Uncertainty Surrounding Medicare Payments to Physicians Continue

Most physicians want to be and enjoy being providers of care to our Medicare aged citizens. However, the business person inside these health care providers realize that at the end of the day this work effort must be compensated by reasonable payment. Physician reimbursement for services has been substantially reduced over the last 20 years.

By example, Medicare reimbursement to an Orthopedic Surgeon for Total Knee Replacement surgery has fallen from $1816 in 1992 to $1412 in 2009, a 22 % drop. When adjusted for inflation this is nearly a 50 % drop in payment for services. Beginning tomorrow we all fall over the cliff, with a further 21 % cut down to an estimated $1116. Leaders of organized medicine call this reduction "the cliff" because, in their view, many physicians will not be able to afford to see new Medicare patients, or even stay in the federal program, or even stay in practice if their Medicare pay drops by more than one fifth. They also call it a cliff for seniors who may not be able to find a physician willing to treat them.

This uncertainty in Medicare Physician payments is not new. Proposed cuts have been staved off by temporary congressional measures for many years. The SGR formula behind Medicare payments is not sustainable or practical, yet a permanent fix can not be agreed upon. Many in the health care world believe the SGR is a discredited and dysfunctional tool.

Personally, the uncertainty over the last 8 years associated with being a participating Medicare provider is increasingly becoming intolerable. While the news today is that a 21 % cut in Medicare reimbursement is taking affect on March 1, the news tomorrow may be that Congress has replaced the SGR and has reversed the cuts in physician Medicare reimbursement. Being on a reimbursement roller coaster that is politically controlled is not be the best business model for U.S. Physicians. I am not going to immediately withdraw from Medicare by the March 17 deadline (involved process requiring legal advice and review all insurance contracts since some require Medicare participation). However, if this matter can not be resolved by the 2011 deadline of December 31, 2010, I will most likely have no choice but to become a Private Medicare Contractor and bill patients directly for my services with a market driven fee schedule. The "cliff" analogy appropriately describes the current state of affairs in Medicare Physician reimbursement.

Below are some excerpts and links.

From the NPR website February 26, 2010- Medicare payments to doctors will fall by 21 percent starting on Monday, but Congress may soon act to block the cut. It's the latest reminder of a chronic problem for the federal government: figuring out how to pay doctors who treat Medicare patients.

The story goes all the way back to 1965, when the federal government was about to launch Medicare — the health-insurance plan for the elderly.

From Medscape Today February 26, 2010- If physicians are true to their warnings, Medicare patients next week may experience difficulty making an appointment. A recent poll conducted by several medical societies representing neurosurgeons, for example, revealed that almost 40% would cut back on seeing new Medicare patients if reimbursement continues to decline, while 18% would stop accepting new Medicare patients altogether. Another 27% said they would treat fewer established Medicare patients.

From AAOS bulletin February 26, 2010 - Although Congressional leaders have said that they will enact legislation to stop the scheduled cut and also potentially eliminate the Sustainable Growth Rate (SGR) formula, such action is not guaranteed to occur before March 1. Additionally, differences between the House and Senate health system reform bills mean that the impact of further legislation on individual physicians is not yet clear.

Specialized Orthopaedic Hospitals Have Better Outcomes for Hip and Knee Replacement

A study carried out by researcher's at Iowa's Carver Medical College concluded the more specialized a hospital is in orthopedic surgical care, the better the outcomes appear to be for patients undergoing hip and knee replacement surgery.

Among more specialized hospitals, there were fewer serious post-surgical complications such as blood clots, infections and heart problems, as well as fewer deaths.

The findings, which were published online Feb. 11 by the British Medical Journal, were based on data for nearly 1.3 million patients who received hip or knee replacement surgeries between 2001 and 2005 at 3,818 hospitals in the United States.

"The findings suggest that more specialized hospitals have better outcomes even after we account for the type of patients each hospital cares for and the number of hip and knee replacement surgeries that each hospital performs," said the study's lead author Tyson Hagen, M.D., fellow in rheumatology at the UI Roy J. and Lucille A. Carver College of Medicine and UI Hospitals and Clinics.

"While specialization appears to be an important indicator of quality, it is just one factor that patients might want to consider along with other important factors, such as how close the hospital is to home," Hagen added.

Dr. Tarlow comments : These researchers developed a method to a measure of a hospital’s orthopaedic specialization - Hospital specialization differs from hospital volume and can be defined as the proportion of a specific hospital’s admissions falling into a single disease category - and then stratified the patients based on certain characteristic such as age and overall health. The conclusion of this study confirms what one would assume using common sense; People should expect to receive better care and have better outcomes at a facility that has a great familiarity with a specific form of treatment. There is a movement in the U.S. to limit future planning and construction of these specialty hospitals be it orthopedic, neurologic, cardiac or what have you. These studies are likely being carried out to support the current trend of smaller, specialty hospitals, many of which are physician owned. There is no questions that patients receive great care and continually comment that these specialty facilities exceed their expectations. I see this first hand at Arizona Orthopedic Surgical Hospital.

Should Surgeons Meet Patients Online ?

A New York Times article January 20, 2010 explored the idea of patients initially contacting health care providers online for treatment options and price quotes for treatment. The article focuses on patients with plastic surgery care, a service usually not covered by health insurance and thus paid for on a cash basis.
Here is an excerpt from the article; "You log on to SurgeonHouseCall.com and create a free patient profile declaring your wish to get a tummy tuck. You fill out a brief medical history and include photographs of the problem area.

In no time, three plastic surgeons offer detailed opinions on the best course of action — with price quotes. It’s as if SurgeonHouseCall.com co-opted the LendingTree slogan, “When banks compete, you win."

While I see this model relevant today I see this more likely to become a reality in the future when physicians are competing on price rather than the health insurance plan fixed fee market currently in place. Doctors will compete on price when they opt to drop off insurance plans such as Medicare or Pacificare (just random examples) or when treating people using Health Savings Accounts to pay for their care. In each of these scenarios one would expect treatment plan, the number of tests ordered, and price to matter when choosing a health care provider. This method would allows the patient to "shop" for physician services similar to shopping for a television or appliance because the patient will factor in price just as they do with other purchasing decisions.

Advocates of virtual consultations suggest that convenience and receiving multiple opinions online benefits to a prospective patient. “It changes the first in-person consultation, empowering the patient with knowledge of the procedure, decreased anxiety level and financial readiness”. Patients benefit from a online type of evaluation. They get an idea of the cost, and what you get for that cost before they make a commitment, before they walk through that door to see the physician. It is a way for patients to use the online information exchange with a surgeon for a connection to the physician, his online mannerisms, his thought process and treatment option. This may be one way for patients to choose their care provider in the not to distant future.

Before online patient information exchange becomes main stream important legal issues must be addressed.

Providing a diagnosis to patients across state lines also raises legal issues. The online contact can not be a medical consultation. A patient-doctor relationship is “clearly established and begun when a physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees.” Such a distinction matters, because usually doctors should only be able to care for patients in states where they are licensed. Under any conditions it would be poor practice and foolish to diagnose a patient and outline a treatment plan without seeing the patient face to face.

Paramount in this brave new world is ensuring that patients receive the same standard of care online and in person, said Dr. Chaudhry of the medical board association. “It should be the same exact standard as if the patient was in your examining room. You can’t cut corners.”

I see in the not so distant future a prospective Orthopedic Surgery patient making online contact with several physicians, providing the online doctor with certain generalized facts about their condition (with or without photographs and xray/mri images), and receiving in return several hypothetical diagnoses and cost estimates to treat these conditions. The patient will then review the options and then decide if and when to seek treatment. In this new Online Information Exchange world this patient is empowered with the background knowledge gained from their online communication - this patient will have a more meaningful dialogue with their doctor leading to a better decision for the treatment they may receive.

Fibromyalgia Syndrome: Outcome Following Total Knee Replacement Not As Good As Most Other Patient Groups

According to Wikipedia, fibromyalgia is characterized by chronic widespread pain and allodynia, a heightened and painful response to pressure.[1] Fibromyalgia symptoms are not restricted to pain, leading to the use of the alternative term fibromyalgia syndrome for the condition. Other core symptoms include debilitating fatigue, sleep disturbance, and joint stiffness.

A Mayo Clinic study of 141 Total Knee Replacements done in patients with Fibromyalgia Syndrome concluded that nearly half of the patients reported continued knee pain after replacement surgery (much higher than most other patient groups) and more patients in the study had trouble regaining knee motion. Total Knee Replacement surgery did provide improvements in pain compared to preop levels.

The conclusion is that there is a high prevalance of continued pain and stiffness in Fibromyalgia patients undergoing Total Knee Replacement surgery. The Orthopedic Surgeon should counsel these patients pre-operatively so this sub group of people can make an informed choice as to whether to have this surgery and to align expectations with reality.

Youth Sports Injury; Common Sense Needs to Prevail

Children playing sports such as soccer, football, basketball, baseball, running, dancing and gymnastics are suffering musculoskeletal injuries at unprecedented rates.

Some alarming statistics from Safe Kids, USA: 3.5 million children age 14 and younger are treated for sports injuries each year, nearly half of all injuries to middle school and high school athletes are overuse injuries, and almost 40% of sports related injuries treated at hopsital ER departments are aged 5 to 14 years old.

Youth sports have become big business. Training intensity is high for individual and team sports, with many athletes training 10-20 hours per week. Many adolescent athletes concentrate on one sport and do not cross train or change body loading environments. There has been an increase in youth injuries that require surgery. Overuse injuries such as stress fractures and little league shoulder and osteochondritis dissecans can cause growth disturbances or permanent joint injury. ACL surgeries, elbow surgery and shoulder surgery are far too common place. Many of these injuries can be prevented by allowing minor injuries time to heal (keep youths out of practice and competition for as long as it takes for their bodies to heal), limit participation in any one sport to 8 months or less. If common sense does not prevail our youth athletes will continue to suffer injuries that may have detrimental long term consequences to their health. This post was inspired by an article in AAOS Now entitled The Changing Landscape of Youth Sports Injuries.