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
This horrid situation occurs because of the unimaginable
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
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.