As I See It

The Fire Next Time

When the Medicare fee cuts return in January 2010, will we confront them or acquiesce yet again?

By Paul S. Koch, M.D. Editor Emeritus

"Did you read this in today's newspaper?" my patient asked, waving a clipping in the air. This occurred shortly after Congress went home for the 4th of July without resolving the 10% reduction in Medicare fees that went into effect on July 1st.

It was a letter to the editor, in which a physician described how, despite the lack of Congressional action, all physicians continued to work. No one refused to see patients, no appointments were cancelled, and no emergency room went uncovered. The theme of the letter was that physicians were kind, giving and generous members of the community, continuing their service despite the fee reduction.

"Why, yes, I did see it," I replied, "and I know the man who wrote it. He's a very kind and excellent person."

"He's a sap," my patient snorted.

I digress here to fill in another thus-far omitted detail. My patient is a well-known labor lawyer. All of his practice is devoted to unions and contract negotiations. That's a big deal in my little state, where unions are so powerful they essentially run the state house. This particular patient was high up in that hierarchy, and when he talks, it's like the E.F. Hutton commercial: everyone listens.

Nice Guys Finish Last

Look, he explained. Your buddy cut you off at the knees. You just lost all your bargaining power. Congress went home leaving you holding the bag. They cut your rates by 10%, which probably cut your net by, what — a third? Doctors should be furious and intimidating.

Instead, you guys write a letter stating that if the government sticks you with a 10% pay cut, you wouldn't mind. You'd still keep on doing the same thing, and not make a single change in response. Are you nuts?

The last thing you should have done is reassure your patients. Never tell them that doctors will keep providing care like nothing happened. Tell them you are assessing the situation and considering your options.

Tell your patients you are disappointed in the people they elected because you have bills to pay, and if you don't get the money from Medicare, then the money will have to come from them. (What? From me?)

Don't say what you will do, just what you might do. You might increase your refraction fees. You might begin charging for your time returning telephone calls, especially if you have to call after hours. You might have to charge for processing a form, including filling out the cards they bring to the registry of motor vehicles.

You never go into labor negotiations saying you'll take a pay cut for the same work. You go in kicking and screaming and fighting for every single cent. If Congress decides to pay you less, make it crystal clear that things will change.

Bring the Heat

As expected, he was entirely correct. Congress went home to a very angry constituency, and the opponents of the bill got hammered by organized medicine and senior groups. Their heads reeling, they couldn't wait until they got back to Washington to cast another vote. The bill was vetoed on the grounds that the money should have gone instead to insurance companies to pay their executives 10 times what we get paid, but then that was overridden, giving us 18 months of peace and serenity.

No doubt this will come up again — Congress pledged to address it next year, in advance of the 2010 cuts — and we will have to react. Some will be like my friend, the letter writer, and turn the other cheek. Others will be like my patient, and have a contingency plan prepared and ready to implement. Me? I have a year and a half to put mine together. OM