CHARLESTON, W.Va. -- In the interest of the elderly, military dependents and physicians, for about the last decade I have advocated for the "Doc-fix."
Each year as practice costs increase, an inane, archaic legislative provision requires that certain federal reimbursements to physicians be reduced a few percentage points from what they were the previous year. Rather than fix the problem, each year -- one or more times -- Congress overrides the provision. Thus, access to care is maintained for several more months by assuring physicians are not reimbursed (about 27 percent this year) less than they were a decade ago.
The fiscal cliff bill overrides the provision for 12 months, when we will again be faced with this crisis. However, in the short run it is a good thing for West Virginia's elderly, military families and physicians. However, it comes with costs (and lessons) that could adversely impact health-care access and quality for West Virginians.
The White House insisted that the cost of the fix could not be met by increasing beneficiary costs or diverting funds intended to initiate new activities under the Affordable Care Act. Several other existing health-care "pots" were targeted for "hard" reductions or projected reductions based upon often fuzzy analysis and unproven assumptions. Some of these portend serious consequences for access to health care in West Virginia.
The $4.2 billion in funds are to come from paying hospitals that care for large numbers of the poor and uninsured less under Medicaid. It is assumed these "disproportionate share" facilities will at some point receive revenues from ACA or Medicaid newly insured patients and therefore no longer need direct payments to care for this segment of the population. However, the validity of that assumption is questionable for several reasons. Disproportionate share funds have been used by many facilities not only to cover the cost of unreimbursed care but support ambulatory facilities, e.g., free clinics, which care for the poor and uninsured.
$1.8 billion in savings is projected by further reducing reimbursements for "subsequent" procedures, when more than one medical procedure is performed on the same day. Given the adverse geographical, health literacy and socioeconomic barriers impacting the receipt of health services for many West Virginians, practitioners often try to get as much done as possible when certain patients "show up." Penalizing practitioners for doing so or requiring patients to come back for subsequent visits that many are unlikely to keep, will adversely impact care.
There are also cuts to medical imaging services and Medicare Advantage that could have an impact. Several other provisions extend for one year (e.g. Medicare Part B premium assistance, certain hospital therapy care, and ambulance services) other programs or exceptions, likely on the assumption (like the yearly "Doc-fix") that any problems will be "fixed" by the ACA or other means during the next year.
Is this the way to run health care? Rather than analyze each medical trade area to determine what are the most effective and efficient policies and expenditures of limited federal funds, impose the same policies and expenditure priorities on all locales? The justification is based upon the assumption that a piece of legislation was so well debated, reasoned and constructed, given a few years, it will provide a health-care utopia for all locales. In the interim, and likely longer (like about a decade in the case of the "Doc-fix"), we will stumble along providing clumsy, temporary, Band-Aids to avoid catastrophe and allay (for a few months) the concerns, uncertainty and anxiety of patients and health practitioners.
Felsen, of Great Cacapon, is a retired public health physician.