Will the quality of care for seniors improve under health care reform currently being considered by Congress?
A recent IBD/TIPP Poll shows that a majority of physicians think the answer is no.
Of the 1,376 physicians who answered our survey, 65% said that government reform would lead to lower-quality care for seniors.
Just 28% said it would lead to better care for seniors, while 7% declined to answer.
"I'm not surprised by the results," said Dr. Alieta Eck, an internist in Zarephath, N.J. "It's not possible to cut $500 billion from Medicare and provide better-quality care for seniors."
While Dr. Gary Kaplan isn't surprised by the results either, he disagrees with them.
"Change is hard and there is a lot about health care reform that is uncertain," said the internist and chairman and CEO of Virginia Mason Medical Center in Seattle. "But I don't think (worse care for seniors) will happen. I'm quite optimistic about reform as a way to improve care."
The plan currently in the House would reduce Medicare spending by $500 billion over 10 years, while the plan recently released by Sen. Max Baucus, D-Mont., would reduce it by $400 billion.
A lot would depend on how reform achieves those reductions.
"Medicare was set up for acute care and hospital care, not to treat those with chronic conditions," said Dr. Laurel Coleman, a geriatrician in Manchester, Maine. "If policymakers would do changes in Medicare to improve chronic care management, it would directly help a disease like Alzheimer's that over 5 million Americans have, most of whom are on Medicare."
While generally supportive of reform, Coleman said she'd have to see specifics before deciding if a policy would improve senior care.
The Baucus plan instructs the Center for Medicare and Medicaid Services to set up an "Innovation Center" that will, in part, be charged with establishing "community-based health teams to support small-practice medical homes by assisting the principal primary care practitioner in chronic care management activities."
Dr. Jane Orient is not convinced this will improve senior care.
"What does it mean to coordinate somebody's care?" asked the internist and executive director of the Association of American Physicians and Surgeons.
"Am I going to review care plans for patients I've never set eyes on? Am I supposed to see these patients to earn money for coordinating care? It's not clear what that means."
One concern that many physicians voiced in the IBD/TIPP survey was rationing of medical care.
"Increased government interference cannot make a huge endeavor function better," wrote one respondent. "There will be mandated protocols, long waits, rationing of care, (and) infringement upon a doctor's right of conscience."
"One of the challenges going forward with Medicare is that it is becoming harder and harder to access primary care physicians," said Coleman. "A lot of it has to do with the costs for primary care physicians and the Medicare reimbursement. Changing the Medicare reimbursement, especially for serving complex patients, would help."
The Medicare Payment Advisory Commission says it found that the number of elderly Medicare recipients who had trouble finding a primary care physician rose from 11% to 17% from 2004 to 2007.
Under the Baucus plan, physicians who practice family medicine, internal medicine, geriatric medicine or pediatric medicine, and who perform about 60% of their services for primary care, will receive a 10% bonus on those services.
But others think the reduction in Medicare spending will inevitably mean reductions in physician payments.
"As Medicare constantly lowers reimbursement, it will be harder for new physicians to take part," said Eck. "People are telling me that it is already happening in gynecology. Medicare patients can often no longer find a gynecologist for routine care, or they have to wait six months."
Others see another side to rationing. "Insurance companies already ration care and limit access," wrote another IBD/TIPP survey respondent.
Added Kaplan, "I think today that health care is rationed. It's plentiful for some and unavailable for 47 million Americans. . . . If we improve access and payment for value and eliminate waste, as we are here at Virginia Mason, there will be more resources available to the American public."
Physicians even disagree over the effect of "end of life" counseling, which some critics have derided as "death panels."
"I think reform is all about giving patients choices," said Kaplan. "Insuring that patients understand not only what's available in terms of their care, but that they have choices to make about aggressive or less aggressive treatment - I think reform will help that to happen."
Responds Orient, "If I'm going to spend an hour with a patient, why should I be paid to go through a list of what your end-of-life options are instead of getting your diabetes under control or helping your heart failure?"
The divergent opinion among physicians is, to some extent, reflected among seniors.
At a recent town hall meeting convened by Rep. Gerry Connolly, D-Va., at the Greenspring retirement community in Springfield, Va., some seniors expressed concern over reform.
Katherine Featherstone worried about what reform would mean for people like her deceased husband, who suffered from Alzheimer's.
"I had the freedom to talk with his doctor and participate in his treatment. I would lose that freedom under this bill," she said.
But others were in favor of reform. "We have to reform health care, no doubt about it," said Mary Thomas. "It needs to be passed."