Recent reductions in physician reimbursement under Medicare have resulted in substantial breast beating by the medical establishment but little appreciation from the public and representatives of the patient or disease group community. This failure to resonate with the government and public has surprised and "hurt" physicians. Resolution of this problem will require more physician effort and public support. Understanding the structure in which this issues revolves may help clarify its complexity.

The Medicare program was designed in the 1960’s to address the acute health care needs primarily of the nation’s elderly and disabled. Substantial changes have occurred since Medicare’s inception particularly a transformation from acute interventions for illnesses of limited duration, to long term management of chronic illness. The reimbursement schedule has not changed to reflect this new paradigm and the more complex evaluations and monitoring of patients required for optimum care. To make matters worse on January 1^st 2002 Medicare cut payments to physicians by 5.4%. This is to be followed by additional cuts of 5.7% in 2003, and 2004 or a total of 16.8% over three years. This represents the forth cut in Medicare reimbursement in the last 11 years. Since 1991 Medicare payments have averaged only an 1.1% increase annually. This is 13% less than the annual increase in the cost of practicing medicine according to data compiled by the American Medical Association.

In general, reductions in physician reimbursement are not greeted with much concern in Congress. Neurologists have long been at one end of the bell shaped curve in terms of income, but most physicians continue to make more per year than their Congressmen and certainly more than their patients. Physicians are seen as relatively wealthy. There is a perception in Congress that our primary concerns are for our pocketbooks. Therefore if couched in terms of physician income these cuts do not appear to have a significant consequences. If however, they are considered in the context of ever-increasing practice costs and the subjective beleaguered feeling of physicians, these cuts may result in a significant problem of access by Medicare beneficiaries.

A survey of physicians by the AMA has found that one third of physicians has or intends to stop seeing Medicare patients. One out of three Medicare patients must wait more than a week to see a doctor. When searching for internists or family practice physicians in the Portland Oregon metropolitan area we recently found that 60% of them are no longer taking any new Medicare patients. The Mayo clinic has estimated that as the proportion of its patient population on Medicare increases from 40 to 42%, increases in charges to non Medicare patients will need to rise by 24% just to maintain current operating margins, and these margins are only 2.7%. Physicians are already cutting back on their volume of Medicare patients and there is no indication that the problem is going to get better.

The unfortunate truth is that Medicare once the "gold standard" for provision of health services has become progressively underfunded. If the current cuts persist, reimbursements in 2004 will be less than they were in 1991. As a colleague quipped recently "If you are loosing money on every patient you can’t make it up in volume." So why does Congress and the public not see this as a problem?

The intimacy associated with physician patient relationships minimizes fiscal issues. Patients are rarely turned away, and when they are there is a sense of public outrage. This has resulted in an expectation that medical services are a social "right" and that cost is not a factor. Most physician practices operate like a small service business, and as such are unable to take advantage of economies of scale or to ramp up or throttle back on production in response to demand. Physicians must always be prepared to deal with patient problems not simply from 9 to 5 but 24/7. This readiness has costs that are not themselves reimbursable. Unlike our legal colleagues we are unable to charge for telephone consultations, reviewing records or reports calling to schedule studies or to speak to patients and families unless we see them face to face. Hospitals have been able to deal with potential losses by establishing elaborate review systems and using the emergency room as a gatekeeper so that the poor and uninsured are lateralled to the attending physicians on their staffs. All the while their public relation machines strive to create images of warm and fuzzy health care systems.

Where there is a true face to face interaction it is more difficult to "just say no". The costs of running a practice are difficult to control. Additional expectations are continuous. New privacy regulations, new charting guidelines, increased staff salaries, increases in malpractice insurance must simply be absorbed. In this atmosphere physicians have developed a sense of resentment. They are unable to say no to the patients they already care for, but they can cut their losses by not adding those with low reimbursement which now includes Medicare recipients. Those Physicians who are close to retirement often find it better to do so earlier than planned. Physicians in training seek specialties where direct patient care is minimized. The result is a slowly shrinking pool of clinicians, and a loss of those with the greatest experience, and progressively less access by patients.

There are proposed remedies to the current series of cuts. They are at this time only proposals. Some are linked to other legislation such as prescription drug benefits. Others are free standing. All will require bipartisan and bicameral action. At best they provide a 2% increase per year for the next three years. This will barely reverse the current 5.4% reduction by 2006. There is no plan for improvements beyond this date. In this election year Congress wants to adjourn early and thus there is little time for a legislative solution.

What can we do? As neurologists we have called upon or patient partners from the Brain Advocacy Coalition for support. They have been strangely silent. They apparently view this a physician issue, mistakenly failing to see how their constituent’s access will be adversely effected. We will attempt to educate and galvanize them. But we must take the lead. The AAN has a section of its Web Site dedicated to federal affairs. Clicking on this brings up a brief summary of this issue and a link to a section that will allow one to either send a "form letter" or compose a more personal note and have it e-mailed directly to your congressman. After the anthrax incident Congressional mail is irradiated taking weeks to arrive so e-mail is now the primary means of communication. A recent notice about the Medicare reimbursement issue was e-mailed to 9,000 neurologists. If 9,000 e-mails arrived at Congress requesting a fix of the Medicare physician reimbursement cuts they would listen. In addition this is an election year. If we all made it a point to ask the candidates for their position it would resonate. What is required is that neurologists stand up and demand action on their and their patient’s behalf. Do not allow this to be couched as an issue simply of income, but of access which in the final analysis it is.