October 25, 2006

Who Killed the Country Doc?

Some forms of murder are more polite than others.

Take, for example, the socially acceptable planned slaughter of rural physicians serving families in California.  The San Joaquin Valley has 25% fewer Primary Care doctors, 50% fewer Specialists and 75% fewer Mental Health providers than the rest of California.  At first glance, it would seem that those of us willing to care for patients in this region are regarded as precious commodities.  Not quite.

Without action by Congress, Medicare reimbursement to physicians will be cut 5.1% in 2007 and an additional 4-5% EVERY YEAR from 2007 to 2013.  Because of these reimbursement cuts, the current Medicare system is on a collision course with disaster. Rural medical practice will no longer be sustainable.

Politely—and without bloodshed—legislation by the U.S. Congress WILL KILL RURAL HEALTHCARE.

I am a solo practice general surgeon in rural South Fresno County, the only Spanish-speaking surgeon in a region where over 80% of the population is Hispanic. As a woman who specializes in the treatment of breast cancer, I have found that many women, particularly the religious Catholic and Muslim women I serve, prefer to be treated by a woman for reasons of modesty.

It is incredibly difficult to attract qualified doctors to this area. It is more difficult, still, for the patients with few resources to find the specialists they need. 

As a surgeon in Selma, California, I am referred patients from as far north as Oakhurst and Coarsegold, and as far south as Earlimart. This is a 70-mile radius around Selma, and these patients travel over an hour for their appointments. There simply aren't enough specialists who accept patients covered by the State's Medi-Cal system, and this has a ripple effect on patients covered by Medicare.  The situation in the small town where I practice General Surgery mirrors that faced by doctors across our state.

The ability of patients in California to find care—particularly those in rural areas—is inextricably linked to Medicare policy. 

Physicians in the San Joaquin Valley are currently the LOWEST reimbursed in the state. Effective 1/1/07, we will be hit the hardest by impending cuts by Medicare. Coastal and urban areas, which have fewer difficulties attracting doctors, provide the highest reimbursement rates. Despite a nearly 30% increase in our practice costs since 2002, my colleagues and I have sustained regular payment cuts and freezes.

My colleagues who practiced in the 1980s are now reimbursed less than HALF of what they were paid for certain surgical procedures then. For younger doctors like me, we have no cushion to soften the fall. We will simply have to stop taking care of patients insured by Medicare or close our practices. 

No rudeness required--KILLING MEDICARE PAYMENTS KILLS PATIENTS’ ACCESS TO CARE. 

Prior to my establishing my practice in 2003, the only procedure performed locally for the treatment of breast cancer was Mastectomy to remove the entire breast. Additionally, all breast cancer diagnoses were obtained with Open Surgical Biopsy, a procedure performed in the hospital, necessitating anesthesia and a noticeable scar.

Because of my training as a surgical resident, I learned to offer Breast Conservation, a set of techniques that allow many women to avoid the pain and disfigurement of losing their breast. Additionally, I perform Minimally Invasive Biopsies for the diagnosis of breast abnormalities. By using local anesthetic and advanced technology in my office (including Ultrasound guidance and computerized probes), I can give a woman with a breast lump a diagnosis (whether benign or cancerous) with minimal discomfort and a 1/8-inch scar.

Because surgery is not used for diagnosis, the results are available within days of a woman first identifying her breast lump or being told of an abnormal mammogram, and the method is more cost-effective than if a hospital procedure were required. This is an incredibly stressful time for any woman, and any delay just prolongs her and her family's anxiety.

I also brought Sentinel Lymph Node Biopsy to my rural hospital. This minimally invasive technique for finding out if the cancer has spread spares many women the pain and complications associated with removal of all of the underarm glands (which used to be the only way to find out if the cancer had spread, and led to severe permanent arm swelling in a large number of women).

It is unacceptable to force women in the Central Valley to undergo unnecessary mastectomies simply because surgeons who perform breast conservation cannot afford to practice here.  I am willing to serve, but I will be put out of business by planned reimbursement cuts.

Well-mannered as well as paved with good intentions: When Medicare dies, Funerals will be easier for Medicare recipients to find than doctors.

The problem of declining Medicare reimbursement doesn't affect only the elderly. The vast majority of private health insurance companies base their payments to physicians as a percentage of Medicare reimbursement rates. So a cut in Medicare cuts payments across the board, making a difficult situation even worse.

For those of us who accept Medi-Cal (despite the financial hemorrhage it creates in our practices—in mine, it is the only health coverage for up to 60% of my patients), the problem is multiplied. The financial viability of my practice, already tenuous, will be gone.

My patients will be forced to travel even longer distances for breast cancer diagnosis and treatment, which will cause dangerous delays as they struggle to find doctors who are willing to care for them.

Kill Medicare? Medi-Cal dies a polite death, too.

How to save the Country Doc.

  1. Inform your legislators.
    Stop the planned Medicare cuts to allow Medicare patients continued access to needed surgical services.  The upcoming reimbursement cuts will decimate the Medicare program.

  2. Overhaul Medicare's flawed payment formula.
    As it stands, the formula used by Medicare skews payments toward physicians who choose to practice in geographically desirable areas (such as the Central Coast or San Francisco) and away from those of us in rural areas, including the San Joaquin Valley. This "unequal pay for equal work" is supposedly based on factors such as physician expenses to practice in a particular area. But it totally ignores facts like the skyrocketing housing costs faced by Valley residents, and the very different patient population whom we serve compared with other parts of the State. We have twice the poverty level, more than three times the unemployment rate, and $14,000 less per year in per capita income than the averages for counties better reimbursed by Medicare. Our percentage of Medi-Cal patients far exceeds that of our more affluent neighbors.

SAVE YOUR DOCTOR; YOUR DOCTOR WILL BE THERE TO RETURN THE FAVOR.