Medicare rationing: one doctor's story

What I am about to relate took place approximately 22 years ago while I was head of a 13- to 14-member anesthesiology group. It was relevant then but is even more so today considering that all of us may be under a government-run health-care plan. It is a story of not only rationing quantity but also quality.

Our group furnished anesthesia services in the two hospitals in Medford, the medical center for Southern Oregon and northern California. We provided anesthesia services for all patients presented to us regardless of their economic circumstance. About 40 percent of our patients were Medicare patients.

In about late 1987 and early 1988 we started getting rejections of payment for our anesthesia services for cardiac pacemaker implantation in Medicare patients. We had been providing that service for years ever since placement of implantable cardiac pacemakers became available. At the time there were three surgeons in our community performing this procedure.

Even though most of the procedures were done under local anesthesthesia the surgeons requested our services to monitor the patient, give sedation when necessary, and take care of any untoward events that would compromise the safety of the patient. Having an anesthesiologist present was considered the standard of care for this procedure.

By denying payment, Medicare was saying our services were unnecessary. This presented a dilemma for us. The surgeons still wanted us present for this procedure, yet Medicare was saying our presence was unnecessary.

Anesthesiologists are in a vulnerable position when it comes to treating patients, particularly Medicare patients. We can't refuse to take care of Medicare patients without committing economic suicide. We would not be asked to provide anesthesia services for non-Medicare patients. In essence, Medicare was forcing us to take care of patients without compensation. At the time Medicare with its price controls was paying us about 40 percent of our regular fees.

I felt we were being treated unjustly. I decided to appeal the Medicare decisions.

There were three levels of appeal. The highest appellate option was a hearing before an administrative law judge of the Social Security Administration. After many months of filing appeals and having our claims denied, we were finally able to get a hearing for one patient before an administrative law judge. We prevailed and were paid the Medicare rate for our service.

During the time we were going through the appeals process for the first patient we had accumulated 22 more cases where we had been denied payment for services. Fortunately, Medicare allowed us to appeal all these cases as a group. We were able to have a hearing for all of these patients at one time before another administrative law judge. We again prevailed with a decision in our favor.

However, it was a Pyrrhic victory. Our success in getting paid for our services did not change the rules. We continued to get denials of payment for our services. During all this time — fighting for what was owed us — I appealed to the surgeons for help. This consisted of them writing a "necessity statement" to be included with each of our billings and a written and signed agreement by the patient that the patient would be responsible for payment of our fees if Medicare denied payment. This didn't change anything.

Needless to say, this extra hassle didn't sit too well with the surgeons and they soon tired of it. The upshot of all this was that two surgeons quit doing the procedure. The third surgeon used a hospital-paid cardiac laboratory technician to monitor and care for the patient. This person was not trained to do "rescue" procedures in case of emergency. Thus Medicare patients were relegated to a lower standard of care.

Were our services necessary? I reviewed all the cases we appealed. Several of the cases could not have been completed were it not for the anesthesiologist's expertise. I think the fact that we prevailed in our appeals before two administrative law judges speaks for itself.

Was it worth it? Monetarily, no, but the experience was worth it if for no other reason than to learn how a bureaucracy works and how it can arbitrarily trump doctors' medical decisions.

Would I trust a government health plan to place a patient's welfare first? Not from my experience.

Gordon W. Dickerson, M.D., of Medford, is a retired anesthesiologist.

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