This is the last in a four-part series, Medicare at 50, on the history and possible future of Medicare.
Focusing on the historic relationship of Medicare with practicing physicians, this series would not be complete without direct comments from physicians and policy experts familiar with physicians' issues. ľֱ contacted practicing physicians and policy experts for their opinions on the program's achievements and problems. Some have already been cited elsewhere in these articles, some appear here for the first time:
, Internal Medicine and Infectious Disease, New Orleans: "I've been in a partnership in practice since 1978, and we took a real hit with the fee freezes under President Reagan. I understand why they happened -- some specialists were increasing their fees to the stratosphere. Also, for something like back pain, a patient can't leave an orthopedic surgeon's office without studies of all kinds for something we treat all the time, and much less expensively. Physicians who do unnecessary tests have their consciences to live with -- I just won't send patients to them."
"We've had some patients leave our practice because I just couldn't handle their insistence on self-referring to specialists. Bundled payments, ACOs and quality-based reimbursement are basically good ideas, but the problem is I might have the incentive to decline more complex patients in favor of easier ones to improve my outcomes and increase my quality scores. I think one effective step toward highly quality would be to give patients more financial buy-in to avoid unnecessary care. Patients often ask me for MRIs, for example, because 'they don't cost me anything.'"
ENT Surgeon, Tulane University School of Medicine: "I think Medicare has worked well overall, providing adequate access for good reimbursement. The problem comes from the Medicare allowable charge of 80% of the doctor's fee, with the doctor having to bill the patient or supplemental insurance for the remainder, which is a lot of paperwork. And for the dually-eligible, we get nothing for Medicaid. The good side is that Medicare is less hassle to deal with than commercial insurers, now that the program here doesn't require pre-authorization anymore."
"Now there's talk about paying for quality, as if we have adequate quality measures, which we don't, and with a big push toward bundled payments, with hospitals divvying up the proceeds. Some of this doesn't affect me directly as yet -- I lost two practices to Hurricane Katrina and, at 73, don't want to start another, so I'm working on a salaried basis for Tulane."
"I think more patient knowledge of costs would help, but public information right now about real costs and not just charges is difficult to come by."
, Fellow, American Geriatrics Society and Chief Medical Officer, University Medicine, Providence, R.I.: "A Medicare Level 4 visit has a fair range of complexity, and this is the area where geriatricians work. So, while the law of averages sort of works out for most physicians, if you're working at the skewed end, like most geriatricians, there is more marked inequity in reimbursement. Also, because they're working largely for one insurer, Medicare, geriatricians can't cost shift among insurers like some other physicians can."
"A lot of patient care in this field does not take place face-to-face in an office. Home care, intensive involvement with pharmacies, consulting with families -- these are necessary and take a lot of time but they're not compensated for. The new codes for chronic care management and advanced care planning will help but some geriatricians may not fully understand the billing rules for these as yet."
"In general, it will be difficult to address everything that should be for the more complicated patients. Quality measures may prove difficult because there's no methodology as yet for evaluating individual physicians with any accuracy, and it's especially difficult with geriatricians, who deal with a wide variety of cases. But it's a good thing Medicare is looking at quality initiatives; it's been behind some private insurers moving in this direction. Medicare has mostly functioned as a payer of bills to this point, but now it has to change toward evaluating what they buy, not just paying for it. That transformation is now underway."
professor of medicine, University of Washington Division of Gerontology and Geriatric Medicine: "The Medicare program is so old it's sometimes taken for granted as a single-payer program that works quite well. It's more transparent than other insurers -- as a physician, you pretty much know what you will get. It's true that geriatricians tend to work outside the norms, and spending most of your time taking care of these patients can be a tough way to make a living. It's also interesting, I've found, that many people these days over age 75 are quite healthy, have no major impairments or difficulties, and by and large don't even need a doctor. By the same token, older people with intensive needs are growing in number as well. In any event, it surely doesn't hurt for people over 65 to have a dependable source of health insurance."
"One thing that is clear to me: the people at CMS tend to be remarkably intelligent and motivated, altruistic, even. Their first order of business is helping beneficiaries and doing whatever it takes to improve quality of care. I think they've been very good about listening to doctors because they're aware that beneficiaries need access to motivated doctors. Their reasons and intentions for doing what they do are generally good ones. Even so, practicing medicine these days for Medicare and other payers is very demanding."
Medical Director, Center for Heart and Vascular Health, Executive Director, Value Institute, Christiana Healthcare: "Medicare is proposing a very aggressive timeline for their value-based reforms but some of the metrics available are neither accurate nor reliable. Medicare has to be very careful not to choose measures that prove to be inappropriate. Achieving this will be a complicated process, but Medicare has been pretty good about adjusting its timelines in the past, so I'm pretty optimistic this will work out."
"I agree there's been divergence between specialist and primary care reimbursement, largely because metrics for the latter have been difficult to define. Access to care, promptness, effectiveness, safety -- we need to get a handle on these. We need strong support for primary care equity in this because primary care is essential to the healthcare system. If you can't attract physicians to primary care -- and there's been some problem with that of late -- you end up with a serious imbalance."
"I would add that Medicare is, in general, much less burdensome to deal with than private insurers and more efficient in providing reimbursement. Medicare has been better about addressing the metrics of care than most private insurers, and in general we've been pretty fortunate to have the program. So many advances in our healthcare system have occurred because we have Medicare."
, Associate Professor of Clinical Medicine, Weill-Cornell Medical Center: "The medical home movement is returning the patient to the center of attention with healthcare moving beyond the office visit. Medical home physicians engage with the patients as their advocates in dealing with other healthcare workers, families, and the community. It's aimed at reversing the trend in which the primary care physician has been removed from the center of the healthcare team, which is a shame. There's been a toppling of the pyramid of primary care, and it's led to a great deal of administrative expense and bureaucracy. The system is becoming untenable, leading to sloppiness in administrative execution and deep dissatisfaction with our jobs."
"We have to be careful with quality measurements. There's been a lot of poor data generated over the years and physicians have been burned more than once by faulty quality measurement systems heavily promoted."
, Professor of Medicine, Yale University School of Medicine, Director, Yale-New Haven Hospital Center for Outcomes Research and Evaluation: "Medicare has, at this juncture, done a pretty good job of providing patient access to a wide range of needed services, and there's been considerable latitude for physicians and patients to make optimal decisions for their healthcare. But we have to recognize that this is a system that is under stress concerning costs and variable quality of care. It's a system that's feeding volume, and cutting payment rates only exacerbates this. It's a crazy system and, in view of that, it's a remarkable triumph that almost any older person in this country is covered for his or her healthcare needs."
"From a policy standpoint, though, there's been an aversion to taking on the tough issues. There's a sense of denial, for example, that healthcare is taking up fully 17% of our gross domestic product. In this sense of denial of a major problem, our healthcare and our national infrastructure needs are a lot alike."
, Director, Health Care Innovation and Value Initiative, Brookings Institution, and former CMS Administrator, CMS (2004-2006): "When I first became CMS Administrator, I reminded my staff that CMS is the country's largest public health agency, with a significant impact on millions. We recognized that physicians in general have lots of good ideas about healthcare. They also have to make ends meet -- but, by the same token, we have to acknowledge the impact of their services on taxpayers."
"I think Medicare has done a pretty good job of paying accurately and on time, but it was also clear back then that fee-for-service for primary care did not support some aspects of care that physicians thought were important. For example, many medical groups were doing good things to improve care, such as sending email reminders, helping patients with diet and medication advice, developing electronic health records and implementing care coordination, but Medicare paid for none of this."
"We did take some preliminary steps toward tying payments to quality when we started accountable care organizations (ACOs) that focused on care of the highest-risk patients to reduce costs and improve outcomes. And we've had some successful ACOs showing us the way -- for example, Palm Beach (Palm Springs, Fla.), Chrystal Run (Middletown, N.Y.) and Rio Grande (Weslaco, Texas). As organizations such as these move ahead with specific improvements, the way ahead becomes clearer. And we're starting to get more experience with alternative payment models (APMs) showing what physicians can do to succeed."
, Senior Vice President for Public Policy, American College of Physicians: "The way budget neutrality has been grafted onto the fee-for-service system over the years, equity between specialists and primary care physicians has been eroded. Specialists had more opportunity to offset this effect by increasing volume and slicing and dicing procedural codes, but primary care evaluation and management codes really haven't changed much over the past 25 years. The recent new codes for chronic care management are the first discrete new codes for primary care in many years."
"Let's hope that we don't set the alternative payment model bar too high because this could be very difficult for many physicians and lose the support of conservative physician organizations. Medicare participation is always at-risk, although the data thus far haven't shown many Medicare patients having access problems. But some markets with growing older populations and stable physician supply could have a problem, eventually. Lots of physicians 55 years old and older say they'll retire within the next 10 years or earlier, if hassled too much. Would doctors who plan to retire in a few years want to invest the time and effort needed to make the transition to quality-based reimbursement? If not, this could lead to significant patient access problems."
"Some physicians have elected to move toward concierge medicine, which at least keeps the doors open for some physicians, but most of these practices involve reducing their patient panels by as much as half, so I don't see these taking up much of any accessibility slack that might occur."
"On the other end of this, fewer physicians are going into primary care, although the role of physician assistants and nurse practitioners is growing, and telemedicine is developing in rural areas. Whether these developments will impact access to a significant degree remains to be seen. So many things are churning right now in the healthcare system that it's difficult to figure out what it all means. Whether the move toward quality metrics will be a game-changer for Medicare reimbursement we just don't know yet."
(Note: the following discussants responded to a brief send-out survey from ľֱ asking two questions: how they assessed the prospects for Medicare, and whether the Medicare model served as a more appropriate model for national health insurance than the Affordable Care Act)
, Associate Professor of Health Policy and Management, Emory University Rollins School of Public Health: "I think the future of Medicare is questionable in terms of funding. The recent slowdown in healthcare costs is a positive development, but I do not expect it to last. Figuring out how to pay for Medicare in the future is the major domestic policy challenge in the US. Would it serve as a better model for national health insurance than the Affordable Care Act? I don't think so. Aside from the fact that the program is already fiscally unsustainable, I don't think it offers any value over and above the current system. Administrative cost savings for Medicare are greatly overstated. Vested interests and bureaucratic inertia make it difficult to change the structure of the program to keep up with changes in technology and care delivery."
, Dean, Robert F. Wagner Graduate School of Public Service, New York University, New York: "I think the outlook for Medicare is positive. The financial situation of Medicare has improved tremendously over the past 6 years. Between changes made in the ACA and the slowdown in healthcare spending, the forecast level of spending will require no more than a modest bump in funding to meet the future needs of baby boomers. To put the estimates in perspective, medium and long-term Medicare forecasts today are well below the levels they were when Congress decided to expand the program by introducing the prescription drug benefit. However, I don't think that expanding Medicare to encompass the population under 65 would be practical. It would centralize and nationalize a vast amount of healthcare spending for a population with incomes and circumstances much more diverse than is the case for the Medicare population. It's simply unrealistic to imagine this happening."
, Professor and Director, Center for Rural Health, Community, Environment and Policy Division, University of Arizona Mel and Enid Zuckerman College of Public Health: "In 1965 President Johnson signed the amendment to the Social Security Act that created Medicare. In the 50 years since, Medicare has evolved to include benefits that help over 50 million Americans obtain health benefits and services. It remains popular with its beneficiaries, though many challenges must be addressed as our nation's health system evolves. Until Congress resolves protracted battles uncoupling physician payment from the unpopular sustainable growth rate (SGR), physicians willing to see Medicare patients will likely decline. The value-based payment modifier could catalyze payment reform, but many are skeptical that it is just another way to cut physician payment."
"I don't think Medicare would serve as a substitute for the Affordable Care Act as a model for national health insurance. The 'Medicare for All' group had strong support as versions of what became the ACA were being drafted, but there weren't enough votes then, and there certainly aren't today. Covering the uninsured through Medicare, Medicaid and the marketplace is pragmatically what we can do now, though it has been unduly tedious, incremental, and complicated."
"The disparities of our healthcare system -- in health coverage, access to quality care, and health outcomes -- are alarming and disturbing. Reducing disparities may start with improving coverage, but certainly doesn't end there. As a nation, we must do better in terms of quality, equity, health, and fiscal outcomes."
, Assistant Professor of Health Policy and Management, SUNY-Downstate Medical Center School of Public Health: "I believe the prognosis for Medicare moving forward is generally positive. The idea of the trust fund 'going bankrupt' is a perennial ploy offered, for the most part, by those bent on the program's destruction, or at least its massive reconfiguration. We may one day have to seriously reexamine eligibility or funding streams, but I tend to believe we will find that the political will is there to do so. Medicare has proven a veritable godsend for generations of seniors -- delivering not only reliable care but economic security, and offers good bang for our healthcare buck. I believe it is here to stay."
"I have doubts, though, as to whether we'd want to replicate Medicare Advantage on a larger scale as a national health insurance model. The idea of 'Medicare for all' is of sufficient political toxicity that it stands little chance of becoming reality. I believe we need to make the most of what is a flawed reform of a deeply flawed healthcare 'system.'"
The first three parts of this series may be found here: