secondly, I'm really concerned with the fragmentation of care that's evolved as we've become more and more dependent on this wide range of specialists. We need to find ways to coordinate care so we don't get all the duplication of medications and missed follow-ups that happen when you have several different physicians seeing the same patient and they're not properly communicating. We pay quite liberally for people to do procedures, but we don't pay very much for anybody to look at the big picture.

MedPAC members have not been able to agree on whether to replace the current Medicare payment formula for physicians. Where might you fall in that debate?

The current formula clearly is seriously flawed, and I doubt it can really be fixed. At the same time, the underlying concern that led to the formula is perfectly legitimate. We do need to control costs and limit the rate of growth. But the idea that you penalize everybody if that rate exceeds the limit means that if I'm cautious and conservative, I'm going to get penalized just as bad as the guy that's extravagant. We have to develop a formula that penalizes the people that are extravagant and reward people that really are conservative.