President’s Page
By Frank Randolph

Physician Advocacy to Address Medicare Woes

Under current law, Medicare’s physician payment rates will be cut by 12 percent over the next three years. The U.S. Senate Finance Committee unveiled a proposal that includes the House-passed Medicare reform package (HR 4954). The proposed package would set annual payment increases at about 2 percent from 2003 through 2005, and is expected to provide an additional $1 billion in Medicare spending for physician reimbursements during the three years.
California physicians’ losses due to the 2003-2005 cuts will total about $967 million or $12,102 per physician. This comes on top of a 5.4% payment cut which cost California doctors a total of $205.3 million or about $2,853 per physician in 2002. An AMA survey conducted earlier this year found that one in four physicians either has restricted or plans to restrict the number or type of Medicare patients treated. One in three has stopped or intends to stop delivering certain services to Medicare beneficiaries.
Additional payment cuts over the next three years could exacerbate these problems and cause significant access problems in California. Physicians in only one other state would see greater total losses than those in California. In 1999, the state had 22.9 Medicare-participating physicians per thousand fee-for-service beneficiaries. However, a number of practices have closed in California and the ratio has been declining. Within the last year, there have been reports of access problems in some California communities such as Marin County. The growth of managed care in the state has already led many physicians in that area to retire. More retirements can be expected since almost 58% of family physicians in the state are 50 or older and more than 25% are 60 or older. Even before Medicare cuts were announced, a national survey firm found that 80% of doctors in this age category planned to retire early, change professions, or cut back on their hours of care. A combination of significantly increased practice costs and reductions in Medicare payments may accelerate this trend, potentially exacerbating existing access problems in some parts of the state. In addition, a shortage of primary care doctors could force some elderly and disabled Californians to seek care in hospital emergency rooms that are already overcrowded and experiencing significant losses on uncompensated care.
A good example of local advocacy to address the evolving problems with Medicare is the SOS initiative. Starting in January 2002, several medical groups and IPAs in San Bernardino and Riverside counties met together at the Riverside County Medical Association to discuss common concern about loosing Medicare Plus Choice Plans in our two counties in 2003. The effort incorporated many local leaders including local member and CMA President-Elect Ron Bangasser, MD. It was called “Save Our Seniors” or SOS. Loss of these plans would effect over 200,000 of local patients; nearly 70% of all Medicare patients. The average income for area seniors is $15,000. The loss of the M+C program in our two counties would cause a tremendous hardship for our patients, including the lack of ability to afford their needed medications ultimately causing increased hospitalizations and increased morbidity and mortality. SOS next invited all the Health Plans who had M+C plans in the area to attend a meeting with the local groups/IPA’s at the RCMA. All the Health Plans attended. By that time, the Bush Administration had proposed a 6.5% increase in M+C for 2003. When asked if they would stay in our two counties if there were a 6.5% increase, the Health Plans all agreed to stay. Discussions then moved to strategies to make sure the M+C increase remained in the Budget Bills, survived a combined House-Senate conference committee to be signed by President Bush. The SOS plan was to send a group to Washington, D.C. to meet with members of the House, the Senate, the Administration, and CMS. In return, the Health Plans agreed to take suggestions from the group/IPA physicians for premiums, co pays, and pharmacy formularies for 2003. SOS participants all agreed that the increases needed to extend beyond 2003.
Several physician members of the group traveled to Washington on April 7, later joined by Joe Criscione from Blue Shield and Bruce Fried from CAPO, and Janet Newport from PacifiCare. They met with a host of leaders over several days, discussing the issues behind Medicare, including David Kreiss, Special Assistant, Office of the Administrator at CMS and Leslie Norwalk, Counsel to the Administrator at CMS; Madeleine Smith, a PhD economist who staffs the Health Subcommittee of the House Ways and Means Committee; Dr. Barbara Paul (Director of the Quality Measurement and Health Assessment Group at CMS, who served on the CMA Board of Trustees in 1998); Julie Goon, Senior VP for Government Affairs, Jennifer Baxendell, Executive Director of Public Programs, Diana Dennett, EVP; Dr. Mark McClellan, Health Advisor to President Bush and a Member of the President’s Council of Economic Advisors, and Katherine Baicker, Senior Economist on the Council; Linda Fishman, Republican staffer for the Senate Finance Committee; Andrew Lyzenga, Legislative Correspondent for Senator Barbara Boxer; Charity Bracy, Senator Feinstein’s Legislative Assistant; Elizabeth Kavalich, Health Advisor to Congressman Jerry Lewis; Congressman Joe Baca and two members of his staff’; Congressman Ken Calvert of Riverside; Pete Stark and his Chief of Staff and Health Advisor, Debbie Curtis; Congresswoman Mary Bono from Palm Springs.
The April trip spawned a subsequent journey on May 17. Dr. Bangasser and Dr. Mark Hoffing, an internist with the Oasis Medical Group in Riverside County, were invited to join other physicians and senior patients in a meeting with President Bush to advocate for increased senior health benefits in the Medicare + Choice plan. President Bush was very engaged in the issues and very conversant in the subject of Medicare under-funding, especially the problem of Medicare Plus Choice. Following their meeting, the President spoke for 25 minutes on the need to fix Medicare and the need for a pharmacy benefit for all seniors. The President spent the majority of his speech on solving the M+C problem with a 6.5% increase in 2003. Dr. Bangasser and other S.O.S. Committee members returned to Washington, D.C. July 15 through July 18. They met with members of the California Congressional Delegation, with U.S. Senators Barbara Boxer and Diane Feinstein, Tom Scully and others. The group’s last trip was September 8 through 11 when they met with Andrea King of Richard Gephardt’s office, Congressional members Jerry Lewis, Susan Davis, Lois Capps, Ken Calvert and others. They were successful in getting members of the California Congressional Delegation to sign a letter supporting an increase in Medicare and Medicare+Choice and sent it to the House and Senate Majority Leaders.

No one would suggest that SOS was assured of the 6.5% increase or that the Health Plans will stay in San Bernardino and Riverside counties in 2003 and beyond but they felt good that they got to their story to a lot of important people in Washington. Congress adjourned in October without taking action on provider payment relief leaving a lame-duck session as the last chance to advance legislation before the election shuffles the makeup of Congress. In late October some lobbying groups, including the American Medical Association and the AARP, continued to wage major campaigns to spur action when the current Congress returns on Nov. 12. Our Society sent out a Medicare Alert and Survey in the last days of October, to support the efforts of CMA and AMA toward a massive physician fly-in to Washington to protest additional Medicare cuts, as many of us continue to send letters and place phone calls to our Congressional representatives. Attending the CMA Legislative Conference in Monterey this past week, my Gestalt of all these events took shape when, during a conversation with CMA’s government relations chief exec Steve Thompson, he spoke from his heart in saying that in his work with the CMA he could imagine no greater example of American Democracy at work. I fully agree.