Health Care Reform's Effect on Heart Disease Treatment
I became angry the other day. We’ve all been watching the ongoing debate about healthcare reform. The Democrats recently celebrated the U.S. House’s passage of a healthcare bill.
News in the U.S. Senate wasn’t so great. Senators said that the bill was dead if the government's public option wasn’t modified. Obviously, compromise will need to be part of any final bill’s passage.
Perhaps you’re wondering why I was angry? Was it the fact that major changes are in the works for healthcare? No. My anger wasn’t about passage of a bill for healthcare reform. I think everyone would agree that our healthcare system is in need of some significant improvements.
What angers me is how unilateral decisions about how healthcare are delivered with little inclusion of physician input.
What am I talking about? Well, Medicare recently decided that a significant drop in physician payments is in order. In January, many cuts are planned for physician payments from Medicare. Specifically, they plan on reducing the payment for the nuclear stress tests that are done in physician offices by 36%. This is after a cut of 20% was passed on these tests in 2009.
So, in 2 years time, Medicare plans on cutting payments to physicians on an essential test for diagnosing heart disease in Medicare patients by 56%. What’s the rationale for such a reduction? Medicare doesn’t say-except that too much money is being spent on health care.
What will be the effect of such a drastic reduction in payments to physicians for this test?
Imagine if your boss decided to unilaterally to cut a big chunk of your salary by 56% (In some cardiology practices nuclear testing accounts for 25% of income. A cut by 56% means a salary reduction of 14%. This is on top of a reduction in other services of 15%. In January of 2008 some other tests were cut 25%)
Clearly some cardiologists and internists will no longer be able to offer this test to their patients. Access to care will be limited.
Of course congress says, “Care to Medicare patients will not be limited.”
Medicare has also decided that heart catheterizations are too expensive. A heart catheterization is a test done in the hospital where a cardiologist examines the heart arteries for heart disease. He/She places a needle into the large artery of the leg. Plastic tubes are passed up into the heart and dye is injected to diagnose heart blockages. The test takes anywhere from 30 minutes to an hour to do (the actual test). Further time is spent reviewing the images, talking to the patient, their family, and dictating a report that goes in the medical record. The risks of such a procedure include minor or major bleeding, a heart attack, risk of tearing the heart arteries, strokes, or death. A heart catheterization in my book is a fairly big deal. In the 20 years that I have been in practice I have seen people have a stroke following the procedure. Patients have had significant bleeding, and I’ve even seen people die.
Last year, Medicare paid slightly over $400 to the cardiologist performing this test. Now Medicare plans on reducing this to around $200. So a physician who spent 10 years in training to learn a specialized skill, a test that has possible serious life threatening complications, a test where the patient places their life in your hands- and Medicare proposes to pay the physician less than the cost of having a brake job done on your car.
Someone who paints one room of your house will make as much. Indeed, a decent meal for a family of four can cost nearly as much.
The question is: “What is your health worth?”
Obviously to Medicare the answer is ”not much.”
What’s really happening here? What is the motive behind these cuts? Many cardiologists believe (I do) that Medicare is cutting physician fees in a dramatic fashion not just to control costs but to make private practice difficult if not impossible.
If physician fees are reduced enough then physicians will be forced to work for hospitals. (Interestingly, fees for these tests have not been cut to hospitals.) Or physicians will be driven out of practice entirely. With fewer cardiologists fewer procedures will be done.
Congress has said that patient access to care will not be limited in health care reform, but if you make private practice impossible then you limit access to physicians. Hence, you limit access to care.
If Medicare wants to reduce spending on health care let physicians, nurses, and hospitals- the people who take care of the patients have a major role in designing how to reduce costs. Don’t just give lip service to the people who truly provide health care.
Last year over 3 billion dollars was spent on what many people think are unnecessary CT scans in Emergency Departments across the country. Emergency physicians are scared that they will be sued if they miss a diagnosis so CT scans are ordered on many, many patients. In Canada, Germany, England, and other countries people who are injured in the health care arena receive compensation and care. But physicians don’t have to fear losing everything if they make a mistake.
Comprehensive malpractice reform is one way to save billions of dollars.
Identifying waste and rooting out fraud is another way to save billions of tax payer dollars. Once I saw a heart patient who another cardiologist had performed 10 heart catheterizations on over a 10 year period. All of them were “normal.” This same patient had 2 nuclear stress tests done every year that were read as mildly abnormal by the same doctor who later did the unnecessary heart catheterizations.
Health care organizations were contacted but no disciplinary action was taken. This cardiologist is still in practice and still does 10 normal heart catheterizations every week.
Many other strategies for health care savings are possible, but the people who provide the care need to have a major role in such decisions. In my opinion, this is the best way to achieve equitable reform.
I welcome you thoughts and comments on this topic.