Medicare Broken

By Craig C. Callewart, MD
Orthopedic Spinal Surgeon
Baylor University Medical Center

"You broke your neck, you're going to live, but it's likely you'll have some problems." Several times a week, I say this to patients while I'm taking emergency room trauma call.

Unfortunately, I must add, "I am no longer a Medicare provider," when the trauma victim is a Medicare beneficiary. "I'm covered to provide service to you during this initial hospitalization. After that, you must pay me directly without using your Medicare Part B insurance, or try to find another physician to care for you." It is unlikely that another physician will take such a high-risk case.

This horrid situation occurs because of the unimaginable economics.

Medicare currently pays a physician such as me $232 to manage this patient and his broken neck - not just during the hospital visit, but for the subsequent 90 days. That is less than $3 a day! Never mind that this type of case is the highest malpractice litigation risk for any human condition. When one realizes that it costs me more than $3,500 a day to run a surgical office, no one can argue that the economics are quite skewed.

And the crisis is worsening. Half of Dallas physicians will not see any Medicare patients or new Medicare patients. This percentage is predicted to grow to 70 percent if the next round of Medicare cuts begins. Physicians already have endured a multitude of fee cuts in the past 10 years, with the actual real dollar payments being 15 percent below 1995 levels (MEI data).

Congress must fix the problem, and I believe it can be done by changing the process, not the payroll taxes.

First, Congress must change priorities in the Medicare system--away from technology and toward paying those who actually do the work. I propose that Congress allow the federal government to begin negotiating with medical device manufacturers and pharmaceutical companies to achieve the best price possible for this technology. It is argued that the size of the federal government makes negotiations unfair to the producers of technology. Arguably, this is true; however, since its inception, physicians have been under federal price controls for their services. Medicare is a socialist system, but allows some components to be "free market" while others are controlled by regulation. This causes the above referenced imbalance between human capital and technology.

Another change that must occur is to reduce litigation because it costs the system much more than is measured by malpractice litigation awards. The fear of litigation causes physicians to order medical tests far in excess of their medical value. Sound medical judgment and medical decision-making are supplanted by the ordering of expensive testing to prevent the accusation of a "missed diagnosis." Our Lexicon has even changed--X-rays, CT scans, and MRIs now are euphemistically called "diagnostic testing."

The charade is that these expensive tests can determine a diagnosis; the medical community understands that these tests can confirm a diagnosis made based on a patient's symptoms and physical exam. In reality, these expensive tests can provide protection from a potential litigation claim, so physicians order them in large numbers. Along with this, state medical boards and the legal system need to follow Texas' lead in reformation, so that high-caliber physician leaders can "police" those within the profession who need to be re-educated or removed from practice.

Finally, thoughtful debate must occur concerning a "triumph of technology over reason." The Medicare system spends about 80 percent of its funds during a patient's last six months of life. With Cultural, religious and legal concerns propelling this spending pattern, at some point our society must engage in an intellectual conversation about the fiscal responsibility of using dwindling resources on patients that have no hope of a meaningful recovery.

Medicare is a successful system that is too large to be allowed to collapse. Our seniors paid into this system for decades and deserve better. I encourage Congress to make these changes.