September 2, 2011

Just before August recess Health and Human Services Secretary Kathleen Sebelius and Rep. Henry Waxman together suggested at an Energy & Commerce Committee hearing (“IPAB:  The Controversial Consequences for Medicare and Seniors”) that Republicans’ concern about Medicare access is overblown because past surveys of physician participation and patient self-reporting show Medicare access has been no worse than access for privately insured persons.  In particular, Democrats rely on a 2010 report of the Medicare Payment Advisory Commission (Medpac).[1] 

Moments earlier, however, every witness on the hearing’s opening panel—all Members of Congress—referred to issues affecting Medicare access. 

Representative George Miller testified 6 million baby boomers are beginning to rely on Medicare.

Senator John Cornyn testified 42 percent of physicians in Texas are considering opting out of Medicare.

Representative Phil Roe testified reductions in reimbursement could make it “economically impossible” for physicians to remain Medicare providers.

Representative Allyson Schwartz testified the President’s Independent Payment Advisory Board (IPAB) “undermines our ability to…ensure [seniors’] access to care.”

So where is the disconnect?

The Medpac data relied upon by Democrats to play down Medicare access is several years old (2000-2009) so it cannot possibly reflect physician behavior in response to significant payment reductions relied upon in current law.  A more current study on Medicare access in the Archives of Internal Medicine is of limited value for the same reason.[2]

Yet there has been a stream of recent surveys and news stories which highlight Medicare access issues. 

For example:

• American Medical Association, AMA Online Survey of Physicians:  The Impact of Medicare Physician Payment on Seniors Access to Care, May 2011.
• The Physicians Foundation, 2010 Survey:  Physicians and Health Reform, November 2010.
• Medical Group Management Association, Medical Groups Prepare Drastic Response to Pending Medicare Payment Cuts, October 25, 2010.
• Richard Wolf, “Doctors Limit New Medicare Patients,” USA Today, June 21, 2010.
• Kristen Consillio, “Locating a Doctor Who Takes Public Insurance Proves Difficult in the Isles,” Star Advertiser, July 18, 2011.
• Lisa Zamosky, “Health 411:  Medicare Guidance is Here,” Los Angeles Times, July 11, 2011.
• Todd Ackerman, “Texas Doctors Opting Out of Medicare at Alarming Rate,” Houston Chronicle, May 17, 2010.
• David Olmos, “Mayo Clinic in Arizona to Stop Treating Some Medicare Patients,” Bloomberg, December 31, 2009.
• Julie Connelly, Doctors are Opting Out of Medicare, New York Times, April 1, 2009.

And as recent as this week: Rosemary Shinohara, “Anchorage Patients Welcome Another Medicare-only Clinic,” Anchorage Daily News, August 29, 2011 (Nearly a third of Medicare beneficiaries in Anchorage do not have primary care doctors.  Many refuse all Medicare patients, won’t accept new Medicare patients, or will see Medicare patients only if patients instead agree to pay fully out of pocket.)

Spotlight Marc Siegel, “When Doctors Opt Out,” Wall Street Journal, opinion column, April 17, 2009:  “More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments. I've had several new Medicare patients come to my office in the last few months with multiple diseases and long lists of medications simply because their longtime provider -- who they liked -- abruptly stopped taking Medicare…Of course, we're promised by the Obama administration that universal health insurance will avoid all these problems. But how is that possible when you consider that the medical turnstiles will be the same as they are now, only they will be clogged with more and more patients? The doctors that remain in this expanded system will be even more overwhelmed than we are now.  I wouldn't want to be a patient when that happens.” – Dr. Marc Siegel, professor of medicine, NYU Langone Medical Center

Furthermore, it is not credible for Democrats to argue Medicare access is not an issue because it is no worse than access for others. 

For example, even using Medpac’s most current numbers, 32 percent of Medicare beneficiaries did not receive urgent care (39 percent for routine care) as soon as they wanted in a clinic, emergency room or doctor’s office.  Fourteen percent of Medicare beneficiaries reported delays in getting appointments for illness or injury and 21 percent for routine care.  The data also show 22 percent of Medicare beneficiaries had difficulty finding a new primary care physician and 12 percent finding a new specialist.[3] 

Are these not access problems simply because people with private insurance have similar experiences?  Medicare beneficiaries are older, less healthy, and require more care than younger people with private coverage.[4] 

Democrats’ attempts to downplay concern for Medicare access in the face of growing evidence denies the importance of the program in people’s lives and the unique needs of the Medicare population.  

Key Take-Aways Medicare access is a real and growing problem. Medicare access will likely worsen because of significant physician payment cuts relied upon in the Democrats’ takeover of healthcare law.  Access for Medicare beneficiaries has special significance on account of beneficiaries’ age, health status, and related care needs.

 

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[1] Mr. Waxman:  “Are you aware of any information on whether Medicare patients are more or less able than private patients to see doctors of their choice?”  Ms. Sebelius:  “No Sir.  In fact, about 98 percent of the physicians in this country are enrolled in Medicare.  I know that there are pockets in communities where doctors are just overbooked but that would apply to private pay and Medicare patients.”  Mr. Waxman:  “Surveys from the Medicare Payment Advisory Commission and numerous other independent surveys all confirm Medicare patients have access to care at least as good as the access private insurance patients enjoy if not better.  That’s for primary care and for specialists.”; this theme echoed not long after in Jonathan Cohn ‘s Kaiser Health News opinion column (“But the stories about doctors turning away Medicare patients turn out to be mostly anecdotal, at least at this point. The best data available, from MedPAC among others, suggests most doctors still see Medicare patients -- and are more open to them than they are to privately insured patients.”)

[2] Tara Bishop, MD, MPH, Alex Federman, MD, MPH and Salomeh Keyhani, MD, MPH, “Declines in Physician Acceptance of Medicare and Private Coverage,” Archives of Internal Medicine, v. 171, no. 12, June 27, 2011, pps. 1117-1119, available by subscription.  (However, study authors are justified in their concern that Medicare access is important “particularly given the shortages in primary care, an aging population, growing prevalence of chronic disease, and insurance expansion under the Patient Protection and Affordable Care Act.”)

[3] The report at least notes the commission “is concerned about the continuing trend of greater access problems for primary care.” 

[4] U.S. Census, Statistical Abstract of the United States 2011, Table 162 Percent Distribution of Number of Visits to Health Care Professionals by Selected Characteristics: 2000-2008, http://www.census.gov/compendia/statab/2011/tables/11s0162.pdf; U.S. Census, Statistical Abstract of the United States 2011, Table 164 Ambulatory Care Visits to Physicians’ Offices and Hospital Outpatient and Emergency Departments: 2008, http://www.census.gov/compendia/statab/2011/tables/11s0164.pdf; U.S. Centers for Disease Control and Prevention, National Center for Health Statistics, Ambulatory Medical Care Utilization Estimates for 2007, Series 13, No. 169, March 2011, http://www.cdc.gov/nchs/data/series/sr_13/sr13_169.pdf#page=21.