Fixing the 'Doc Fix'

I saw my doctor Saturday, not in the examining room but on the op-ed page of the Washington Post. Dr. Michael A. Newman is one of the most dedicated public servants I know. When we think of the phrase "public servant" we conjure up an image of a politician trying to find a word that poll-tests better than "politician" to describe himself. But, doctors, too, are public servants in a broader sense.

Newman was writing to urge Congress to bite the bullet and fix the Medicare reimbursement rates which currently are so low, they are driving doctors to decline to take Medicare patients. "Now is not the time for Congress to be penny-wise and pound-foolish," Newman writes, an admonition I delivered last week regarding stimulus spending. Stimulus spending is different from a permanent "doc fix." The latter will have an impact on the budget for the long haul, while Stimulus is, by design, a one-time expenditure of funds to prime the pump. But, they share a different, non-fiscal similarity: the American people need to have confidence in the management of the economy and our seniors need to have confidence that there will be doctors available to care for them. If this is not an example of how to "promote the general Welfare and secure the Blessings of Liberty," I am not sure what is.


In his article, Dr. Newman notes that specialists are often paid considerably higher than general practitioners, which is something that bears analysis and modification. I am sure that this difference is market-driven, but I am also sure that there are ways to set parameters around the market. In fact, we do that all the time for teachers, whose school budgets must be approved by voters, for other employees of the government, and, most especially, for members of the Armed Forces. Those who think the market solves everything and denounce government interference should ask themselves why we make national defense a monopoly, controlled entirely by the government? The reason: There are public purposes that we, as a people, believe should not be subjected to the vagaries of market conditions. I would have preferred a health care reform bill that went further in this direction, but I know that no such bill could pass.

What Newman points out, however, is that the health care reform will not work if the current system is made to absorb 30 million new patients and, because of pay scales, the number of primary care physicians does not grow, or the primary physicians we do have get out of the business of caring for the elderly. Certainly, those 30 million new customers represent a powerful bit of leverage for the government. We could, for example, stipulate that no specialist, such as a cardiologist, can be reimbursed through a health care policy purchased on the new exchanges unless ten percent of their caseload is made up of Medicare and Medicaid patients. Or twenty percent. I will leave the numbers to Mr. Orzag.

The key is that we have a fundamental responsibility as a society to make sure that we have made provision for health care for our elderly, indeed for all. Health care is a basic human right as the Church has taught consistently in all of her statements on the issue. That responsibility to care for the aged and the inform cannot be shirked. The health care reform bill was a major step towards fulfilling that responsibility, but addressing this complicated issue of Medicare reimbursement is critical as well. I do not detect in the Congress or in the White House much in the way of pre-election courage for any policy proposals that do not create jobs. But, if not action can be taken earlier, the day after the election, the Congress should take steps to fix this problem and to do so permanently. Our older citizens deserve not only good health care, they deserve peace of mind that such health care will be there. And doctors like Dr. Newman should not be forced into early retirement because Congress has been spooked into being pound-foolish.

Michael Sean Winters

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Robert Lynch
8 years 7 months ago
No, sorry, David, "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness".
8 years 7 months ago
Norman and MSW are right - many are already seeing in practical ways the refusal of physicians to accept medicare patients.
We should publish the percentage of med school grads who agre to be general practitioners when they have to pay off huge loans and can make so much more specializing.
Changing the current scene will not be easy as ideology will get in the way of trying to implement the common good!
Liam Richardson
8 years 7 months ago
Also, if you want to incentivize the extension of retirement ages, you are going to need to come up with viable insurance options for people who will not be hired (pace the ADEA) because by their ages they will skew the cost of employer-provided health insurance.
James Lindsay
8 years 7 months ago
For David and Gan, the right to health care that MSW was referring to was not one found in the constitution but in Catholic doctrine. Not all considerations of what people are entitled to need to be referenced in American ideals of liberty. The Magisterium of the Catholic Church states that there are positive rights that people are entitled to, regardless of what their governments declare, and among these are health care and a fair living wage (meaning that families need to earn enough to survive and larger families deserve greater consideration). To the extent that political or economic libertarianism is inconsistent with this teaching is the extent that Catholics must ignore their politics and support doctrine. This is also true in abortion - however in all cases, it is best left to the Catholic politicans to say how this is best done. Note that the Social Security system was designed in consultation with a Jesuit priest based on Catholic social encyclicals (Fr. Ryan). I would argue that living wage legislation is the best way to solve both our economic obligations and our obligation to protect the lives of the unborn (just as providing low cost or mandatory rehab is a better way to fight alcoholism than prohibition).

On the subject of paying for care - paying for a doctor fix, the medical needs of the baby boomers, the need to provide affordable medical coverage to people on COBRA and the need to provide for extended unemployment insurance all have a ready made answer, although many will find it distateful. These are all from funds that were designed to be self-supporting originally. Expansions of these programs or merely making them cost effective must ultimately be funded by raising their dedicated revenue streams - however we need not do so in advance of need. We can drop the requirement that the Medicare trust fund maintain some type of long term balance that must be pre-funded. It would be better to allow the tax rate to be raised automatically than to mandate budget cuts instead - or perhaps we can mandate a mix of both unless Congress acts.

In the short term, deficit finance is necessary - however in the long term, subsidizing COBRA, funding doctor fees adequately, providing for longer term unemployment and for Medicare Part D is best done with payroll tax hikes. Indeed, in the area of unemployment - a higher tax rate may have employers think again before assuming that laying people off is in their best interests. The whole point of the tax was to add a little bit of pain to the decision to reduce payrolls to save money. Perhaps this is just the time to make that pain increase.
8 years 7 months ago
The road to Hell is paved with good intentions, as they say.
The Obamacare plan is not about the common good or Catholic doctrine, it is about "bending the cost curve" as he specifically highlighted during the run-up to its passage.  So, you cannot have it both ways, my fellow (liberal) Catholics.  You cannot call for deficit spending as a moral imperative when the very party you follow states that the health plan is really an austerity measure.
But we all know that this is not true.  The health care is will not save money in the long run and you only need to look at one bankrupt European nation after the next to understand this fact.  Not to mention that the federal govt. currently controls over 60 percent of the medical market via medicare, medicaid and Vetrans Hospitals.  This does not even consider the immorality of our current spending and the unintended consequences of a government that will soon be as bankrupt financially as it is morally.
Perhaps we have forgotten that centralized planning - even in the name of the common good - causes more misery and dehumanization than relief. This is not about health, it is about political power and the abortion issue (its expansion via this bill is an absolute moral evil if there ever was one) is proof of the dishonesty or confusion of those support the Democrats in the name of the common good or moral principle.
Finally, a note on this blog - I really am tired of all of the hyper-partsian, hyper-liberal posts by what is supposed to be prestigous Catholic magazine...
Where are the posts on theology, culture, big ideas?  First Things may be right leaning, but at least there is serious intellectual debate and topics - as opposed to talking points from the DNC that appear to dominate this blog...
I am very close to giving up on you guys.
8 years 7 months ago
What is health care?  I am not being facetious.  Just what is it.  What are we entitled to. Are we entitled to more health care today then someone five years ago, 10 years ago, 50 years ago, 500 years ago?  What is meant by this progression is that we should recognize that we may not be able to afford everything that some designate as health care.  Certainly most people would be able to afford easily the health care that was available in the early 1500's but they may not be able to afford the health care available in 10 years, 30 years or 50 years from now.  Suppose we settle on what was available in 1990 then the cost of providing that is much less than providing for every possible option.
Suppose we develop a procedure or medicine that costs hundreds of thousands of dollars and gives someone a 95% chance of surviving an illness, should everyone with the illness get the treatment?  Should someone with millions of dollars be allowed to access the treatment if it can not be made available to everyone?  Or should the treatment be eliminated for even the rich folks?  Suppose the previous treatment for this illness gave no better than a 50% chance for survival but only cost $5,000.  What should we do?  Suppose there are only 5 doctors qualified in the world to do a certain procedure.  Do the doctors have a say in who they treat or how much they can charge?
This is a hypothetical question but we all recognize that the causes of the rising cost of health care are fairly obvious. There are two main factors that have led to the continual increases in medical cost.  
The first is the constant increase in available options for treating any illness as alluded to in my example above.  Anyone who is seriously ill wants the best treatment possible.  These new procedures and medicines are expensive but who is going to deny anyone hope for recovery so all the resources are thrown at every patient and they are expensive.  A cousin of mine told me about the new MRI machines that will be coming on line soon and how they will make any machine currently available obsolete.  No hospital will be able to do without one and they won't come cheap.  Multiply that by a hundred other tests and procedures and you get the picture, rapidly rising expenditures at hospitals and other medical facilities.  During a recent forum at Stanford the head of the Stanford Hospital talked about how they were completely modernizing their health care delivery to be the best.  And I am sure very expensive.  The local hospital system here in suburban New York demanded higher fees from the insurance companies because they just spent $100 million modernizing their four hospitals.  It goes on an on as each year brings something better and more expensive.
  The second cost driver that was not addressed by the Stanford experts was the Tort System that awards large settlements to lawyers who sue over bad medical outcomes.  I have seen this figure as $20-$30 billion or referred to as a drop in the bucket of over $2.5 trillion dollars spent on health care each year.  Yes it is, but a significant portion of the $2.5 trillion is defensive medical practice by doctors to avoid the suits they so desperately want to avoid.  In the last few years several of my friends and myself have all pointed to each one of us or our families who saw this played out in various ways by doctors. Just this small group could point to over $100,000 of unnecessary medical costs all covered by insurance.  One person felt chest pains and $16,000 later it was diagnosed as probably indigestion.
So I ask, what is health care and how much of this right should people in our society provide economically to others to meet this right?  Most of the world does not consider it such a right and it is only in the highly successful countries that it can even be brought up.  And then again what if mandating such a system is actually counter productive, that is it provides less of this service than if a coercive system was not implemented?
James Lindsay
8 years 7 months ago
A lot of what is called defensive medicine is repeat testing designed to get an insurance reimbursement or more likely is a retest to see if the patient's condition has changed. It also verifies the accuracy of the previous test, which many have lacked the same controls as a later test. For example, when I was in the diagnostic process for my adrenal tumor, NIH reran many of the diagnostics - not because they were afraid of being sued (because you can't sue NIH anyway) but because the original test was conducted without changing my medications - and to give the Endocrinoloy Fellow managing my case the experience of dealing with adding the permissible medications, managing me on them and interpreting the results for herself.

Oddly enough, either a single-payer system or a full own expansion of the Public Health Service (which is excellent, by the way, given my first hand experience) to British National Health Service levels would end defense medicine (since, as I said, you can't sue the government for malpractice) and would any coverage of abortion now provided through private insurance outside the strictures of the Hyde Amendment.

In judging the enforcement of a right to health care under the Magisterium, it is easier to say when it isn't happening than saying when it is. Obviously, the system the nation had for treating the uninsured did not pass muster, especially when compared with the changes. Is it perfect? No. It won't even be adequate until employers are mandated to provide sick leave so that people can take their kids to the doctor during working hours without losing wages (thus keeping them out of the Emergency Room).

Personally and professionally, I believe single-payer is inevitable (rather than national healthcare ala the UK), since the individual and company mandates are way too low to keep people from abusing the system by dropping coverage until they get sick, then picking it up again under pre-existing condition reforms. Once Wall Street picks up on this, the entire sector will go to TARP for a bailout and TARP will consolidate the industry into a single-payer system - possibly on a state-by-state basis (like in Canada). Some states are already effectively single-payer systems (like Nebraska, where Blue Cross does over 90% of the business). Once this occurs, tax reform - either a Value Added Tax, a health care payroll tax, or a consolidation of low rate income, payroll and corporate profits taxes into a single Business Income Tax (possibly with a Retail Sales Tax to maintain visibility) is almost inevitable. Such a tax could also be used as a channel for an expanded Child TAx Credit (which would bring us closer to what the Magisterium demands of us).
Dale Rodrigue
8 years 7 months ago
Be careful what you ask for.
As one of those specialists you malign let me tell you that as specialists we train longer, it is more costly, our offices are more expensive to run and our malpractice insurance costs are also much higher than general practitioners. As such we are paid more.
The real problem is that health care is tied not to the government but to ''politics''. Starting today our medicare reimbursement rates are being cut 20% because some in the house of representatives want to use it as leverage against Obama.
What do you want us to do? My expenses are not cut 20%, our insurance reimbursements are all over the place depending on the insurance involved. This in addition to all the charity work we do. We HAVE NO CHOICE but to stop seeing Medicare patients. As far as forcing specialists to see a percentage of medicare/medicaid patients, well that is crap. I tell you what. How about everybody on this site, including all the America editors, and MSW too, take a 20 % reduction in pay and subscription rates. Not too pleasant when spread around is it. My children, products of Catholic education I might add, do not want to become physicians and are horrified when they see what my office has to put up with. No other profession has to put up with as much garbage as we do. I have maybe 15 yrs left to practice. After which I say good luck to the next guy because it is a mess now and will only get worse. First, the OB/GYN's are quitting en masse, next it will be everybody else. As far as GP's they're quitting too, they're tired of the socialized state of medicine. Everybody is determining how much they should be paid except for the physicians themselves.

Finally, the problem actually is this: We want excellent healthcare but we don't want to pay for it.
8 years 7 months ago
You are exactly right. I mentioned this in other posts about health care on this blog. I refuse to discuss the issue of the ''right of health care'' until we establish the definition of ''health care''

The drive for health care reform had two goals. First was ''universal coverage'' and second was ''bending the cost curve''.

If there is one truth about government, its that they have a terrible time controlling costs. The ''doc fix'' is exhibit #1 when it comes to controlling costs. None of the politicians can deal with the so called ''doc fix'' because it involves very difficult political decisions. So they delay and delay the decision. Now they have taken on even more decisions.

There will be no ''bending the cost curve'' prior to the 2010 elections. There will be no ''bending the cost curve'' prior to the 2012 presidential election. In fact the cost of health care will continue to excellerate as the congress and president try to make people feel good about the new health care system.

One of the main reasons for the dramatic increase in health care costs is precisely the existing governement control of health care via Medicare and the crazy incentives of employment based health insurance. This has created an unsustainable drive by industry to come up with new technology and new drugs. Medicare patients want these new expensive therapies. Those with employee based insurance plans expect them. And now everyone has a right to them. I would argue that tech and drug development has gone too fast due to the government. Controlling costs is controlling the incentives. Give the consumer the choice back. They will decide what is worth it.

The only people who can reliably make hard decisions concerning allocation of funds is the consumer of the service.
Stanley Kopacz
8 years 7 months ago
Right now, I'm listed on my driver's license as an organ donor.  But why should I contribute my kidney or heart when the system would not give equal access of my organs to everyone?  In addition, if healthcare is to be rationed by ability to afford, I would want a contribution from the rich to the poor for use of my organs, if going to a rich person.  Otherwise, perhaps I should remove my innards from an unfair system.  Also, if healthcare is to be unevenly distributed, with the most advanced procedures denied to the non-rich, then taxpayers' money should not be spent developing new techniques that will only benefit the rich.  It should be supported privately or a progressive tax should be imposed on medical care to reimburse the denied ones.  We're talking benefits from the Human Genome Project, etc.
8 years 7 months ago
At the current rate that government is ''controlling costs'' nobody will be able to have a transplant when the system crashes.

Utopia is a great ideal however the consequences of government engineered utopia are tragic.

There still is a role for the Church that does not involve lobbying the government!
Stanley Kopacz
8 years 7 months ago
We may NOT have the money to do these things.  But there were no cries about the deficit when we started these multi-trillion dollar wars in Iraq and Afghanistan.  Wars should be subject to cost/benefit analysis just like anything else.  The worst panicky emotionalism was evident after the attacks on the Twin Towers and the Pentagon.  Nobody worried about the deficit then, but they should have.  Now we're into nation building in countries we don't understand while ours collapses.  Cutting costs for social programs is out of the question while we bleed funds for endless stupid wars.  It's just not fair.
8 years 7 months ago
The rightness or wrongness of the two wars has nothing to due with a sustainable model for health care.  They have no relationship at all.
Tom Maher
8 years 7 months ago
Thank you Dr. Rodrigue. It is always good to hear from someone in the real world. i do not doubt that doctors would be driven out by ill-conceived government programs that ignore their interests.

One of the basic problems with Medicare is itis a wage and price control system. Government tries contol valuable services by settin rigit wage and price limits. This politiized the price setting process such that price are rarely raised even if costs require prices increases. Years and decades go by before Congress notices that the prices they control have not made sense for years if ever. Doctors should set the prices of their services.

The idea of the government limiting doctor's wages does not make sense either.

Finally periodically politicians come out with schemes proposinhg that Doctors become slave labor. Politicians propose that Doctors be forced to work without pay or limited pay in order to get their medical degree or license renewed. They actually propose to make Doctors indenture servants, serfs or slaves to the state in violating of the basic equality of all people. Doctors are singled out to make some underfunded governemnt program work. The politicians are not concerned that Doctors have real exepenses too. Politicians love to read the Constitution as if a free lunch is a right for their constituants that someone else is msut pay for.

With health care, government is the problem, not the solution.
Stanley Kopacz
8 years 7 months ago
For Joe,
What do you mean they have nothing to do with each other?  Yopu're complaining about debt.  Taxes in, what out?  It's all from the same pot.  It goes here or it goes there.  You don't want to waste it.  Neither do I.  If you're worried about spending money we don't have, we certainly don't have money to turn Iraq and Afghanistan into utopias.  And we don't seem to be going in that direction.  Close down the wars that the last stupid administration started, save money, reduce debt.  Then talk to me about cutting off medical care to Americans.  If we have money to bomb poor people, we have money to save poor people.
For Dr. Rodrigue:
Nowadays, Doctors seem to have these staffs just to handle the variegated insurance paperwork.  And we patients are caught in the middle of this tug-of-war.  Is dealing with insurance companies any better than dealing with the government?  I would rather some of that 30% of administration monies absorbed by the insurance companies go to guys like you or medical staff. In Europe, it's nowhere near that administrative overhead.  Why are we so screwed up?  If you want to keep the government out, why don't you doctors conglomerate and sell insurance directly and cut out the no-value-added middleman?
8 years 7 months ago
I still don't follow.
The rightness or wrongness of the two wars and the unsustainable growth of health care expendature have nothing to do with each other.  Whether the wars are just or not do not affect whether the health care system is sustainable.  They might affect the point of collapse.  Though I suspect this would be a minimal effect.
Do liberals (or progressives) change the topic to the war because they don't have better arguments?  Is this a standard talking point?  Are you instructed to fall back to the wars when backed into a corner?  Why not just stick to one issue?
Stanley Kopacz
8 years 7 months ago
I'll try one more time, and then I promise, I'll quit.
You are a person who is either by himself or head of a family.  You have a budget.  Do you have money for the kid's braces and a Lexus, or do you just have money for the kid's braces and a hyundai or just enough for the kids braces?
WHen you say rightness or wrongness of wars, you seem to be talking morality and justice.  I'm leaving the moral question aside.  I'm not that nice a guy anyway.  I'm just asking "What are we getting out of having these wars and is it worth the cost?  Can we afford them?"  The same affordability questions you're asking about health care can be asked about military costs and wars?  That is all I'm saying.
I believe these wars are purely a waste of money, that there are cheaper alternatives, and that they are not accomplishing what they are supposed to be accomplishing.  They were initiated without cold, hard calculation and based on 9/11 hysteria.  They are also draining the economy, something I thought conservatives or at least fiscal conservatives worry about.  I can only imagine what the eventual cost of health care for the veterans will cost.
Everything should be put on the table when talking about deficits and saving money.  At the same time.
Stanley Kopacz
8 years 7 months ago
Anyway, if we end up running this thing all Republican-Darwinian, maybe there's a way for the coverage underprivileged to take advantage of "medical tourism".  Go abroad for surgery and treatment at 80% reduction in price, they advertise.  If the Army's telerobotic research pans out, you can eventually have a hindu in India remove your appendix here.  They already examine your x-rays over the internet.
While we wait for these technological developments, maybe something can be arranged with Cuba.  The transportation costs could be a lot lower.  If Cuba set up an insurance plan in conjunction with this, it might be proportionally cheap.  It may even drive down health costs here the good old screw you capitalist market way.
Someday, I guess we'll all be working for $150 per month or not at all.
Beth Cioffoletti
8 years 7 months ago
"I believe these wars are purely a waste of money, that there are cheaper alternatives, and that they are not accomplishing what they are supposed to be accomplishing.  They were initiated without cold, hard calculation and based on 9/11 hysteria.  They are also draining the economy, something I thought conservatives or at least fiscal conservatives worry about.  I can only imagine what the eventual cost of health care for the veterans will cost.Everything should be put on the table when talking about deficits and saving money.  At the same time."
Well said, Stan.  I totally concur, and wonder why this point is so seldomly raised in Catholic conversations.
Look all over the Catholic blogosphere, in all the Catholic publications, liberal and conservative, the cost of war is not discussed. To date, $1.05 trillion dollars have been allocated to the wars in Iraq and Afghanistan.
Vince Killoran
8 years 7 months ago
In this age of globalization I'm surprised we don't have a dialogue with Catholics in other countries about such things as war & health care.  All of the comments here are premised on a kind of "American exceptionalism."
8 years 7 months ago
One of the big problems with health care is the fact that technology has so advanced with great expense, and everyone wants to be entitled to the very best procedures without consideration of the quality of life and extension of life involved. Thus, e.g., an 85 year-old lung cancer patient gets expensive surgeries and chemotherapy to live an extra month or two; and why not if the insurance covers it?

I submit that any health insurance plan should include a free market element in which the patient's decision to undergo a medical procedure would have an economic element to it. Going back to the 85 year-old cancer patient, e.g., allow the patient to either get the treatment OR refuse the treatment and get a cash payment to his family in the amount of, say, 50% of the costs of the refused medical procedures. This forces those who are sick to assess the actual value of the care to them (and the value of refusal, which currently has no value) rather than just saying "yes," and having the insurance company pay out the full cost of treatment. Insurance companies will pay out less, families of people who are going to die imminently will benefit, and the sick patient can feel some satisfaction that his refusal of treatment has benefited others. Expensive procedures that fai to improve life expectancy or quality of life will be weeded out as demand for them drops.

Obviosuly not well thought out here, but as long as there is no incentive to refuse treatment, costs and insurance premiums will continue to rise.

8 years 7 months ago
I know you and I are Irish and Catholic, but I read this and thought- wow Michael sure has 'chutzpa' !
At the time you bragged about all the pretend savings and deficit reduction in ObamaCare when you knew, and everyone knew, that the doc fix was ignored to cook the books with savings.
Now- oh my- what a surprise. And it is unconscionable to overlook the doc fix and not help seniors. Really? How did you think that this was going to be financed- just pass mandate after mandate and no cost controls and kick the can?
I am guessing the AMA is still pumping up this plan - till the payments decline. At my workplace our June 1 medical insurance rates increased 50% after a competative process.( also known as a cartel that has no interstate competition asked for by those meanies the GOP) 
Folks- not sure if he GOP will actually take advantage of this situation but by next winter the lies about keeping your medical plan and ''beltway' cost controls will be obvious. Anyone who thinks this is just a few tea party and Glenn Beck crowd types making noise is asleep at the wheel. They will simply ride the wave generated by tsunami ObamaCare.
Those who want to implement Catholic social doctrine and provide medical access for all will be well advised to be working with those congressman who will implement the fix that is coming after the midterm elections. Adding forced benefits and wiping out medical insurance as we know it has had a far more negative impact then my good friend inside the beltway and his fellow talking head brethren truely realize.


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