When Ted Kennedy came onto the Senate floor, his colleagues cheered.

He was there to vote on the bill that would prevent a 10.6 percent cut to physicians who treat Medicare patients.

Just before Congress broke for the July 4 holiday, the bill missed the 60 votes needed to pass by just
one vote.

Today, Kennedy, who is battling a brain tumor, brought that vote to the Senate floor. “Aye,” the 76-year-old Kennedy said, grinning and making a thumbs-up gesture as he registered his vote.

Meanwhile, it appeared that Republican members of the Senate had been released to vote as they wished after it became apparent that the 60-vote threshold would be met. Pressure from seniors,  the AARP ,  and the AMA  had been mounting on members who voted against the bill June 26.

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Back in April, the Journal of Rural Medicine published an article that spelled out some of the ways in which rural medicine is a tough gig: Rural primary care physicians “tend to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients” than urban physicians. Worse still, “[a]fter adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practice in rural settings made $9,585 (5%) less than their urban counterparts."

So being a doctor in a rural region means less pay, longer hours (anywhere from 4 to 10 percent longer per week than urban doctors), and more Medicaid patients—none of which is particularly appealing to doctors.  (As I noted last year, reimbursement rates for Medicaid are abysmally low across the nation). At this point you may be thinking that this sounds like a warning to anyone even thinking about becoming a rural doctor.

Income

Not so fast. According to the Center for Studying Health System Change, the notion that the average rural doctor earns less is, well, what you might call an urban myth. While the Journal of Rural Medicine (JRM) looked only at primary care physicians and concluded that they make 5 percent less than their urban counterparts, CSHSC’s study of all physicians in rural practice tells a slightly different story.

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More and more doctors are fed up with private insurers.  It’s not just a question of how stingy they are, but how difficult it is to get reimbursed. Paperwork, phone calls, insurers who play games by deliberately making reimbursement forms difficult to interpret…

Some physicians have just said “no” to insurers.

What does this mean for patients? Business models vary. Some doctors charge by the minute. I recently read about a physician who punches a time-clock when the appointment begins. She has calculated that her time is worth $2 per minute. Fifty-nine minutes = $118.  Will you be paying cash, or by charge today?
Somehow, I think the meter would make me nervous. I suspect I might begin talking very quickly. But this is only one model.

Rather than charging by the minute, some doctors charge fee-for-service. In those cases, many physicians mark up their fees well beyond what an insurer would pay. But, they point out, they also spend more time with their patients. No one feels rushed.

A story in a New Jersey newspaper describes how physicians in Northern Jersey have begun following in the footsteps of “elite Manhattan doctors and are withdrawing from all insurance plans.” The article compares fees with and without insurance.  On the right, the fees that insurers typically pay for these services; on the left, the fees that Jersey doctors who don’t take insurance charge:

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This week, conservatives and liberals will face off on a question that has divided the Senate—and united the House:

• Should Medicare slash the fees that it pays physicians, across the board, by more than 10 percent?
• Or should it try to save money by trimming the subsidy that it now shells out to private insurers who offer Medicare Advantage?  (Medicare pays private insurers 13 to 17 percent more than it would lay out if the government program cared for seniors directly. In theory, patients receive extra benefits that equal the bonus, though skeptics say insurers are simply pocketing extra profits. )

The battle began, in earnest, on Tuesday, June 24, when the House voted 355-59 to block a 10.6 percent pay cut for physicians which was scheduled to kick in on July 1.

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By Maggie Mahar

Today, I posted something on TPM
Cafe that readers may find of interest.

I reprised some of what I
said about events in the Senate last week, but then went on to consider what this
means for Medicare reform. Perhaps reform requires a degree of “bi-partisan
statesmanship” that a highly polarized Congress doesn’t have.

 What that in mind, HHS
Secretary Mike Leavitt has made a startling proposal. I think it’s worth
talking about it. If you’d like to comment, post on TPM, or come back here.

By Maggie Mahar

Regular reader, author (108
Days), and patient advocate Lisa Lindell recently sent me a story that
aired on her CBS television affiliate in Houston. It’s a tale I have heard before, but what is
shocking is that no one has managed to find a solution to such a patently
unfair wrinkle in our health care system.” Even strongman California Governor Arnold Schwarzenegger has not been
able to the break the deadlock between doctors and insurers
over whether surgeons have a right to charge $2,000 to $3,000 an hour—and
whether the patient should be stuck with a bill that the insurer won’t pay.

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By Maggie Mahar

Writing on Health Care Policy and Market Place
Review over the week-end, Bob Laszewski called what happened in the Senate last
week : “ the most amazing turn of events I have seen in 20 years of following health care policy in Washington, DC.”

It all began Tuesday, when the House voted 355 to 59 to block a pay cut for physicians. As regular
readers know, Medicare is scheduled to slash physicians’ fees tomorrow (July 1)
by an average of 10.6 percent across the board. Another 5 percent cut is
scheduled for January 1, 2009. Some physicians have
threatened that if legislators take an axe to their fees, they will stop taking
Medicare patients

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This week, over at Disease Management Care
Blog Jaan Sidorov hosts Honk Wonk Review, a compendium of the best
health care posts of the past two weeks. Sidorov offers a tasty buffet, with
links to all of the posts.

 Just a few highlights:

At Health Access
Anthony Wright  is on the news as he  rails against private insurers who explicitly factor in gender (care to guess if males pay
more or less?) and a past history of a caesarian section in their health insurance pricin . (Elizabeth
Edwards also weighs in on this topic here.)

On InsureBlog, H.G. Stern reviews Fed Chairman Ben Bernanke’s pessimistic economic assessment of
health care. “It costs a lot. It’s going to cost more. Information tech
doesn’t hold a candle to growing demand paired with . . . ever pricier treatment options. And we
are all going to pay for it.”

Julie Ferguson, of Worker’s Comp Insider fame, posts about I.T.
behemoth Google’s foray into the electronic medical-personal-health
record with links summarizing both the benefits and the problems.

To peruse the full
menu go directly to Disease
Management Care Blog.

“It seems that John McCain may have stolen some of the fire that
Democrats traditionally wield on health issues by making cost
control his top priority, rather than universal coverage.” –Rob
Cunningham, “Health Affairs” May/June
2008

Last week, the bold proposal for health care reform that Dr. Ezekiel Emanuel
outlines in Healthcare, Guaranteed drew
high praise from the American Prospect’s
Ezra Klein. As
Klein described it:

Emanuel’s Guaranteed Health Care
Access Plan maps out “a total transformation
of the system.  It does not build on the
inefficiencies of the current structure, preserving them in amber for the next
generation.” 

Rather than expanding on the
dysfunctional system that we have today, Emanuel, who is the director of
bioethics at NIH (and brother to politician Rahm Emanuel), is calling for
structural reform. This is what makes his proposal both brave and fresh.

But Emanuel’s plan isn’t just
exciting; it’s practical. As usual, Klein cuts to the heart of the matter: “the big deal, he explains is
cost control. In health care, cost control is everything.”

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If you’re feeling disillusioned about medicine—and physicians—take a look at the Buck-Eye Surgeon’s musing on week-end rounds here.   

I think you’ll enjoy it.

He also takes on the sticky question of specialists who are underpaid–and who might be overpaid–by dividing doctors into two groups: (1) The "Hit and Run Bandits" and (2) The "You Operate, You Own It Crew.”