THE DOCTOR’S NOT IN

A recent study in the Journal of the American Medical Association describes a decrease in doctors’ work hours over the past decade to 51 hours a week, down from 55 hours. “After adjusting for inflation, mean physician fees decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in physician hours.” Alarmingly, “[t]he decrease in hours was largest for  …  physicians younger than 45 years ….”

Tomorrow, March 1st, Medicare reimbursement drops by 21%, the culmination of four years of threatened 5% decreases that, at the last moment, were deferred. For those of us who are practicing cardiologists and who have seen some recent Draconian cuts in imaging reimbursement, and those of us who already have lower reimbursement for being “rural,” regardless of the cost of living, the reduction is, in a word, untenable. Practices and services will, inevitably, contract. The first shot hasn’t yet been fired from the physician side, but withdrawals from Medicare, or a decline in the acceptance of new patients, are likely. It is not an easy decision since, in practices heavily tilted toward geriatric medicine, the loss in revenues can be crippling. Of course, this is what the government counts on. It’s tried-and-true negotiating tactics—go as low as possible, find the point of resistance, and back off a trifle. Sounds simple, doesn’t it?

Unfortunately, it won’t take into account the physicians who decide to retire early rather than continue to take the daily stress and 3 a.m. calls for unacceptably lower salaries. It won’t take into account the vacuum filled by physicians of lesser training and experience from less well-vetted institutions overseas and mid-levels (physician’s assistants and nurse practitioners). And don’t count on this as a means of reducing cost. I’m not opposed to a role for mid-levels. I’ve worked and continue to work with them in my practice for years and they are invaluable as physician extenders. But they won’t replace physicians or specialists as their work hours decline, and in many cases I’ve seen the use of specialists increase when less experienced care providers are the referring source.

I’ve made the case repeatedly that there is overutilization in the system by physicians, for a multitude of reasons, and this sorely needs to be addressed. In fact, any reform that does not tackle it is doomed to failure. But blunt, across-the-board cuts in reimbursement of the magnitude we’re now seeing will impact physician access.

Think about that the next time you see the sign in the office window, “The doctor’s not in.”

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