Thursday, April 3, 2008

A [now open] letter to Congress re: Proposed Medicare Reimbursement Cuts

I'm not sure that this is entirely in keeping with the theme of this blog, but I will justify it by saying that the health of the healthcare system is of vital interest to all stakeholders including researchers with an interest in clinical trials. The following letter was sent via the ACCP to my senators and congressmen in regards to the Medicare reimbursement cuts that are to be instituted in July of this year. We were solicited via the medical professional society to be a voice in opposition to the cuts....

Dear Sir or Madam-

Physicians' income, especially that of primary care providers, upon whom patients rely most heavily for basic care, has been falling in real dollars (not keeping pace with inflation) for years, and the newest cuts will markedly exacerbate the disconcerting trend that already exists.

Most physicians do not begin earning income in earnest until they are over 30 years old, a significant lost opportunity due to prolonged schooling and training. This compounds the problem of substantial debt burden that recent graduates must bear. Economically speaking, medicine, especially in the essential primary care fields, is no longer an attractive option for many talented students and graduates. From a job satisfaction standpoint, medicine has also become far less attractive due to regulatory burdens, paperwork, lack of adequate time to spend with patients, and fragmentation of care.

This fragmentation of care is in fact at least partially driven by Medicare cuts. When reimbursement to an individual physician is cut, s/he simply "farms out" parcels of the overall care of the patient to other physicians and specialists. This "multi-consultism" militates against any cost savings that might be achieved by cuts in reimbursement to individual physicians. Perhaps more alarming is the fact that care delivery is less comprehensive, more fragmented, and less satisfying to patients and physicians alike, the latter which may feel a "diffusion of responsibilty" regarding patients' care when multiconsultism is employed. Reduced reimbursements also likely drive the excess ordering of laboratory tests and radiographic scans, both in situations where the physician stands to profit from the testing and when s/he does not, in the latter case because the care is being "farmed out" not to another physician, but to the laboratory or radiology suite. The result is that Medicare "cuts" may paradoxically increase overall net healthcare expenditures. Physicians are already squeezed as much as they can tolerate being squeezed. Further cuts are certain to backfire in this and myriad other ways.

A perhaps more insidious, invidious, and pernicious result of reimbursement cuts is that it is driving the talent out of medicine, especially primary care medicine. Were it not for the veritable reimbursement shelter that I experience as a practitioner at an academic medical center, I would surely not be practicing medicine in any traditional way - it is simply not worth it. Hence we have the genesis and proliferation of "concierge practices" where the wealthy pay an annual fee for entry into the practice, only cash payments are accepted, and more traditional service from your physician (e.g., time to talk to him/her in an unhurried fashion) can be expected by patients. Hence we have, as pointed out in a recent New York Times article ( ), the siphoning of medical student talent into specialties such as dermatology and plastic surgery because the lifestyle is more attractive and reimbursement is not a problem since the "clientele" (aka patients) are affluent and pay out-of-pocket. Hence we have the brightest physicians, such as my colleague and close friend Michael C., MD, leaving medicine altogether to work on Wall Street in the financial sector. All of these disturbing trends threaten to undermine what was heretofore (and hopefully still is) one of the best healthcare systems on the planet. I, for one, will not recommend a career in primary care to any medical student who seeks my advice, and to undergraduates contemplating a career in medicine I say "enter medicine only if it is the only field you can invision yourself ever being happy in."

The system is broken, and we as a country cannot endure and thrive if our healthcare expenditures continue to eat up 15+% of our GDP. But cutting the payments to physicians, the very workforce upon which delivery of any care depends, is no longer a viable solution to the problem. Other excesses in the system, such as use of branded pharmaceuticals (e.g., Vytorin or Zetia) when generic alternatives are as good or better, use of expensive scans of unproven benefit (screening CT scans for lung cancer) when cheaper alternatives exist (stoping smoking), excessive and wasteful laboratory testing of unproven benefit (daily laboratory testing on hospital inpatients, wanton ordering of chest x-rays, head CTs, EKGs, and echocardiograms), use of therapeutic modalities of very high cost and modest benefit (AICDs, lung transplantation, back surgery, knee arthroscopy, coated stents, etc.), and provision of futile care at the end of life are better targets for cost savings, limitations on which are far less likely to compromise delivery of generally effective and affordable care for the average citizen.

I urge congress to consider the far-reaching but difficult to measure consequences of further reimbursement cuts before an entire generation of the most talented physicians and potential physicians determines that the financial, lifestyle, and opportunity costs of practicing medicine, especially primary care medicine, are just too much to bear.


Scott K Aberegg, MD, MPH, FCCP
Assistant Professor of Medicine
The Ohio State University College of Medicine


  1. excellent letter.

    Hopefully doesn't fall on deaf ears.

  2. Other excesses in the system, such as use of branded pharmaceuticals (e.g., Vytorin or Zetia) when generic alternatives are as good or better, use of expensive scans of unproven benefit (screening CT scans for lung cancer) when cheaper alternatives exist (stoping smoking),

  3. Dr. Aberegg for President!!!

  4. Dr. Aberegg for President!!!

  5. Dr. Aberegg for President!!!

  6. JDT - I pray you are not an citizen of the United States. You know not what you propose. :)

  7. I'm not disputing that this is a good letter, however, you're saying that you had NO clue as to what you were in for whilst you were in med school?

  8. Hello, thanks for your comment!

    I will add a few things, I may think of more later.

    1.) Medicine has changed quite a bit since I was in medical school, more since I was making the decision to go.

    2.) When you are trying to get into med school, you're not considering these things, you're just focused on getting in.

    3.) From a rural lower middle class background, I did not have the fortune of knowing any physicians to inform me of these things, least not any candid enough to admit unsavory things about their careers.

    4.) Once you find these things out, it's a bit late.

    5.) Medical education shields you from these issues and has no focus on economics, but rather devalues the importance of the latter in one's life decisions.

  9. So I suppose it is what it is and there's no use crying over it, right? I'm afraid letters will be written from here to eternity, with no avail.
    Just how much do you think the government cares about what you make/get reimbursed for anyway? Think about those labs out there that are putting in "secret" bids to medicare and the lowest $$$ wins the contract. The losers can just go to hell, of course after they can no longer afford to operate.

  10. I should clarify, the whole medicare v. secret auction bids is in the courts for now, apparently, it's unethical. Go figure. This also brings up a plethora of how MD's are able to find loop holes to get reimbursements and cheat the system. I am of course referring to private practice, biopsies being sent to "pod labs" and the patient being billed numerous times for a biopsy because it is on many slides. (That's the gist) Medicare pays out, however there have been issues with this practice and these little labs are being phased out. I suppose over billing patients is not addressed in the Hippocratic oath, but as a MD wouldn't one feel guilty to cheat the patient or the system just to make a buck?

  11. Dr,
    So here's your $100,000 question. Would you do it all over again?
    Please be honest with yourself before answering, I doubt your career hinges on your reply.

  12. Hello and welcome to the blog! Here's the honest answer to your provocative question:

    I was one of those people who thought that there was not other profession at the time that I could ever enjoy, so I didn't really consider any other options. Plus, from a small rural high school, I did not have exposure to other occupations. I knew what a doctor and what a lawyer was, and that the professions were intellectually challenging. I didn't know anything about engineering, finance, economics, etc.

    If I could do it all over, I would make myself less naive as a young man, and would have considered a broader range of possibilities, such as some of those listed above.

    Regards, Scott

  13. I find the last two comments/questions of this thread interesting. I think I would add, it's never too late to revamp your career , especially if you're as bitter about being a doctor as you sound. Ever heard of "burn out"? You don't want to go down that road.
    Good luck.

  14. Here is a NYT article that touches on some of these issues:


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