Medicare is one of the most popular and successful programs ever devised in this country. It has improved the length and quality of life for millions of our most vulnerable citizens - the elderly and disabled - while affording them dignity, choice and security in their medical care.
Despite the program's success, there are problems with the quality of care Medicare beneficiaries receive. Patients complain they have to wait weeks for an appointment with a primary care physician, if they can find one. When the doctor finally sees them, it may be for only a few minutes. Analysts, on the other hand, argue that doctors pile on useless services because they are paid a separate fee for each one. Everyone agrees that many Medicare patients see too many doctors, who don't always work together.
Reform is desperately needed - and if it's done right, it will entice more doctors into primary care, where the need is greatest. It could even begin to lead us in the direction of greater fiscal responsibility.
At President Barack Obama's health care summit last week, some participants called for radical changes in the health care delivery system. For example, analysts have proposed reducing or eliminating small, "inefficient" physician practices in favor of large "accountable health care organizations" with impossibly complex reimbursement schemes. Instead of choosing their doctors, patients would select a system. Many academics and insurers still believe in managed care, despite the public backlash of the 1990s.
Others put all their faith in the free market. Medicare dodged one bullet last year - the Republican solution to gradually turn the program over to the private insurance industry. That plan turned out to be even more expensive than traditional Medicare.
There is a simpler answer: We need to pay more for care we do want, and less for care we don't. The venerable fee-for-service system can still work, if we pay the right fees for the right services.
Right now, we don't. As Sen. Max Baucus, chairman of the Finance Committee, observed, physicians favor tests and procedures because they are far more profitable than office visits. Indeed, there are vital services Medicare doesn't pay for at all, such as making telephone calls, writing reports and coordinating care: These have all traditionally been "free." The result? Last year, only 2 percent of internal medicine residents chose careers in primary care; all the rest will become specialists.
The government now sets the fees Medicare pays physicians (they had skyrocketed under the original "customary" standard). But the government recognizes only the cost of services, as determined by a committee of private physicians in secret proceedings. Instead, Medicare needs to consider value along with cost - in open proceedings. And we need to pay physicians for coordinating care, especially for complicated patients. We need to pay doctors for the time they spend reading records and consulting, just as we pay lawyers. And we need to pay more for the time doctors spend talking with patients.
In the long run, a more rational fee structure could save money. Thoughtful discussions aren't just a nice thing for patients; sometimes they can prevent an unnecessary procedure. Doctors can substitute more convenient telephone calls for some office visits.
We can pay more for these "cognitive" services by reducing what we pay for procedures, tests and imaging. Over time, these reductions should focus innovators on techniques that improve care while lowering costs. More young physicians will choose primary care, particularly for the complex Medicare patients who need them most. Studies demonstrate that systems with more primary care physicians provide better care at lower cost than systems dominated by specialists.
Of course, this reform will not be simple. However, adding value and transparency to fee-for-service determinations has to be easier than pushing patients and doctors into a radically altered delivery system that many have rejected.
Dr. Caroline Poplin, a former general internist at Bethesda Naval Hospital, recently spent a year as a visiting scholar at the Georgetown University Law Center. Her e-mail is email@example.com.