Sometimes you hear something over and over again and you think you know it, and yet you can still suddenly understand it in a different way.
I've been hearing about the pay "cut" geriatricians experience versus other physicians for more than 15 years. And I've spent a good deal of effort learning about Medicare billing, documentation, and payment policies so I've felt like I've understood what is going on.
It isn't really that complicated: geriatricians, like most "non-procedural" providers (e.g., general internists), get paid mostly for "evaluation and management" services: non-procedural assessment through physical examination and talking that leads to advice, referral, and/or changes in medications. Because Medicare pays poorly compared to commercial insurance (like I have, thanks to my employer) for these "evaluation and management" services, those whose income is ultimately dependent upon Medicare (the insurer of virtually all those 65 and up) will get less money. A general internist or family physician isn't paid more by Medicare than a geriatrician for a service; it's just that fewer of their billable encounters are with Medicare beneficiaries and more are with people covered by better paying insurance--so at the end of the day, they have more income.
But why this discrepancy? It isn't that commercial insurance plans are particularly generous or want to cross-subsidize the care of people who aren't generating premium payments.
Last week I was at a meeting of the special New York Chapter of Grantmakers in Aging, and I heard the story of reduced geriatrician pay once again presented by Jennie Chin-Hansen, the CEO of the American Geriatrics Society. But this time, her talk came directly after a presentation by the leader of the Community Health Care Association of New York State, the group that represents Federally Qualified Health Centers (FQHCs). FQHCs are the primary care safety net, largely serving the poor who either have no insurance or have Medicaid (the federal-state joint program for very low income people, mostly focusing on women and children).
Do you think Medicare pays poorly for primary care "evaluation and management services?" Medicaid is worse. Nationally, the best numbers I could find show that in 2008 Medicaid paid 66% of Medicare rates for the same services--one-third off! Every now and then there is hand- wringing about how Medicare beneficiaries are losing access to the physicians of their choice as providers opt out of the program and refuse to take Medicare as insurance. So far it isn't a very common problem. However, it is a very common problem for Medicaid beneficiaries, but nobody seems to be very worried about it. FQHCs, which receive additional federal grant subsidies to operate, are typically happy to see Medicaid beneficiaries and can be very excited about serving more Medicare beneficiaries. (Interestingly, the Affordable Care Act starting next year is set to increase Medicaid payment rates for physicians to be equal to Medicare rates, paid for by federal revenues.)
Perhaps we should stop looking at this as a provider payment issue and think of it as a beneficiary rights issue. I don't think anyone probably cares enough to actively discriminate against geriatricians. But is it right that the payments our insurance providers will make on our behalf differ depending on our age or our wealth? Both poverty and age are predictors of greater medical complexity. Purchasing equivalent health outcomes for those populations should cost more, not less. I can't help but think that we are expressing something of our social values in how little we are willing to pay on behalf of poor people and older adults--and it doesn't make me proud.