Craig C. Callewart, M.D.: Critical Condition

Medicare is in bad shape, but with Congress' help and a shift in priorities, it could pull through

05:44 AM CDT on Wednesday, August 31, 2005

You broke your neck, you're going to live, but it's likely you'll have some problems." Several times a week, I say this to patients while I'm taking emergency room trauma calls.

Unfortunately, if the trauma victim is a Medicare beneficiary, I must add: "I am no longer a Medicare provider. I'm covered to provide service to you during this initial hospitalization. After that, you must pay me directly without using your Medicare Part B insurance, or try to find another physician to take care of you." It is unlikely that another orthopedic surgeon or any other physician will take such a high-risk case.

This horrid situation occurs because of economics. Medicare pays a physician such as me $232 to manage this patient and his broken neck -- not just during the hospital visit, but for the subsequent 90 days. That is less than $3 a day. Never mind that this type of case has the highest malpractice litigation risk of any medical condition.

And since it costs me more than $3,500 a day to run a surgical office, no one can argue that the economics aren't skewed.

The crisis is worsening. Half of Dallas physicians will not see any Medicare patients or new Medicare patients, and that percentage is expected to increase. Physicians have endured six fee cuts in the last 10 years. Net payments have been reduced 12 percent, while practice expenses have increased 27 percent.

Congress must fix Medicare when it returns from summer recess and before funding cuts begin in the fall. Social Security, immigration and tax reform are on the president's agenda, but resuscitation of Medicare should be the top priority.

I believe the program can be fixed by changing the process, not the payroll taxes.

First, Congress must change priorities in the Medicare system -- cut spending on technology but pay those who actually do the work. Congress should allow the federal government to begin negotiating with medical-device manufacturers and pharmaceutical companies to achieve the best price possible for technology.

It is argued that the government's size makes negotiations unfair to the producers of technology. Arguably true, but since Medicare's inception, physicians have been under federal price controls for their services. Medicare is a socialist system, but it allows some components to be free market, while others are controlled by regulation.

Second, litigation must be reduced because it costs the system much more than just malpractice litigation awards. The fear of litigation causes physicians to order medical tests far in excess of their medical value. Sound medical judgment and decision-making are supplanted by expensive testing to prevent the accusation of a "missed diagnosis." Our lexicon has even changed -- X-rays, CT scans and MRIs now are euphemistically called "diagnostic testing."

The charade is that these expensive tests can determine a diagnosis, but the medical community understands that these tests confirm a diagnosis that is based on a patient's symptoms and physical exam. What these expensive tests do is provide protection from litigation claims, so physicians order them in large numbers.

Finally, thoughtful debate must occur concerning what we know as "a triumph of technology over reason." The Medicare system spends about 80 percent of its funds during patients' last six months of life. Cultural, religious and legal concerns propel this spending pattern. It is not right, and it is a huge waste of money.

Medicare is a successful system that is too large to be allowed to collapse. Our seniors paid into this system for decades and deserve better. I encourage Congress to make these changes.

Dr. Craig C. Callewart is an orthopedic spinal surgeon and private-practice staff member of Baylor University Medical Center. His e-mail address is ccallewart@ntspinecare.com.

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