House Committee on Ways and Means
Selma, California 93662
July 20, 2005
Dear Congresswoman Johnson, Congressman Thomas, and Congressman Nunes,
First, please accept my gratitude for your interest in the issue of access to health care for women with breast cancer. The ability of patients in California (particularly those in rural areas) to find care is inextricably linked to Medicare policy. I hope that your colleagues share your concern; the stakes for my patients are high.
I am a solo practice general surgeon in rural South Fresno County. I am 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 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.
Prior to my establishing my practice in 2003, the only procedure performed locally for the treatment of breast cancer was Mastectomy. Additionally, all breast cancer diagnoses were obtained with Open Surgical Biopsy, a procedure performed in the hospital, which necessitates anesthesia and a noticeable scar. Because of my training as a surgical resident, I learned to offer Breast Conservation, a set of techniques which allows many women to avoid the pain and disfigurement of losing their breast. Additionally, I perform Minimally Invasive Biopsies for the diagnosis of breast abnormalities. Using local anesthetic and advanced technology in my office (including Ultrasound guidance and computerized probes), a woman with a breast lump can be given a diagnosis (whether benign of malignant) 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 brought Sentinel Lymph Node Biopsy to my rural hospital. This is another minimally invasive technique for staging breast cancer which spares many women the pain and complications associated with removal of all of the underarm glands (which used to be the only way to stage breast cancer, and led to severe permanent arm swelling in a large number of women).
Financially, my practice is failing. The reasons for this are clear below. It is likely that in the absence of a change, I will be forced to close my practice and leave the San Joaquin Valley (and probably the State of California) within TWO YEARS.
The negative consequences for me personally and for my patients will be significant. My husband's family has lived in this area for generations, and we had hoped to spend our lives here. 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.
THE PROBLEMS:
MEDICARE
1. Because of planned reimbursement cuts, the current Medicare system is on a collision course with disaster. Although physicians in the San Joaquin Valley (as the Centers for Medicare and Medicaid Services call us, "Area 99") are currently the LOWEST reimbursed in the state, we will be hit equally hard by the impending cuts. Coastal and urban areas, which have fewer difficulties attracting doctors, provide the highest reimbursement rates. The San Joaquin Valley has 25% fewer Primary Care doctors, 50% fewer Specialists and 75% fewer Mental Health providers than the rest of California.
2. Without action by Congress, Medicare reimbursement to physicians will be cut an additional 4.3% in 2006 and between 4 and 5% ANNUALLY between 2006 and 2013. This despite the fact that for certain surgical procedures, my colleagues who practiced in the 1980s now are reimbursed less than HALF of what they were paid 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. 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.
3. 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.
THE SOLUTIONS:
MEDICARE
1. SPONSOR OR CO-SPONSOR THE "PRESERVING PATIENT ACCESS TO PHYSICIANS ACT OF 2005." Senators Jon Kyl and Debbie Stabenow, and Representatives Clay Shaw and Ben Cardin have introduced this legislation as S. 1081 and H.R. 2356. This legislation will help ensure Medicare payments to allow Medicare patients continued access to needed surgical services, and provides an alternative to the upcoming reimbursement cuts that will decimate the Medicare program.
2. OVERHAUL MEDICARE'S FLAWED "GPCI" FORMULA. As it stands, the "Geographic Physician Cost Index" is a way of skewing Medicare 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.
3. STUDENT LOAN DEBT FORGIVENESS. As a surgeon, I spent thirteen years training to practice my profession. Although I worked throughout my education and earned scholarships to help relieve the financial burden (like most of us, my family couldn't provide unlimited resources to send me to school), I incurred nearly $200,000 in student loan debt by the end of my five-year residency training. At the age of 35, when most of my friends were well established in their careers, I was just starting. Despite the fact that the only debt my husband and I have is our mortgage (we don't have expensive habits; I drive a pickup truck and our last vacation was a stay with family in Big Creek, CA), we are struggling to meet my student loan payments and still keep our house. I am willing to serve as a specialist in an area with perpetual physician shortages, where it takes years to recruit even one physician. Perhaps this service has enough value to merit helping with the investment it took to get me here, so that I may stay and continue my work.
4. CONSIDER THE IMPLICATIONS OF VALUE-BASED PURCHASING ON PHYSICIANS IN SOLO AND SMALL PRACTICES. I would gladly and willingly participate in a program which encourages better health care for patients by rewarding those who provide high quality care. I believe in my ability to provide such care; I would leave my profession if I couldn't meet the standards which my patients deserve. But PROVIDING HIGH QUALITY CARE IS A DIFFERENT MATTER THAN DOCUMENTING IT. As a solo practice rural surgeon, my “bottom line” would be devastated by having to come up with $15,000 or more for Information Technology in addition to the high overhead I already struggle to pay.
As a solo practice physician, I have ONE employee, and not because I wouldn't like to hire more. I am the secretary, the bookkeeper, the medical assistant, the receptionist, the cashier, the laboratory manager, the equipment technician, the computer “guy,” and often the housekeeper. Oh, yes...I am the surgeon, too. I answer the phones at my office and do my own copying not because I prefer it to being a doctor; it's a financial necessity to keep my practice viable. Please consider the burden that a complicated, expensive reporting system would place on those of us who want to do good work but are limited in resources and staff to document it.
Thank you, Muchas Gracias and Obrigado on behalf of my patients. G-d bless you for your interest.
Sincere regards,
Linda Halderman, M.D.
General Surgeon