[Congressional Record Volume 152, Number 132 (Tuesday, December 5, 2006)]
[House]
[Pages H8707-H8713]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HEALTH CARE EXPENDITURES
The SPEAKER pro tempore. Under the Speaker's announced policy of
January 4, 2005, the gentleman from Georgia (Mr. Price) is recognized
for 60 minutes as the designee of the majority leader.
Mr. PRICE of Georgia. Mr. Speaker, I want to thank you so very much
for allowing me to come to the floor. I want to thank the leadership
for allowing me to come and talk about an issue that is extremely,
extremely important and timely right now as we complete congressional
business this week.
I would like to talk a bit about health care and health care
expenditures and how the current system is set up that will, I believe,
and many people believe, adversely affect how patients are treated
across our Nation. And it has to do with the Medicare program, and it
has to do with something called a sustainable growth rate, or SGR,
which is currently the way in which it is determined on the part of the
government how physicians are compensated for caring for Medicare
patients.
Now, before I came to Congress, Mr. Speaker, as you know, and others,
I was a physician, orthopedic surgeon; practiced over 20 years in
private practice of orthopedic surgery on the north side of Atlanta.
And there are probably another 10 or 12 physician Members of the United
States House of Representatives, and each of us knows and appreciates
and understands that the manner in which the government has decided
reimbursement for physicians over the past number of years has resulted
in, in many cases, in many cases across this Nation, a disincentive for
physicians to be able to see patients.
And that is an important point that we need to think about, Mr.
Speaker, because as that disincentive has increased over a period of
time, and I, and many others would argue that it continues to increase.
In fact, it is getting much, much worse. There is a decrease in the
access that patients have to quality care all across this Nation, and
we are seeing it in numbers that we will talk about today, time and
time again, especially in many of the specialties, subspecialties.
So what has happened with the manner in which the government makes
decisions regarding reimbursement, regarding how much physicians are
paid for services, oftentimes what has happened is that patients can no
longer find doctors, having difficulty finding doctors. So what we
would like to do for the next few moments is to chat about, to discuss
this issue of physician reimbursement as it relates to patient access
to care and to talk about this SGR, sustainable growth rate.
I joke back home about how the SGR really is not a sustainable growth
rate; it is an unsustainable reduction rate, URR, and we will have some
numbers that will back that up.
Oftentimes when we think about the expenditure of health care dollars
in this Nation, we think, well, every single dollar is obviously going
to doctors to take care of patients. In fact, that is not what happens.
And this chart is a great example of that.
This is national health care expenditures in the year 2004, the most
recent for which this kind of data is available. The total in 2004 was
$1.88 trillion, Mr. Speaker, $1.88 trillion of money being spent on
health care. And I always, whenever I present this kind of information
in a forum where individuals can ask questions, they are always
surprised to find that a relatively small portion of that health care
dollar goes to their doctors. In fact, on this pie chart, only 21
percent goes for what are called clinical services; that has physician/
clinical services, which means what it takes to take care of patients,
ordering tests and prescription drugs and the like.
In fact, the amount of money going to physicians out of a given
health care dollar is in the low teens, 12, 13, 14 percent on the
dollar, which means that it really is pennies out of the health care
dollar that we are spending in this Nation that goes to the individuals
who are providing the vast majority of the care.
Now, that is not to say that these other things aren't important; but
it is important to appreciate, Mr. Speaker, that the amount of
compensation, the reimbursement, the providing of the cost for the
services that are being provided by physicians is a relatively small
portion of the health care dollar. And that is important, because what
we have seen over the past number of years is that the way in which the
Federal Government is reaching their targets as to how much they spend
on health care is to decrease the reimbursement for physicians, and
therein lies the significant problem.
So how did we end up in this boat?
Well, in 1965, middle '60s, Medicare was passed. And at that time,
the manner in which it was determined how much physicians should be
paid and therefore what kind of access patients had to physician care
was that each individual physician would bill Medicare for certain
services, and then the amount of difference between the amount that
Medicare paid and what they had billed, the physicians were then
allowed to then what's called balance bill or bill the patient. And
initially this program compensated the physicians, as I mentioned, on
the basis of their charges, and allowed them to balance bill.
What happened over a period of time, for a variety of reasons, and I
would suggest, not necessarily physician related, but in 1975 the
Medicare payments were continued to be linked to physicians. But the
annual increase in cost, the annual increase in fees began to be
limited by what was called and is called the Medicare economic index or
MEI. And because the changes were not enough to prevent the total
payments from rising more than were desired at that time, from 1984
through 1991, the yearly change in fees was determined specifically by
legislation.
So between 1984 and 1991, instead of allowing physicians to bill for
certain procedures and certain activities that they would perform in
taking care of patients, what happened is that Congress decided,
between 1984 and 1991, what physicians in the Medicare program would be
compensated for those procedures or that activity. And then starting in
1992, this charge-based system was replaced by what was called a
physician fee schedule. And this fee schedule bases payment for
individual services on measures of the relative resources provided to
them.
Now, this is extremely important because in 1992 was the time when
the Federal Government, and we as a Nation, decided, in essence, we
will determine at the beginning of the year, January 1, how much money
we will spend for health care for the entire year to come. Without
regard to how many patients there were to be seen, what kind of health
challenges and problems they had, we were going to set this finite pot
of money as a Nation and say, this is what we will spend on health
care. It doesn't make a whole lot of sense when you think about it,
because those kinds of things are not necessarily predictable.
Now, at that time it was stated that that schedule, this physician
fee schedule, was not intended to control spending; but it was designed
to redistribute the spending among various physician specialties, so if
it was determined by the Federal Government that thoracic surgeons were
gaining too much of this small portion of the pie, then they would
shift that money to another specialty, remembering that when those
monies are shifted, what happens is that many patients oftentimes lose
access to the care of a quality physician.
Now, the schedule was updated at that time, in 1992, using a
combination of the Medicare economic index that I mentioned before and
an adjustment factor that was designed to counteract changes in volume
of services being delivered per beneficiary. That adjustment factor was
known as the volume performance standard. And over a period of time,
relatively short period of time, that led to significant variability in
the amount of payment rates. And Congress then replaced, in 1998, all
of this system with what is currently in place, which is called the
sustainable growth rate.
{time} 1530
Now, the sustainable growth rate is something that has come under
significant scrutiny, because in fact it hasn't been a growth rate; it
has been, as I mentioned before, a reduction rate. It hasn't answered
the true question of
[[Page H8708]]
how we are going to provide services as a Nation, how the physicians of
this Nation are going to provide appropriate health care services to
patients all across the Nation and what kind of compensation they
should receive.
Many people, when I talk about this at home to folks and talk in
health care conferences, many people really don't appreciate and
understand that, in fact, the Federal Government is setting
reimbursement rates for physicians all across this Nation, the kind of
price-fixing that we have as a Nation said, no, it doesn't work in any
other industry. But, in fact, that is the way we do it in health care.
The reason that it is important and not just related to Medicare is
that the vast majority, Mr. Speaker, the vast majority of insurance
companies tie their reimbursement rates of physicians to what the
reimbursement rate is for Medicare. So what happens is that an
individual insurance company will impose reimbursement for physicians
of a certain percentage, 100 percent of Medicare, 90 percent of
Medicare, 110 percent of Medicare. The result is that, de facto, the
Federal Government is setting the reimbursement rates for physicians
all across this country, and it hasn't worked well. It hasn't worked
well.
The SGR mechanism aims to control spending on physician services
provided under Part B of Medicare, which is where the physician block
is, but it is also where other services are. It does so by setting,
once again, an overall target amount of spending on certain types of
goods and services, as well as payments that Medicare makes for certain
items. As I mentioned, there are other things besides physician payment
in this portion of this pie; for instance, laboratory tests and X-rays,
imaging services and many of the physician-administered drugs.
Now, the Congress had two main goals in mind when it adopted the SGR
mechanism: the sustainable growth rate mechanism, ensuring adequate
access to physician services and controlling Federal spending on those
services in a much more predictable way than that volume performance
standard did. The problem is that the SGR accomplishes neither well.
We find ourselves now over the past few years in a very, very
difficult situation. Since 2002, the spending measured by the SGR
method has consistently been above targets established by the formula.
As a result, the SGR mechanism under current law will substantially
reduce payment rates for physician services over the next several
years. Payment rates would decline by a total of somewhere between 25
and 40 percent, 40 percent, over that period of time.
I have got some charts that will demonstrate a few other matters as
they relate to physician reimbursement and access to care and quality
care.
This is a chart that compares the payments for varying aspects of our
health care delivery system, and each of these bars, there are four
bars, for Medicare Advantage which is part of the Medicare program,
hospitals, nursing homes and then physicians on the far right portion
of the chart.
It is important to keep in mind that the physician portion of this
was slated for a decrease in all of these years, but these are the
actual payments that have gone out, increases in payments or decreases
in payments over the past 4 years. The portion of the Medicare program
Medicare Advantage has seen decreases in the 5 to 7 percent range over
the past 4 years.
Hospitals, appropriately, they do it, they perform a wonderful
service in our health care systems. What they have seen is increases in
the range of 3, 3\1/2\ percent over the last 4 years. Nursing homes, a
comparable level.
It is important that when we have this discussion that we get across
the point that nobody, nobody is saying that these numbers necessarily
ought to decrease, because hospitals and Medicare Advantage, nursing
homes, all of them are providing an absolutely vital and imperative
service. The problem comes, I and many others would suggest, in the
final group of numbers, which is where the physicians have been over
the last 4 years, remembering that the physicians were slated for a
decrease every year.
What that means is when physician reimbursement goes down, physicians
who have been contemplating retirement say, well, it is just not going
to cover my costs anymore; I am not going to be able to practice, too
many headaches from the Federal Government. And many of them retire
prematurely.
I am a third-generation physician. My grandfather saw patients until
he was 94 years old. I guess there are some that would argue that he
ought not to have been seeing patients at that time, but physicians
routinely, over the last 30 to 100 years of the history of our Nation,
routinely retired at a much later date than the general population.
They oftentimes practiced into their seventies and eighties.
That whole trend, that whole trend has changed completely, so that
now we see physicians retiring, if not at the rate of their peers in
other businesses and other endeavors, in fact, many physicians are
retiring at a much younger age because of a combination of factors:
litigation problems, reimbursement problems, aspects of governmental
intervention, regulation kinds of things. But what that means is that
when physicians retire is that patients have a decreasing likelihood of
having access to care, and that is where the concern lies.
When you see this chart here and the past 4 years as it relates to
physician reimbursement, what has happened is that physician increase
in 2004 and 2005 was in about the 1.5 percent range last year. It was
absolutely flat.
So the proposal for this next year, a 5.1 percent decrease that will
take effect, Mr. Speaker, in less than 30 days, in less than 30 days
unless this Congress acts, unless this Congress acts, and there are
incredible surveys and statistics and information we have on what the
consequences, what will be the consequences to American health care if
that 5.1 percent decrease takes effect.
As I mentioned a little bit ago, that decrease is slated to be year
after year after year for the next 6 to 8 years. So it is not that a
5.1 percent decrease in fiscal year 2007 would result in a significant
increase in 2008 or 2009 or 2010 so that folks could plan their future
in terms of their practice and caring for their patients; that would be
followed by a 5 percent decrease in 2008, a 5 percent decrease in 2009,
a 5 percent decrease in 2010 and so on and so on.
The challenges are huge, because what will happen if we allow this to
occur is that patients, many patients across this Nation will have
continuing and increasing difficulty in finding a physician to care for
them. The information on the amount of the number of physicians who
would see these decreases, because it isn't absolutely even 5 percent
across the board for every single physician, is that the vast majority
of physicians would see more than a 5 percent, a 1 to 5 percent cut.
In fact, some physicians would seek decreases in their reimbursement
of 16 to 20 percent, 13 percent of those would see decreases up to 15
percent. So you see where the nationwide effect would be. Sometimes you
will hear folks from the Center from Medicare and Medicaid Services
saying, yes, but some folks would be getting increases. I think that is
arguable.
However, even if that were true, it is only in the 6 percent range,
and it is not among the primary care folks, the internists, family
medicine specialists, family practitioners, those individuals all would
be seeing a decrease.
Remember, Mr. Speaker, the consequence of a decrease in physician
reimbursement rate in Medicare means that there is a ripple effect
throughout the entire system, so that insurance companies reimburse
physicians at a decreased rate, and consequently what happens is that
patients, patients lose their ability to see physicians all across this
Nation.
Now, any of that might be okay if, if there were decreases in the
costs of providing the services. But you and I both know, Mr. Speaker,
that when you go to your doctor, there are more tests that are
oftentimes taken now, because the technology is available. I know when
I go it oftentimes seems to me that there are more people in the office
itself, and most often they are individuals who are not necessarily
involved in the actual care, they are individuals who are involved in
the administrative side of a medical practice; so they are filling out
the paperwork for the insurance company or filling out the paperwork
for the government. So the costs continue to increase.
[[Page H8709]]
This chart here is titled ``The Gap Between Cost Increases and
Payment Updates,'' and this goes from 2001 through 2007, so the past 6
or 7 years. If you take zero percent at 2001 as the baseline, what has
happened to physician practice costs over that period of time is that
the annual increase has bumped up each and every year. Each and every
year the costs of providing the service to patients in any practice has
increased, and that is just like anything else in our economy, by and
large.
Now what has happened to physician payments or physician
reimbursement over that period of time, and you see, Mr. Speaker, where
the challenge is, because this line is not even flat, it is a
continual, continual decrease over a period of time.
Again, the problem, the consequence of this, is that patients are not
able to see the physicians that they desire oftentimes or they are not
able to find a physician to take care of them. It has been estimated
that fully a quarter of patients out there who are trying to find a
primary care physician who will accept Medicare cannot do it. They
cannot do it right now.
When you talk with physician groups about what are the consequences,
again this kind of decrease in 2007, what is going to happen? Nearly
half of the physicians who say if that decrease goes into effect, then
what will happen is that they, their practice, will no longer be able
to take new Medicare patients.
Mr. Speaker, you and I both know that as members of the baby-boom
generation that we are demographically an aging population in this
Nation, and there are more and more individuals who are reaching
Medicare age. Now, if there are more and more individuals reaching
Medicare age, and fewer and fewer physicians or physician practices who
are able to take new Medicare patients into their practice, then, as
you see, Mr. Speaker, it means that access to care is limited and
consequently quality health care in this Nation will suffer. That is
the magnitude of the challenge that we are talking about.
As I mentioned before, there are a dozen or so physicians in the
United States Congress, and I am pleased to have, hopefully, many of
them join us today, this evening, to talk about this issue. I am so
pleased to have my good colleague and friend from Georgia, Congressman
Phil Gingrey, who is a fellow physician and obstetrician/gynecologist.
Both he and I served in the Georgia State senate together, and we are
both privileged to serve here in the United States House of
Representatives.
I thank you so much for coming today and sharing some words about
what is truly, truly a matter that we must address as a Congress this
week.
Mr. GINGREY. Mr. Speaker, and Dr. Price, thank you for giving me the
opportunity to weigh in on this. I appreciate Representative, Doctor
Price, leading this hour. It is such an important issue and time, of
course, is of the essence. The physicians, the chart that Dr. Price is
showing, is a clear indication that, as he points out, Mr. Speaker, the
cost of doing business, in this instance, the business of providing
medical care to our seniors especially, continues to go up, as does the
cost of doing business in any other profession.
Yet the reimbursement is not even staying level. Our physicians, our
providers, are not just running in place, they are losing ground each
and every year, and that therefore the need is to try to fix this
ultimately on a permanent basis by eliminating this flawed formula,
this so-called SGR way of reimbursing our providers.
But at this point we have to do something about the scheduled 5.1
percent decrease update, a loss of reimbursement for the fiscal year,
or calendar year 2007. And we have a very short period of time to do
this. Dr. Price and Dr. Boustany and Dr. Burgess and the other
physicians, medical and dental, doctors in this House of
Representatives, hopefully on both sides of the aisle, understand the
urgency of this.
{time} 1545
It is not about necessarily boosting the income of any of our
providers, although those who practice the specialty of primary care,
our pediatricians, our family practitioners, our general internists,
their income is certainly not extravagant by any stretch of the
imagination.
But it is really about, and I am sure that Dr. Price has already
mentioned this, the availability of providers for our seniors. That
pressure is getting greater each and every day. Thank God, they are
living longer and healthier lives, and I think the Medicare part D
provision that we passed in November of 2003 is really adding to that
well-being, that our seniors are going to get the benefit of a
prescription drug coverage that they never had.
But if we don't have any of these primary care physicians willing to
accept these patients because we are not paying them enough to even
reimburse their practice overhead, much less a small profit margin, as
has been pointed out by my colleagues, then the situation gets worse
and worse.
So thank you to my colleague and friend, Dr. Price. As a physician,
Members are here today to try to emphasize the importance to each and
every Member, to our leadership. Let's get this done. Let's make sure
that we not only mitigate a 5.1 percent loss that is calculated on the
basis of this flawed formula, but let's have a positive, a slight
increase of maybe 1 percent for all of our providers. Then if voluntary
reporting is a part of this bill, then, fine, increase it a little bit
more. That is an issue that Dr. Price may want to discuss in more
detail as we go forward in the hour.
But I want to thank him again for taking the leadership on this issue
and giving me an opportunity to weigh in.
Mr. PRICE of Georgia. Mr. Speaker, I thank my colleague for coming
and joining us today and pointing out the importance of this, but also
pointing out very clearly the urgency of this matter.
As I mentioned before, if this Congress doesn't act, then what
happens on January 1, less than 30 days away, is that patients will
have less access to high quality health care than they do today;
patients all across this Nation, not just Medicare patients, patients
all across this Nation, from birth to their last days.
It is extremely important that we as a Congress address this. Again,
it is not just Medicare. It ripples into all sorts of other insurance
company reimbursement to physicians all across this Nation. I think
that is important to appreciate, because with the election results on
November 7 of this year, what has happened is that the party in power
will shift after the first of the year, and there are some on the other
side of the aisle, some of my friends on the other side of the aisle
believe we ought to move toward a Medicare system for all, for all
people across this Nation. I personally believe that would be an
absolute disaster in terms of the level of quality care available to
patients all across this Nation. I believe that for a variety of
reasons, not the least of which is this kind of issue.
What we see is a Congress that has been for years, not just 2, 3, 4,
5 years, for years, decades, has struggled with how to fashion
reimbursement for health care across this Nation. I believe that as we
continue to move in the direction of greater control at the level of
the Federal Government, that what happens is that we actually decrease
the access of patients to care and decrease the quality of care that is
provided.
So I thank my colleague from Georgia so very, very much for doing
this and for pointing out the urgency of this, the importance of acting
while we are here this week.
There are a number of proposals that are available in order to allow
us to solve this problem, and I urge my colleagues on both sides of the
aisle to embrace one of these and try to make certain that we do so
before we head home.
I am so pleased to be joined by a new Member of the United States
Congress, another physician Member, Dr. Shelley Sekula Gibbs from
Texas, a practicing dermatologist before she came to Congress, who has
great experience in the community back in Texas and served on the local
city council and has struggled as well, I know, with the kind of
ability to deliver high quality health care to her patients.
We appreciate you coming today and look forward to your insights and
perspective as it relates to patient access to care and the sustainable
growth rates.
Ms. SEKULA GIBBS. Thank you very much, Dr. Price. I appreciate you
[[Page H8710]]
bringing the subject up for the people at home so that they can
understand where their Medicare premiums are going and how the Medicare
dollars are being spent.
I want to also thank Congressman Dr. Gingrey, Dr. Boustany, Dr.
Burgess and a number of the other physician Congress Members who have
worked very diligently to bring this issue to the floor and ask the
American people for their support and understanding of how to make
health care more accessible to our seniors.
I think that having family members, like many of us, who are under
the Medicare program, it is easy to see how Medicare has become more
and more complex over the years and how each time there is one of these
actions that you detailed chronologically, 1965 when it was implemented
it was much simpler and easier. There were also fewer seniors at that
time to cover. Then as time passed, the government looked for ways to
reduce expenditures, reduce spending, but at the same time we saw other
pressures coming to bear on the senior population.
We saw the fact that more and more people are living longer. They are
having vigorous, active lives; and they want to have access to
activities that will allow them to enhance those lives. They are
working longer. They are active in sports.
In order to achieve that and to make sure that they can participate
fully, and that is what I want when I hit those years as well, it
requires a lot of work on the part of the physicians and the health
care industry. That means that they have to have access to
physicians; they have to have access to primary care doctors. And I was
one of those before I was a specialist. I went through that residency.
I know how hard that is, to take care of the whole person and to work
and interrelate with a specialist. It is very difficult, and it
requires the right kind of individual to do that.
We need to support it. And the primary care doctors are the ones who
get hit sometimes the hardest. In your graph that you showed on which
doctors are going to receive a little tiny bit more with that 5 percent
cut, and the vast majority, 95 percent are going to get cut, quite
frequently it is the primary care doctors who get stuck in that. And we
want to encourage people to go into primary care and take that loving
hand who will help our seniors.
But those patients are more complicated. They require more medical
care when they do get sick, and they require more specialists to bring
them out of those medical crises and restore them back to their health
so they can get back to the business of living full quality lives.
I have been a physician for over 20 years, and I have watched as the
Medicare situation has gone really from a situation of more and more
complicated and the reimbursements now are going down, down, down. I
have watched it, how it affects my father and my mother.
My father, who recently passed away, was lucky enough to receive
veterans benefits. That really moved him out of the Medicare arena and
allowed him to have access to the benefits he deserved through the VA.
My mother, on the other hand, has witnessed something that I hope
others never have to see, but she actually has had a physician, a
primary care doctor in a small town in south Texas, go bankrupt, go out
of business.
That is shocking, to think that someone who has spent all the years
that this doctor did in training and becoming a quality physician could
then lose their practice. It is predominantly because in a small town
in south Texas many of the younger people who have private insurance,
some of them move away. And who are left? A lot of the seniors.
Now, it is not to say that is all that is left, but whenever that
balance of having a larger and larger Medicare practice goes out of
kilt, sometimes the physician can't even keep their doors open because
there are so many patients who are there, complicated, elderly patients
who need that care, and they can't get the reimbursement to keep those
doors open, to pay their staff, to keep the lights on and to pay the
rising medical malpractice insurance that goes along with it these
days.
So the notion, knowing that that already happened to my mother and
she lost that doctor who she really trusted and he went out of
business, knowing that that happened before this cut goes into place, I
shudder to think what will happen across small towns all over the
Nation if they are visited with a 5 percent cut, not only in 2007, but
then a large cut in 2008 and another cut in 2009. What will that do to
the primary care doctors who are trying to give that care across the
small towns of our country? We can't let that happen.
So I really support you today, Dr. Price, in asking the colleagues
here on the floor, give the physicians an opportunity to continue to
deliver care to the seniors. Don't make it so hard that they have to
limit the flow of the seniors who are coming in their doors.
That will happen first. They won't out and out quit, but they will
start to limit the numbers that they take. And that is also very
disabling to a senior, when they call and say, do you take Medicare,
don't make it so that they hear on the other end, I am sorry, we can't
see you. That is not right, and we need to open the doors so that more
seniors can have access to health care.
I join you in asking for that, and I hope that our colleagues will
find a way to fix this situation and allow the seniors across the
country to continue to receive the very best health care that is
available in the world.
Mr. PRICE of Georgia. Thank you so very much for your comments and
your participation and for your commitment to service, to standing up
and rising and being a Member of the House of Representatives. We
commend you and thank you for what you have done and appreciate your
perspective and your expertise.
You said it better than anybody could about this isn't about
necessarily reimbursement or money for physicians, this is about access
to care. Because when that physician closed his or her doors in small-
town Texas, which is not unlike small-town America anywhere, then those
patients, those citizens, those American citizens, lose their access to
care.
So this is an urgent issue. It is absolutely imperative that we in
this Congress address it. Once again I call on colleagues on both sides
of the aisle to make certain that we do so this week.
I am pleased as well to be joined by some other physician colleagues.
Dr. Boustany, Congressman Boustany, is a fellow freshman Member from
Louisiana, a cardio-thoracic surgeon, has great expertise in this area
and an understanding and appreciation for the finances of what it takes
to deliver health care, but more importantly for the finances and what
it takes to provide that kind of access to quality health care that
patients all across our Nation deserve and expect. So I welcome you,
Congressman Boustany, and look forward to your comments.
Mr. BOUSTANY. Mr. Speaker, I am pleased to be here today. I want to
thank my colleague and friend from Georgia for organizing this hour and
for yielding me time.
A December 1 Congressional Quarterly article mentioned that a
colleague from California across the aisle shed crocodile tears,
``crocodile tears for providers who faced a cumulative cut of almost 30
percent under the Medicare physician payment formula.'' This colleague
quipped that he had difficulty sympathizing with providers who might be
giving up their golf games.
Instead of revoking negative stereotypes to justify cuts under an
artificial price control formula, Congress ought to consider the real
injustice the formula imposes on patients, such as an 85-year-old
caregiver who has to wait longer and drive further so her ailing
husband can visit a physician.
While Medicare does not force providers to treat Medicare patients,
especially when the cost of providing care exceeds declining payments,
for seniors who turn 65, it is Medicare or no care. It is virtually
impossible for someone at age 65 to find insurance coverage for
physician services outside of Medicare part B.
Medicare needs to honor its commitment, and seniors need more than
access to a waiting list. MedPAC, the independent Federal body created
to advise Congress on Medicare reimbursement issues, calls the Medicare
physician payment formula ``a flawed inequitable mechanism for volume
control.'' It says it could ``threaten beneficiaries' access to care.''
[[Page H8711]]
In fact, the agency already warns that subsets of beneficiaries
report access problems. In 2005, more than one in five Medicare
beneficiaries reported that they sometimes, usually or always
experienced delays in getting an appointment. The same proportion
indicated that they had difficulty finding a new primary care physician
to treat them. MedPAC also writes that among the subset of people who
reported any problems, Medicare beneficiaries were somewhat more likely
in our 2005 sample to characterize the problem as big versus small than
their privately insured counterparts.
{time} 1600
Also, the share of Medicare beneficiaries indicating that they
experienced big problems accessing a primary care physician grew in
both 2004 and 2005 samples. One in four seniors who faced access
problems said that their problem finding a doctor was because they were
covered by Medicare, and this is simply unacceptable.
Equally troubling is a recent survey reporting that 38 percent of
responding physicians indicate that they would decrease the number of
new Medicare patients they accept when the next physician payment cut
occurs and Medicare payments continue falling below the cost of
providing care.
Congress might avoid a cut this year, and it is imperative that we do
that, while leaving the artificial price control intact, as it did for
2003, 2004 and 2005. Yet officials with the Congressional Budget Office
have repeatedly explained that the formula requires these automatic
cuts to be made up in future years. This kick-the-can approach might
seem like the least expensive on paper, but it is clearly
unsustainable. The formula must be changed. Otherwise, the annual cuts
will become more difficult to avoid, and the problem of access will
only grow worse.
Congress needs to look past government accounting gimmicks and
realize that adequate payments will help to ensure timely care and be
more cost-effective for the overall program than addressing serious
health problems with more intrusive and costly medical procedures
later.
Also, all Americans have a personal stake in this issue, and once
informed of the cuts, people understand that cuts mean more than just a
canceled golf game. Almost 9 out of 10 respondents agree that cuts
would severely limit seniors' access to physicians.
Seniors want the freedom to access their physicians, but cuts will
exacerbate projected provider shortages as the baby-boom generation,
one-third of our workforce, becomes Medicare eligible. MEDPAC aptly
warns that the formula's cuts could ``discourage medical students and
residents from becoming primary care physicians.''
Today, fewer radiologists specialize in mammography and fewer
surgeons complete breast cancer fellowships. In addition, fewer
students are entering the specialty of heart and lung surgery, while
half of the heart and lung surgeons in the United States intend to
retire within the next decade, and more than 70 percent plan to retire
within 13 years.
Mr. Speaker, it is disappointing that some lawmakers want to expand
price-fixing in Medicare under the false label of negotiation.
Economists widely agree that artificial price controls lead to
scarcity, which is why Americans do not rely on them in other sectors
of our economy and why we must develop market-based alternatives in
Medicare.
Congress, Mr. Speaker, has a duty to avoid the cuts and to replace
the artificial price control formula with a realistic physician payment
system that protects patient access.
Mr. PRICE of Georgia. Mr. Speaker, I thank Congressman Boustany so
much and appreciate your perspective and the stories that you told and
the statistics you brought to us because it really puts a face on it.
When we have the kind of divisive conversations that oftentimes occur
on the floor of the House, it is not helpful, does not help patients
all across this Nation. So I appreciate you bringing that perspective.
You mentioned again many of the ripples that occur when these kinds
of decisions are made here. What happens in terms of access to care is
maybe the most important thing, but what also happens is it ripples
down the line of what bright young men and women across this country
choose as a profession. Are they choosing to go into medicine; are they
choosing to go into some of the more difficult subspecialties that many
of us will require the care from over our lifetime? And what is indeed
happening is that they are not choosing those things. They are not
choosing to go into medicine in the numbers that they have in the past.
So the ripple effect is huge.
All of it boils down to a decreasing access to care that patients
have across this Nation and a decreasing access to quality care across
this Nation.
I am so humbled by the participation of many of our physician
colleagues in this hour on the floor of the House today. And
Congressman Burgess from Texas has joined us, an individual who has
great expertise in the health care arena, a preeminent member of the
Energy and Commerce Committee, and has a wonderful perspective and has
talked about this issue since his arrival in Congress and has put on
the table specific solutions.
So I welcome him today and thank you for your comments.
Mr. BURGESS. Mr. Speaker, I thank the gentleman for his kind
comments. Of course, the gentleman from Georgia has already done a
great task with the posters this afternoon, but let me just reuse one
that was seen a little bit earlier today.
This one tells such a great story, but unfortunately, it only tells a
portion of the story. The year I took office was 2003. That means my
last active year in practice was the year 2002, and missing from this
graph, the year 2002, is a similar downward bar when doctors received
the 5.1 percent what we euphemistically called a negative update. So
the actual physicians' compensation for the 5- or 6-year moving
budgetary window that we are all so fond of talking about has in fact
been much less than is actually shown on this graph. And that is an
important point to be made because, as we can see, all of the other
aspects that deal with health care reimbursement once a year receive a
cost of living, a market-basket update, but physicians' offices are
expected to bear the brunt of cost reductions on a year-by-year basis.
As you so eloquently pointed out a few moments ago, that is
unsustainable for any small business. If you are losing something on
every transaction, you do not make it up in volume and stay in practice
for very long.
One of the things that I think is so important that we discuss, we
spend some time discussing this afternoon, as hopefully we get to a
resolution of this problem in the conference committee that is now
going on, is to talk a little bit about the pay-for-performance aspect
of it. So much of the physicians' reimbursement is tied up in the talk
of the pay-for-performance concept.
I would just like to submit that if we drive the best doctors out of
providing Medicare services, if we really let the train run off the
tracks on this, we will not be able to pay enough for performance in
the future if we do not recruit our best and brightest to be the
physicians of tomorrow, as Dr. Price has so eloquently stated, or if we
drive out doctors who are in their mid-forties to their mid-sixties,
doctors who are at the peak of their diagnostic abilities, the peak of
their skills in the operating room. If these individuals stop seeing
Medicare patients, we then make the whole system more expensive to
administer if we have only the second and third tier of providers
involved in that care.
Well, one of the things that we hear talked about is a pay-for-
performance indicator, one that has the initials PVRP that stands for
Physician Voluntary Reporting Program. Now, this is a program that is
going to be articulated by CMS some point later in this year, and the
reason I am concerned about it is we are being asked to accept the PVRP
performance indicators as the standard against which we are going to
judge physician practices for years to come, and we have not yet seen
them in their totality. These are rules that will be put out by CMS
some time later this year, perhaps April, perhaps May or perhaps June.
My understanding of the PVRP program is that it is largely a
structural program and not necessarily outcomes-based. That is, does
every diabetic receive a hemoglobin A1C test every so many months,
rather than do we look
[[Page H8712]]
at the world of diabetic patients within this physician's care and make
certain that the emergency room visits and the out-of-control
hospitalizations are, in fact, in line with what would be expected.
Earlier this year, I introduced bill, H.R. 5866, to repeal the SGR
formula in its totality, in order to acknowledge that there is a
growing sentiment out there that some type of performance measure has
to be built in. I did ask that the individual quality organizations
that are already in place be allowed to provide voluntary guidelines
for physicians to follow. These quality measures taken as a whole
provide a balanced overview of the performance of an individual doctor
or clinic or billing unit, if you will.
The whole idea was that they would be consistent; they would be
relevant. They would be not overly burdensome time to collect and they
would account for patient satisfaction. The goal of the system was fair
assessment to reduce health care costs, improve health care outcomes,
but very importantly, not contribute to the problem that we already
have in this country of health care disparities in some communities.
Therefore, in order to account for the differences in patient
population, health status and compliance, these formulas would need to
be very tightly drawn.
In addition, there would be a measure reported back to the physician
himself or herself as to how they did in comparison with their peer
groups. These report cards, if you will, would not necessarily be made
generally available to the public, but whether or not a physician or a
clinic complied with the data that was required, would be made public.
I think it is important to give providers, to give clinics, to give
doctors some measure of flexibility in this regard, and whether it be
the participation in a medical home, whether it be the participation in
the PVRP program, whether it be the participation in the national
quality forum programs, that any of these should be seen as complying
with the intent of the legislation to provide quality measures. They
should be voluntary, and any increase in reimbursement should not
necessarily be tied to the baseline of quality reporting, but an
additional increase in reimbursement would be provided to those
physicians and clinics and offices that did indeed provide some type of
reporting data.
Again, I want to thank the gentleman from Georgia for bringing this
very timely issue to the floor of the Congress. I do know there is a
lot of work going on on this very issue right now, and my goal in this
is to be helpful in the overall process and make certain that in the
future we do not saddle physicians' offices and physicians' practices
with additional reporting requirements that are not voluntary, that are
mandatory, that are punitive in their nature and end up decreasing the
overall quality and character of medicine that we have grown to enjoy
in this country.
I thank the gentleman from Georgia.
Mr. PRICE of Georgia. Thank you so much for your perspective and for
your wisdom in this area. It is extremely helpful and positive and
productive for the debate that we are having or the discussion that we
are having.
I think you point out a very important aspect, and that is, this
voluntary reporting requirement that might come soon for physicians is
an increase in the regulation. And as you so appropriately point out,
it ought not be punitive in nature, because if it is, what we will see
in addition to the challenges that we have with levels of
reimbursement, decreasing access that patients have to care, we will
see further decrease in physicians in the community, and that will
significantly harm the ability of patients to see physicians and get
the care that they so appropriately deserve and require.
Sometimes you will hear folks say in this debate or this discussion,
well, there really is not an access problem. And in having some
discussions with the folks at the Center for Medicare Medicaid
Services, the high-level individuals in the department who are charged
with making certain that physicians are there to take care of patients
from a Federal Government perspective, I had a specific conversation
with one of them.
I said it is imperative that you not continue to decrease the
reimbursement to physicians because they will no longer be able to
cover the costs of providing that care and they will decrease the
number of Medicare patients, if not end seeing Medicare patients all
together.
The response from that individual was chilling, Mr. Speaker. What
that person said was, well, we have not seen it yet, and until we do,
we have not cut them enough.
Mr. Speaker, that is not the kind of collegial activity that we know
to be productive in health care. It also takes incredible advantage of
the Hippocratic oath that all physicians take in this Nation.
I have come to a conclusion that has been very difficult over the
past decade, and it is more so true now, I believe, than ever before,
and that is, that our health care system is held together today by many
things but not the least of which is the altruism of the physicians
involved in caring for patients who understand and appreciate the
importance of that care and also respect and recognize that the oath
that they took to care for patients, oftentimes regardless of the
reimbursement, is the most important thing, but that takes advantage of
the goodwill of so many men and women who are highly trained and
educated across this Nation and who each of us rely on for high-quality
health care.
Because all of us are patients at some point, every single one of us.
So it is imperative that we do the right thing here as a Congress and
make certain that we address this issue.
Sometimes you will hear folks say there is not an access problem,
like the fellow at CMS who made that statement. Let me point out, Mr.
Speaker, a couple items.
A recent survey, a recent study by the Medicare Payment Advisory
Commission charged with looking into these things found that even
before these cuts that we are talking about today might go into effect,
25 percent, fully one-quarter of Medicare patients looking for a new
primary care physician are having difficulty finding one.
{time} 1615
One out of every four new Medicare patients is having difficulty
finding a primary care physician, and that is all the more important as
we mentioned before, Mr. Speaker, that our population is aging. The
demographics are making it such that we are seeing a graying of our
population. So more and more Medicare patients will be coming online.
The congressionally created Council on Graduate Medical Education,
which is the body charged with making certain that we have high quality
physicians trained in this Nation, have reported existing or looming
physician shortages. In fact, they are predicting that as again the
baby boomers enter Medicare and more seniors are requiring health care,
that the country will experience a shortage of 100,000 physicians over
the next 15 years. 100,000 physicians over the next 15 years. And that
is an important time frame to talk about because that is about the time
that it takes to train a physician. From undergraduate school to
medical school and through residency, it is somewhere between 10, 12,
15 years, sometimes even longer.
Mr. Speaker, it is appropriate that we are discussing this. It is
urgent, it is urgent that we correct this remarkable, remarkable
challenge that we have to make certain that all patients across this
Nation have the opportunity to see and be seen and cared for by a
caring, high quality physician.
In closing, Mr. Speaker, let me just say that you have heard much
discussion about the problem, you have heard some discussion about the
solution. I would point out that I think there is a short-term solution
and a long-term solution. A short-term solution is to make certain that
the cuts that have been envisioned and are on the books right now and
will take place on January 1 if the Congress does not act, to make
certain that those decreasing reimbursements don't occur. It is
imperative that we make certain that those don't occur so that we
maintain the opportunity for patients all across this Nation to see
their physicians.
In the long term, it requires either a fix of the formula or truly
changing the system that we have in place that
[[Page H8713]]
provides for reimbursement of physicians so that we can ensure into
generations to come that we have a system in place that respects
individuals who are caring for patients and, more importantly, respects
patients' opportunity to receive access to the highest quality health
care that is available.
And the system that we currently have will not provide for that. It
will not deliver that kind of health care system not only today but
into the future. And so I challenge and ask my colleagues on both sides
of the aisle, we have so much opportunity to do good in this
institution, this is one of those instances that ought not be a
Republican challenge or a Democrat challenge. It is an American
challenge, and we need to come together to make certain that we address
this in a way that allows patients all across this Nation to continue
to have access or to regain access to the highest quality health care
that is available.
I thank once again the leadership for allowing me to organize this
hour. I thank my colleagues who participated and brought so much wisdom
and light to this issue. I appreciate the leadership for allowing me
this time, and I thank you, Mr. Speaker.
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