As the storm of health care reform rages in Washington, the sand is running out of the hourglass for Medicare, already projected to be insolvent by 2017. The system significantly underpays physicians for necessary services to Medicare beneficiaries. Over the past 20 years, Congress has expanded Medicare benefits and authorized payment for important new technologies at the expense of physician services.
Each year, a flawed formula known as the Sustainable Growth Rate is used to calculate Medicare payments for physician services. Over the past several years, the growing negative calculation has led Congress to override it with a last-minute “patch” to the fee schedule — further sustaining insufficient reimbursement and only for short periods.
Congress is merely kicking the can down the road, avoiding a solution to appropriately reimburse physician providers for their services to Medicare beneficiaries. As a result, each year it is increasingly difficult for physicians to provide patients with what they desire most: access to concerned, thoughtful physicians, who can direct the right tests or treatment, at the right time and right place, effectively.
An important example of the crisis is in the delivery of cancer care. Cancer has remained a formidable foe for modern medicine; however, the past decade has witnessed vast advances in the treatment of the disease. We are now seeing substantial declines in the incidence rates and significant improvements in the survival rates of cancer. The U.S. leads the Western world in the best survival statistics. The success is not attributable to any one measure, but through myriad advances in a delicate and complex delivery system that includes healthier lifestyles, prevention, screening, diagnostics and treatments.
Medicare covers most of these, and has adopted a payment system that updates the payment for costly pharmaceuticals four times per year, often costing tens of thousands of dollars. Yet, Medicare significantly underpays for physician services needed to safely administer complex cancer treatments. Preliminary results of a national survey indicate that Medicare pays just 56 percent of the cost of administering complex chemotherapy services in community cancer centers. The Medicare payment system “allows” payment for the cost of chemotherapy drugs, but it only pays 80 percent, resulting in prohibitive co-payments for Medicare patients who don’t have co-insurance.
Compared to the “doughnut hole” in the Medicare prescription drug payment system, these co-payments represent a “black hole” for Medicare cancer patients and providers. To add insult to injury, the CMS physician payment schedule for 2010 and beyond cuts even deeper, reducing payment for chemotherapy administration services an additional 5 percent annually, up to 20 percent by 2013. There are more cuts for cancer diagnostic imaging and physician consultations.
Every year over 120,000 Medicare beneficiaries in Georgia are diagnosed with cancer. The CMS cancer cuts threaten their access to what is currently the best cancer care delivery system in the world. The current health care reform bills do nothing to avert this crisis.
Dr. Robert C. Hermann, a Marietta oncologist, is secretary of the Community Oncology Alliance.