Congress is scheduled to leave at the end of this week to go home to campaign for the mid-term elections. But a big item remaining on lawmakers' to-do list is deciding whether to cancel a scheduled cut in Medicare payments to doctors. And, if they do, whether to pay doctors different amounts based on how well they do their jobs.
If Congress doesn't act, Medicare payments to doctors will drop by 5.1 percent starting Jan. 1, 2007. The cut isn't intentional; it's the product of a funding formula originally implemented in the 1990s.
"It's a policy that nobody really wanted to happen," says Paul Ginsburg, president of the Center for Studying Health System Change. "But they don't want to face the consequences of doing something about it."
Those consequences include the fact that eliminating the cuts will potentially add tens of billions of dollars to the federal deficit. And, because Medicare premiums are linked to what Medicare pays doctors, any increase in doctor payments will come, in part, from patients' own pockets.
On the other hand, if lawmakers don't cancel the cuts, doctors have threatened to stop seeing Medicare patients. And because Medicare is such a big part of most doctors' income, they say it will affect non-Medicare patients as well.
"We have a crisis," said Steve Nissen, president of the American College of Cardiology. "In rural and inner city communities we don't have cardiologists. If we don't fix this problem, our health care is going to seriously deteriorate."
Doctors say the fact that Medicare payments haven't kept up with medical inflation is keeping medical students from pursuing specialties that take many years of training. For example, nearly a third of residency positions in cardio-thoracic surgery have gone unfilled for the past several years. Frederick Grover, president of the Society for Thoracic Surgery, says that's in no small part due to declining Medicare payments.
"It's massive, which really has to impact young people when they're looking at long training, debt already on board, and pretty hard work," Grover says.
But if Congress is going to give doctors more money, lawmakers want something in return: better quality care. Specifically, says Sen. Max Baucus (D-MT), Congress wants to give increases only to doctors who agree to provide data on the actual care they give.
"It's important generally to encourage quality by linking compensation to quality," Baucus says. "That is to say, doctors who report certain quality measures show they're giving even better quality care, so they get a little additional compensation."
Doctors, however, have resisted most of the proposals offered by lawmakers. Cardiologist Steve Nissen says it's not that doctors object to getting paid based on quality.
"We're absolutely in favor of pay for performance, that's the concept of reimbursement in exchange for quality," Nissen says. "We think it's a great idea."
Rather, Nissen says, it's that most of the proposals offered so far are based on Medicare claims data. And he says that could lead to problems. Take, for example, a patient who goes to a local hospital with a heart attack. That hospital tests the patient's cholesterol, decides he needs more advanced care, and sends him on to another facility.
"And along with them comes their record," Nissen says. "And we look at it and see their cholesterol has been checked. We don't want to repeat the test. It's not cost effective. So we don't repeat it. Then, when that claim goes to Medicare, they say, 'Ah, you didn't measure the cholesterol,' and you get dinged."
Doctors also have another problem compared to other health providers, like hospitals or nursing homes.
"The fact that they are dealing with fewer patients and there's always the issue of 'My patients are sicker than other physicians' patients and I'm going to look bad because of that,'" Ginsburg says.
But Congress is far from having to address that problem. So far, it's just looking at some basic reporting requirements. But even those are encountering resistance from physician groups, leaving open the possibility that the issue could linger on after the election or even into next year.
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