HHS Secretary Delivers
Harsh Message to Physicians
Ronald Szabat, J.D., L.L.M., Director
Governmental and Legal Affairs
s
one of my favorite duties at ASA, I have the privilege
of staffing our delegation to the American Medical
Association (AMA) annual and interim meetings. Like
most physician meetings, it’s a great opportunity
to see friends and colleagues from across the country
and learn about common struggles and secrets for success.
Not surprisingly, ASA has emerged as a powerhouse
in the house of medicine with two anesthesiologists,
Rebecca J. Patchin, M.D., and Joseph P. Annis, M.D.,
now serving on AMA’s Board of Trustees; and
Dr. Patchin has the added distinction of serving on
its Executive Committee. Along with a large section
council of anesthesiologists from across many states
and anesthesiologists serving on key councils, the
ASA delegation to AMA, ably led by our own past president
John B. Neeld, Jr., M.D., sets a high standard for
leadership. Within the larger house of medicine, ASA
continues to highlight important scope-of-practice
issues and other matters through policy-making resolutions
that it regularly and successfully brings before the
AMA House of Delegates. In short, ASA epitomizes through
word and deed the motto “together we are stronger.”
We need organized medicine, and it needs us!
Against this backdrop of informed policy debate and
participatory democracy, the AMA House, like our own
ASA House of Delegates, is a place where dedicated
physicians come to exchange ideas and learn. Imagine
the surprise, then, when a much-anticipated recent
speech to the November AMA Interim House of Delegates
in Las Vegas, Nevada, by Health and Human Services
Secretary Michael O. Leavitt amounted to a virtual
denunciation of fee-for-service Medicare in favor
of the untested theories of pay for performance and
a privatized Medicare system. Even worse, if my ears
heard correctly, in the question-and-answer session
that followed his remarks, Secretary Leavitt ended
up blaming physicians for Medicare’s patently
unfair Sustainable Growth Rate (SGR) formula and its
annual cycle of regressive conversion factor cuts!
Mr. Secretary, if you’re listening, please consider
the following:
First, anesthesiologists, like nearly all good hospital-based
physicians, generally cannot “control volume”
or patient utilization of services as the evil Medicare
SGR formula seems to demand they do. As anesthesiologists
know all too well, their contractual obligation to
the hospital or other surgical or outpatient facility
where they practice is to show up and provide expert
anesthesiology medical care without fail to all patients
who come before them, be they Medicare, Medicaid,
insured or uninsured.
How is it, Mr. Secretary, that anesthesiologists can
control volume and help hold down national Medicare
expenses without endangering patients? Would you have
anesthesiologists deliver less anesthetic or allow
pain to take over during surgery? How exactly should
anesthesiologists lessen volume? Violate their contracts
and refuse to treat Medicare patients? Where is the
commitment to the elderly and good medical care in
a Medicare system that every year pays physicians
less for doing more? And while we’re at it,
Mr. Secretary, are you aware that your own agency,
the Centers for Medicare & Medicaid Services,
recently took an added $4 billion out of Medicare
in applying the budget neutrality adjustment in the
Medicare five-year review as harshly as possible?
Where exactly is this Administration headed when it
comes to its commitment to health care for the elderly?
In your remarks, Mr. Secretary, you talked movingly
about societal advances since the time of your daughter’s
birth and through your granddaughter’s birth.
You speculated wistfully about the state of the world
when you become a great-grandfather. But what, Mr.
Secretary, about the relative number of Medicare beneficiaries
at each of these mileposts? Where and how does the
unfailingly harsh SGR formula account for an ever-increasing
number of Medicare seniors, whose numbers grow by
leaps and bounds each year even as life expectancy
grows ever longer thanks to medical advances? How
will physicians cope when the baby boomers swell Medicare’s
ranks in five short years? Why should physicians simply
earn less and less each year from Medicare for the
privilege of seeing their patient case-mix predominated
by the elderly? Does this make sense?
The answer, you seemed to suggest, Mr. Secretary,
is for Medicare physicians and patients to embrace
the privatization of Medicare, where billions of tax
dollars would then flow to greedy managed care executives
“managing care” by denying benefits and
further ratcheting down payments to physicians and
hospitals. Has voodoo economics resurfaced? If the
goal is to create a Medicare system that would serve
no one but investors in managed care companies, then
bravo. Otherwise, Medicare-Advantage is a prescription
for disaster, and the Democrats, now in charge of
Congress, know it. Stay tuned! The opportunity for
health plan accountability has resurfaced!
So, too, with the notion of “pay for performance.”
While true bonus payments might ensure that some chronic
care patients receive needed care, the applicability
of this largely untested concept to the rest of medicine’s
patients remains soft science where physicians have
to play or lose. So, Mr. Secretary, when you tell
the house of medicine that “pay for performance”
is the answer to all that ails Medicare, the good
clinician must ask where is all this alleged “sub-quality
care?” Or is this yet another attempt to divide
the house of medicine, pitting one specialty against
another, fighting for a larger piece of a static pie?
Or worse yet, are we simply handing managed care a
new tool to arbitrarily reduce payment?
Mr. Secretary, with all due respect, I fear you are
not getting the whole story. Today, the Medicare anesthesia
conversion factor stands at only slightly above where
it was in 1992 in real dollars, and when adjusted
for inflation, anesthesiologists have seen nearly
a $4-per-unit drop over these years.
To put it bluntly, this is unsustainable and will
soon undermine access by destroying the viability
of hospital-based medical care across the country.
Now, more than ever, the federal government needs
to renew its commitment to Medicare and pay the freight.
This will be a major focus of ASA’s advocacy
for 2007 and beyond. The battle is joined!
return to top