This week’s New England Journal has an article that addresses this problem clearly. I read the article, written by Dr. Bruce Vladeck, as saying that we are stuck in a legislative bind with regard to medicare spending, both because we spend too much on medicare, mainly due to the fact that we overspend in general without adequately supporting primary care, and also due to rules we established years ago regulating overall expenditures for the Medicare program. The rules were good, if a bit optimistic, and required that we curb overall outlay for Medicare year by year. Each year that we fail to live by the formula that cuts Medicare spending increases the required cuts for the next year, so that required cuts have become virtually unimaginably large at this point. Many of the things that we spend money for in the Medicare program are overpriced, but we are trapped at this point by a relative value scale that favors payments for procedures and specialty care over the thinking, listening and prescribing that is involved in primary care. The formula that governs our medicare payments is called the Sustainable Growth Rate (SGR) and clearly needs some very fundamental revision.
This last weekend I was on call and had direct experience with what it means to be paid well for performing procedures. I had a pretty busy weekend, but most of it was managing issues over the phone. I make no money for that, but it is one of the most useful things I do. I don’t mind providing this service, but it does not feed my family. I spoke to a woman whose mother was dying at home and having the agitated delirium that is so common in the last few days of life. We arranged for her to get appropriate medications and I attempted to get her set up with hospice, which wasn’t possible on a Sunday. I helped arrange for the Red Cross to pay for and obtain medications for a man whose house had burned down, pawing through his computer records, speaking with his wife, and negotiating which of his many pills were vital. Then I was called in to the intensive care unit twice due to a potentially fatal heart arrhythmia in a patient on a ventilator recovering from a severe lung infection. As part of his treatment his heart needed to be shocked into a more stable rhythm on 3 occasions. This involved the nurses placing sticky patches on his chest and back, hooking him up to a cardioversion machine, and pressing a button at my request. I spoke 3 words “100 joules, unsynchronized” and received hundreds of dollars for that each time. I guess it all evens out in the end, but it’s a pretty screwy payment system.
I am attaching a link to the article which addresses the SGR much better than I can.