Divide the Physicians and Conquer Them

Politics soils everything it touches.

The looming 21% cut in Medicare rates is a “Sustainable Growth Rate” (SGR) reduction. This mechanism has been in place for years. Onerous as it sounds, it should be distinguished from the specialist / primary care battle which is implicit in Obamacare. The one is a previous effort to control costs, the other is the germ of large future war in the physician community.

SGR was an attempt to tie Medicare’s inflation rate to a target number, by governmental decree. But this was for all services alike, procedural and cognitive, specialist and PCP. Up till now, everybody in the physician fee schedule is still in the same boat. Since economic laws do not actually obey government decrees, of course, it didn’t work.

Then, in a stroke of Machiavellian genius, somebody in the Obama administration realized all they had to do was divide and conquer by exploiting a previously undiscovered lode of progressive math. Why do all the dollars have to come equally from all kinds of doctors? Aren’t there a lot more primary care doctors then specialists? Don’t you see your PCP more than your orthopedic surgeon? If your kindly Marcus Welby loves the new government program you will think it was a success. If Dr. Welby wants you to go see the orthopedist, will your orthopedist reject the referral and will the grumbling of the surgeon influence you more than the rapture of the doctor who sees you and your children?

But don’t the expensive procedures live in the surgical world? The math is beautiful. Take high dollars from the few, and give some of them to the many. Take dollars from the specialists, give some of them to the family doctors, and “save” the rest! (Note: “save”, here, means “fund 100 new agencies”. Note that the budgets of these new agencies will no longer be counted in the metric “health care expenditures”. ) The family practice dollars are about to get about a 10% fee increase from Medicare.

With this bribe, they get the approval of the AMA – “the doctors” — which is a group of mostly primary care doctors. The specialties gather in their own societies, and journalists simply do not need more than one quote per news story from each faction. So objections of the specialty societies never even make it into the newspapers anyway.

So, in the Obamacare health care debate, I believe we see something never seen before in American medicine: primary care and specialties became adversaries – and didn’t even seem to notice it. Why? Because they didn’t cut anything yet. Another tactic from the left: you always give money away before you raise it, because the support of those who receive it is your leverage for extracting it from those who “contribute” it. The fee increase for the PCP’s will of course accelerate the creeping insolvency of the program, and we will have to get it out of the physician B fee schedule somewhere. So: step 2: cuts for surgical specialists.

From this point on, specialties become lobbying groups against each other. In other words, the Medicare physician fee schedule has just been politicized.

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