Doctors split on effects of healthcare reform

As the battle over healthcare reform nears the home stretch, many doctors are worrying more, and more loudly, about how their income and practices will be affected.

Specialists worry about proposals that could mean less in Medicare payments for specialists, particularly cardiologists and radiation oncologists. Other doctors argue greater government involvement in medicine means they'll lose more control over how patients should be treated.

"We're worried that we'll work harder and make less," said Robert Lum, an Oxnard radiation oncologist and former president of the Ventura County Medical Association. "I believe the system is broken and something needs to be done but I worry that the solution might be worse than the current problem."

In a debate marked in every community by conflict and polarized interpretations, doctors are no different. They argue about pay and whether reform will make it harder for patients to find doctors who will care for them.

The division is fueled by differences in the five reform proposals in Congress and a tidal wave of activity that includes an expected Senate vote this week on a formula used to calculate Medicare payments to doctors. There's so much flux that no one has definitive answers on how medical practices will change, said Dr. James Hornstein, a Ventura family physician and a supporter of reform efforts.

"Reform is looking to change the way we deliver healthcare for the first time in 70 years and it's understandable for everyone -- doctors, nurses and hospitals -- to wonder how that will impact their daily lives," he said.

Hornstein cites the 46 million uninsured people and the explosion of the cost of healthcare as evidence that the system will collapse without reform. He thinks any reductions in government reimbursement to doctors is a much greater concern if it threatens their ability to practice than if it just means a little less money.

Leaders of the California Medical Association contend the reform bill passed last week by the Senate Finance Committee could mean huge cuts in reimbursement unless Congress does away with the existing payment formula known as the sustainable growth rate. It enables annual Medicare payment cuts that are typically overridden by Congress. It could cut reimbursements by more than 20 percent in 2010.

A stand-alone bill repealing the formula is scheduled to be voted on in the Senate this week.

Even if the formula changes, the finance committee's reform package would cut Medicare reimbursement to specialists, with radiation oncologists and cardiologists among those hit particularly hard, said Elizabeth McNeil, a federal lobbyist with the medical association. Primary care doctors would get rate increases.

Specialists would also be hit by quality-control penalties levied on doctors who order significantly more tests and procedures than their colleagues, she said. A House reform package offers more protection to specialists but also raises reimbursements to family doctors and generalists.

Dr. Richard Declusin, an Oxnard heart surgeon, worries that emphasizing preventive and primary care at the expense of specialists means there will be fewer doctors trained to help people with heart attacks, cancer and other illnesses.

"If you get sick, you're going to be out of luck," he said.

But there's a desperate need for more primary care doctors. And the pressure to control the costs of reform means options are limited, said Dr. Michael Rodriguez, a UCLA professor of family medicine who advocates healthcare reform.

"Specialists' salaries are significantly higher than general physicians', in some cases multiple times higher," he said. "If you're not going to increase the overall amount spent for physicians but you want to put certain incentives in the system, then the implication is that the money is going to have to come from other places, including possibly some of the money that comes from specialists."

Declusin disputed suggestions that either Medicare or private insurance pay specialists handsomely. He said reimbursement for a triple bypass surgery is about $2,000 including care before and after the procedure.

Cutting income means jeopardizing doctors' ability to pay for staff, malpractice insurance, rent for an office and a growing list of expenses needed to stay afloat, he said. Others cite the investment they've made, including debts of $200,000 or more for training and education.

"To say that finances are not important is to be naive," Lum said.

Doctors also worry that reform could mean more outside control of medicine as private and public insurers try to control costs.

"I don't like it when insurance companies do it and I don't like it when governments do it," said Dr. Gregg Hartman, a Simi Valley orthopedic surgeon.

Others contend the concerns are misguided. Gerald Kominski, associate director of the UCLA Center for Health Policy Research, said reform proposals don't change what private insurers pay and are focused on slowing the rate of increases in Medicare payments.

"What they're going to get paid is essentially what they get paid now," he said, suggesting the volume and intensity of protests show the realization that the reform battle is inching closer to victory. "This is, in a sense, your last opportunity to try and stop this process."

Some observers said there's no indication of a growing division among doctors. Others think anxiety is rising.

"I would say that we're pretty evenly split," Lum said.

Dr. Irving Loh, a Thousand Oaks cardiologist who supports reform, emphasized how changes will allow doctors to help people who can't get care now.

"I think they have to remember why they became doctors in the first place," he said, suggesting doctors and other stakeholder groups are hit by tunnel vision.

Hartman isn't sure current proposals will change what he sees as a monopoly in the insurance industry. Instead he feels as if he's being pressured to make up his mind right now.

"Any time someone tries to sell something quickly, I get nervous," he said.