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The real-world consequences of declining Medicare physician payment. From, 2001 to 2023, Medicare payment has declined 26% when adjusted for inflation. Alice Coombs, MD, an anesthesiologist and internist at Virginia Commonwealth University Health joins to discuss the ways this underpayment impacts physicians and patient care, including longer wait times and less access to care. Dr. Coombs also shares how physicians can advocate for change based on her experience as the president of the Medical Society of Virginia. AMA Chief Experience Officer Todd Unger hosts.
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- Alice Coombs, MD, anesthesiologist and internist, Virginia Commonwealth University Health
Unger: Hello and welcome to the AMA Update video and podcast. We've talked a lot about the AMA's work to reform Medicare payment over the past year. Today, we're discussing how these payment cuts affect physicians and patients.
I'm joined today by Dr. Alice Coombs, an anesthesiologist and intensivist at Virginia Commonwealth University Health in Richmond, Virginia. Dr. Coombs is also president of the Medical Society of Virginia and serves as a member of the AMA Council on Medical Service. I'm Todd Unger, AMA's chief experience officer. Dr. Coombs, welcome.
Dr. Coombs: Thank you very much. It's great to be here.
Unger: Dr. Coombs, help us first understand how cuts to Medicare payment and the instability of the payment system overall affect your patients and your ability as a physician to care for them.
Dr. Coombs: So, in my own practice, what I've seen at Virginia Commonwealth University is that patients who are Medicare beneficiaries come into the hospital sometimes with delayed care not because they necessarily get to the hospital late from being referred for self-referrals.
But many times there, they actually have to see their primary care doctors, who are—a lot of times, the main referral process and workup occurs in those offices. So, if the primary care doctors are really inundated with patients, whether they be patients without insurance or Medicaid beneficiaries, as well as Medicare beneficiaries, they may have panels that are exploding at the seams with these patients, and therefore may not be able to take care of them in a timely fashion.
And it's been shown with Medicare beneficiaries that the wait time for a certain subset of patients—minority patients—wait longer to see doctors. And it's not because they choose to wait longer. It's because the doctors have a longer wait list. And that involves a lot of other decision making that goes into when a patient actually gets to see the doctor.
Unger: Do you hear that same problem reflected as you talk to physicians around the state of Virginia? Of course, in your role as president of the Medical Society of Virginia, I'm sure you've come in contact with a lot, as well as at the AMA. What are you hearing from your colleagues?
Dr. Coombs: So it's very interesting. We think that it's all the traditional fee-for-service Medicare, but it's not. It's actually some of the other robust, advanced health care models that have been advertised as the superior model, such as Medicare Advantage.
We have seen also in several of the accountable care organizations where certain physicians who take care of predominantly minority patients have complained that I am a part of this program, but I missed the point for performance. And, as a result, I don't get a bonus. I actually get penalized because of some rubric that's been put in place that says your performance is good or not so good.
And so I think it's a problem not just with traditional Medicare. So if we look at the other programs in Medicare Advantage, as well as accountable care organizations that are out there, I think it becomes problematic for doctors who do have vulnerable populations, partly because of risk adjustments and adequately saying that this patient population is much sicker, and therefore, your performance is going to be different than someone who is taking care of predominantly mostly healthy patients.
Unger: One of the things that we talk about in reviewing Medicare and issues there are just the stories and how important those are, especially to get to legislators. I'm curious if there is one particularly difficult scenario or story that you've experienced that sticks with you and shows why Medicare payment reform is so badly needed right now.
Dr. Coombs: Well, I think Medicare payment as it exists right now is actually forcing physicians and health care systems to make different decisions. For instance, one of the things I actually heard in a meeting when someone discussed, well, Medicare payments are so low and relative to commercial—what does this health care system—and it was questioning someone who was presenting—what do you do with your Medicare and your Medicaid patients?
And their response was, well, if it's a commercial insurer, we will allow the physicians to see those patients. The patients with Medicare and no insurance—they will see the physician assistants or a nurse practitioner.
Now, on background, it looks like that's actually a reasonable thing for access—improve access. But what I want to point out is that not all access is actually access to the right care at the right time. There are many times that some of the physicians will be specialized physicians, and a specialist may refer to another specialist.
And if they can't see a physician because of their insurance, then you get a second or third-year non-physician provider caring for a highly difficult, complex patient because of the fact that that patient is a Medicare or Medicaid beneficiary. And I think that that's really unfortunate.
Unger: You've really made clear a lot of these access issues have real implications for patient care. I'm curious. In your view, what are the practical changes that need to happen for Medicare to function effectively for all patients?
Dr. Coombs: We have to address this whole issue of underpayment. And it is—when you actually look at—and I actually did this for an anesthetic—for instance, a patient was having a thoracotomy with a tumor that was adhering to the chest wall. And when you looked at how much was being allotted for the care of that patient for six hours, it would be on par to someone going to a hairdresser and having a manicure/pedicure.
It is really an embarrassment to say that our Medicare system in the United States is so stringent that it would not even consider the actual cost of two providers in an operating room, such as a nurse anesthetist and an anesthesiologist, caring for a very sick patient, putting all the lines in, putting the patient to sleep and waking the patient up.
All of those things are really time consuming, and you really want to do good by your patients in terms of having them have a good outcome and wake up and do well. So, when we compare the two, it's just unconscionable how Medicare does not take those things into consideration.
Unger: Now, Dr. Coombs, you're a member of AMA's Council on Medical Service. It studies and evaluates socioeconomic factors that influence the practice of medicine, and that includes Medicare, and then makes policy recommendations based on that. Tell us a little bit more because I'm not sure everybody knows just how significant that work is. But about the AMA Council on Medical Service—how does that contribute to the efforts to reform Medicare payment?
Dr. Coombs: So the AMA Council on Medical Services addresses every aspect of Medicare payment, and so from things looking at such things as prospective payment models, looking at even the loss of public health coverage during the pandemic—during the emergency—and how does that look when the pandemic is no longer in existence. And what does our policy look like on the books in terms of what we advocate for Congress—even considering things such as drug price negotiations.
All of those things are really important. And I think that we neglect to see even how durable medical equipment impacts patients being able to have the proper procedure and also the proper appliances that are necessary.
So it covers the basic evaluation and management code. It covers inpatient, outpatient. The council has actually delved itself into every aspect of Medicare payment. And I think part of the council's role is to really look at what the House of Delegates is telling us. And they have experiences that actually reflect what they're actually going through in the grassroots.
And it matters that it's not all the same. It's rural. It's urban. It's looking at health care systems. It's looking at individual doctors. And so, from that the council understands that not one size fits all, but we are actually in a classroom of the House of Delegates, and we're learning constantly from them what their experiences are. So, yes, the council has done tremendous work and I'm very proud to be on the Council for Medical Services.
Unger: Dr. Coombs, you are obviously very, very active in organized medicine. You've got your leadership role at the AMA. You're president of the State Society of Virginia. You probably know better than anyone else that problems like Medicare payment reform are not going to go away on their own. How do you talk to other physicians out there and encourage them to get involved in organized medicine to make a difference where it really counts here in patient care?
Dr. Coombs: So, number one, I think it's really important—organized medicine is a collective voice that gets before groups of individuals in your state, because it starts in the state. And then federal is—the vehicle is the AMA. And so I think it's really important to join the AMA, but also be active in your local societies as well. Because what happens at the state can culminate to affect other states across the union—across the United States.
I think the other issue is advocating with the legislators in your own community, the ones that represent you and at the federal level. It is no doubt that we can have influence across the board with some of our legislators that are in Washington, D.C. They do listen to us. We are their constituents. And I think us giving testimony and talking about our actual patient experience is far more important than anything we ever do.
And as a former Medicare Payment Advisory Commissioner, I had to really argue for certain things that I saw in practice that many people around the table who did not touch patients at all—they had no experience. And even some people who were scientists, and even maybe physicians who didn't practice—they were administrative physicians—doctors are powerful when they bring the patient in the room.
Unger: Absolutely. What a great way to end this segment. Dr. Coombs, thank you for joining us today. All of your work is so impressive and we appreciate you for helping us to see the challenges in the context of patient care.
For the latest developments on Medicare payment reform, check out the online home for the AMA Recovery Plan for America's Physicians at ama-assn.org/recovery. You can also go to our website, fixmedicarenow.org, to get involved in our grassroots advocacy efforts. And as Dr. Coombs has told you, that is so very important. We need to hear the stories from you.
That wraps up today's episode. We'll be back soon with another AMA Update. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.