We Won … Now What?

At the close of 2005, San Diego physicians faced the prospect of cuts in major government medical program reimbursements. In the Medicare program, the beginning of a series of annual cuts leading to reduction of payments of nearly 25 percent over six years was set to start. For Medi-Cal providers, the governor had decided to impose a 5 percent across-the-board cut allowed by the termination of a stay set up a few years ago by a lawsuit filed by CMA against California for violating federal statutes. And for San Diego and nine other so-called Area 99 counties, lack of correction of the flawed GPCIs spelled continued, unfair underpayments for Medicare patients and other patients whose health plans base their fees on Medicare.

On each of these fronts, certain actions occurred that one could call successes, but in each case all that happened was that things were returned to the status quo. And each of these so-called “wins” was the result of a hard fight by our CMA and its component societies, as well as by AMA. When I am confronted by non-member physicians who say that they don’t see the value in paying dues because their reimbursements aren’t going up, I have to remind them that while I agree with their frustration, the fact is that things absolutely would be much worse without the actions of CMA and AMA on these critical issues.

On the Medicare cuts, all was set for holding up the cuts, until the Senate altered part of the budget package after the House recessed for the holidays. So the reduced fee schedule went into effect despite an understanding that this was not to have happened. With great pressure to act quickly, the House voted shortly after reconvening at the end of January to halt the cuts, retroactively to January 1, 2006. Now we are beginning to see not only the “increased” reimbursement but also payment by Medicare carriers for the temporary reductions.

So, we won the battle on the cuts, right? Not really. We avoided one year of cuts, but in reality we owe no thanks to the government for not cutting our reimbursement. The fact is that our costs to practice keep escalating, but we are not seeing even inflationary adjustments to keep pace. Worse yet, no formula changes were made to address the flawed SGR that got us into this mess to begin with! So, now it’s back to the same fight we have had every year for the past three or more years, just to reverse planned cuts mandated by a formula that every party agrees is flawed. That is just plain ludicrous!

We were also well along the way to finally fixing the GPCI problems that result in San Diego, Santa Cruz, and other high-cost counties being included in the lowest payment area in the state since 1997, causing at least 5.5 percent underpayments to San Diego for the past decade. After amazing efforts by many individuals and CMA, a relatively inexpensive fix (“budget dust” has been used to define the moneys involved) was in play and presumably ready to get leadership push in Ways and Means. All of our local legislators were on board, as well as key folks around California, as we put forward a national fix for this smoldering problem. But, as is often the case where political action is needed to fix injustices, the story wasn’t over until the fat lady sang … and she never did! And hence, for the second year in a row, the problem with a reasonable solution went unfixed. We are once again back in the fight to fix this once and for all. In fact, new proposals are already in play to get San Diego and nine other counties their just due under the GPCI formulas, along with ending SGR. But, like in past years, tremendous amounts of man hours and political capital will need to be spent trying to finally overcome the inertia on the legislative side.

In California, the governor wanted us to be grateful that he chose not to recoup the 5 percent Medi-Cal cuts for the past two years when the courts freed him to impose the old cuts retroactively, regardless of the fact that the budget no longer needed to be balanced on our backs. He thought that by only imposing the cuts from January 1, 2006, forward in the current budget year, he was giving us something to thank him for. Well, no thank you, Mr. Governator. The fact that we were already number 50 out of 50 states in Medicaid reimbursements seems to be lost on you. CMA and its coalition partners quickly and forcefully engaged the legislature to fight these cuts, which threatened access to care and moved patients to the already overcrowded ERs. Although efforts to make any reversal of these cuts retroactive to January 1, 2006, were blocked by federal issues, Senator Ducheny and others from both sides of the aisle quickly recognized the importance of reversing the cuts as soon as possible. Despite outright lobbying by the governor’s office to the very end, votes in both the Assembly and the Senate came quick, loud, and strong, with not a single vote to support the governor’s cuts. With such overwhelming opposition to his plans to continue these cuts, the governor signed the law repealing the Medi-Cal cuts the day after it landed on his desk. Such is the power of unity by doctors and their representatives, all too often ignored by our colleagues when we fight each other rather than those that impose upon us.

But even this is not a real win. Sure, it’s far better than not getting the repeal, and we should be thankful to our CMA lobbyists and leadership for winning this battle. But we are really only still back at being 50th out of 50! Now we begin the real battle, with the momentum brought on by this most recent win, which united both sides of the aisle in recognizing that doctors must be reasonably compensated for their services in order to remain in the program. CMA’s Medi-Cal coalition will seek increased reimbursements for providers in the Medi-Cal program this year, aiming at a 15 percent increase to make at least some headway on the lack of any increases for years past.

All of these issues highlight the struggles in representing doctors and demonstrate that we are effective in doing so. I firmly believe that those who feel CMA and AMA accomplish nothing are either unable to digest the simplicity of how much worse things would be without the actions of organized medicine, or are self-justifying their non-participation while others work hard and pay dues to organized medicine. Yet they must realize that all physicians end up reaping the benefits supported by those who are active in organized medicine, and non-members are simply taking advantage of members’ actions. One could include in those benefits the thousands of dollars many individual physicians have received and will receive from the RICO settlements. These suits were pursued and funded principally by CMA and other medical associations, yet all doctors have been eligible to participate in the awards and prospective relief in the settlements.

Can we do better? Sure we can, and we will. But the more each individual physician participates in the process, by action or support, the more we will accomplish. So the next time you are upset about something, don’t just complain. Write your congressman, senator, assemblyperson, or SDCMS about it! We will all do better with your voice behind us.