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Up Front | Nov 2005

My Case Against P4P

A Ophthalmology in 2005—what a great, vibrant field! As evidence, I submit the articles in this month's edition of Cataract & Refractive Surgery Today, which proudly present newer, safer, and more efficient ways to perform ocular surgery and to restore or improve vision. In essence, they herald modern miracles of science, technology, and medicine for the rest of patients' lives. Yet, as optimistic as I am about the clinical side of medicine, I am haunted by the inherent problems of socialized medicine's delivery systems worldwide.

Why would our political organizations (the AMA, ASCRS, and AAO) enable the push for Pay-for-Performance (P4P) mandates? P4P seems to perpetuate a broken system. The total monies available for services are fixed, says the government, and there must be a reduction in reimbursement per event. If Congress doesn't fix the underlying payment formula, Medicare will slash what it pays physicians by 26% over the next 6 years. Again, the fiscal balancing act rests solely on physicians' backs.

Quite simply, there are too few tax payers for the increasing number of recipients entering the CMS roles. A similar situation has arisen in the private sector (eg, Delphi and General Motors). The monies collected for benefits are vastly lower than the projected benefit expenditures. Workers and pensioners will have to pay more out of pocket for desired services. If we did not have to pay for high-dollar pharmaceuticals, expensive cancer cures, etc., maybe LBJ's Great Society would still work. Expanding possibilities plus expanding expectations costs infinity, and a society cannot be taxed enough to continue this paradigm.

The free market is needed in American medicine. Providers and industry must help move our current iron-wall system to one that allows everyone of retirement age to get a basic care plan and those who are willing to pay for upgrades in care to receive them. Such a free-market model will allow the US to continue to lead the world in innovative medical care.

Solutions? How about shifting more of the cost to the secondary/supplemental insurance companies? Their expenses decrease with every fee cut Medicare makes. If they pay 20% of the Medicare allowable, and the Medicare allowable falls by 26%, instead of paying $200 for a $1,000 service, they will only pay $146. They pocket the difference in profits. Instead of slashing the allowable paid to physicians, the allowable could be increased. Medicare would pay less than 80%, and the supplemental insurance companies would pay more than 20% (Table 1). The plan? Increase the allowable by 3% each year, so that Medicare reduces its allowable share, and supplemental insurance increases its share.

And, what about rolling over the Flex Spending Account balances so they can accumulate, instead of having to be spent (wasted) or lost at the end of the plan year? You get the picture: there are more solutions than simply cutting physician reimbursement. 
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