opinion

Medicare turning retirees into new "medical tourists"

A message to all physicians from AMA President Peter W. Carmel, MD.

By Peter W. Carmel, MDis a pediatric neurosurgeon in Newark, N.J., and is immediate past president of the AMA. Posted Sept. 5, 2011.

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I suspect that in many of our patients' minds, there is a disconnect between the turmoil in Washington and their relationships with their physicians.

They don't quite understand the connection between Medicare payment and Medicare physician availability for themselves. Other people, yes, but for themselves, no.

Most people don't make the connection among cuts in Medicare physician payments, the rising cost of medical care and their own welfare. They think that Medicare will be there for them when the time comes, or as it has been since they turned 65. And for many, that will be true.

But depending on what happens during the deliberations of the Joint Select Committee on Deficit Reduction, which are beginning in September, it may not be the case for many others.

Year after year, increases in physician practice costs have exceeded Medicare payment updates. Even using the government's own index of practice cost inflation, average Medicare payments since 2001 have fallen about 20% behind.

By 2020, with the Medicare physician payment cuts forecast by the Medicare trustees, payment rates will be just half what they were in 2001. When Medicare payments no longer keep pace with the cost of care, physicians are forced to make one of two choices -- either limit their Medicare patients or opt out of the program completely.

Either way, patients and physicians both suffer.

Welcoming Medicare patients has always been a good way for newly minted physicians to develop their practices, but that is becoming more difficult as the gap widens between payments and the cost of actually treating a patient.

Similarly, in many rural areas and inner-city neighborhoods, where Medicare patients are a large part of the local population, physicians cannot earn enough from treating non-Medicare patients to cover the deficits they face from treating Medicare patients.

Physician shortages already exist in many rural and inner-city neighborhoods. Another drop in Medicare payments will further hinder any effort to keep physicians in those areas -- and any effort for the local residents to find doctors.

Deciding whether or not to keep seeing Medicare patients can be agonizing for physicians. The thought of turning any patient away is an anathema to most physicians.

In fact, many physicians facing that painful decision acquiesce in the end and decide they will go ahead and keep existing Medicare patients -- but accept no new ones.

Lately, I have become aware of a growing phenomenon in New Jersey, where I practice. I think of it as reverse medical tourism.

Just as many parents are seeing their college-graduate students move back home, my colleagues have heard from a great number of patients who have retired and moved away -- and want to come back to their original doctors for treatment.

Once those retirees get to wherever they have staked out "the good life," many have discovered they cannot find a physician. "No one is taking new Medicare patients," they tell my colleagues. "Can I come back?"

And so, instead of traveling to see grandchildren or to new places, many of these relocated retirees find themselves returning to their old hometowns several times a year for doctors' appointments. For those who need specialists like cardiologists and gastroenterologists, it's even more likely they will become new-style medical tourists.

The government estimates that almost 95% of physicians participate in Medicare. That may seem like good news for seniors. But according to a 2010 AMA survey, about one in five physicians overall, and nearly a third of primary care physicians, say they are being forced to limit the number of Medicare patients in their practices due to the ongoing threat of future cuts and inadequate Medicare rates.

In terms of what this means to our senior citizens, these numbers are unforgivable. And in regard to the aging baby boomers, they portend disaster.

As the deficit committee convenes in September, the AMA strongly urges that it address the 30% cut in Medicare payments due to take effect in January 2012. We all know that this kind of Draconian cut in payments would drive physicians out of Medicare and massively disrupt our seniors' access to the health care they need and deserve.

Further, any long-term effort by the deficit committee to reform Medicare must begin with elimination of the sustainable growth rate formula. Failure to do so will only increase future costs.

For example, if Congress were to wait until 2016 to eliminate the SGR, the cost is estimated to approach $600 billion over 10 years -- twice the cost of doing so today.

And then there is that other issue. Should the deficit committee fail to come to agreement by Nov. 23, the new budget law calls for an across-the-board cut in many parts of government spending, including a maximum of 2% for Medicare. That's over and above any SGR-mandated cuts that are not eliminated.

As physicians, we have faced far too much uncertainty over these past years as we watched our costs go up and payments not keep up. Still, many of us continued to treat Medicare patients at a financial loss, because we are physicians and because caring for people is what we do.

But things must change. No more acquiescing to a flawed payment system. The best way for our country to control health care costs is with new delivery systems and new payment models. We need systems that not only improve efficiency and quality of care, but also ensure that seniors will get the health care -- and choice of physicians -- they have been promised.

The deficit committee has a huge task before it -- and a very short time to accomplish it. By Dec. 2, committee members are required to send an approved bill to the president, House and Senate.

I, for one, wish them Godspeed.

Peter W. Carmel, MD is a pediatric neurosurgeon in Newark, N.J., and is immediate past president of the AMA.

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