Congress approved legislation to keep the economy from going off the “fiscal cliff,” thereby sparing Medicare providers a 2% payment reduction that would have gone into effect Jan. 1.

The agreement eliminates scheduled tax-rate increases for most Americans and postpones spending cuts to Medicare and numerous other federal programs — but only for two months, at which point negotiations on ways to cut spending are expected to resume. Congress and the White House will be dealing not only with the spending sequester, but also the need to raise the federal debt limit.

While saluting Congress and the White House for reaching the agreement, Karen Daley, RN, PhD, FAAN, president of the American Nurses Association, voiced concern about the potential harm of the 2% payment reduction that still might take effect at some point: “Without a comprehensive solution, Medicare cuts triggered by the sequester will lead to job losses and put millions of vulnerable people at risk of not receiving the healthcare they need.”

Some cuts already in place
Even though overall Medicare spending remains unaffected for now, hospitals still face a long-term decrease in payments. The compromise legislation includes the “doc fix,” which negates a 26.5% decrease in Medicare payments to physicians that would have begun Jan. 1.

Hospitals must cover almost $15 billion over the next 10 years, or about half the total cost of the one-year fix. Most of the reduction will come from an adjustment in annual base payment increases for inpatient or overnight stays. Another portion will come from a decrease in Medicaid disproportionate share payments.

“Although we believe that we need to address the provider payment formula for Medicare reimbursement with a long-term solution, this short-term fix will likely result in a reduction of important healthcare services,” Daley said in a news release.

Rich Umbdenstock, president and CEO of the American Hospital Association, expressed a similar outlook: “While fixing the physician payment formula is essential, it should not be done by jeopardizing hospitals’ ability to care for seniors and their communities. That’s why we are very disappointed at the approach taken in this measure.

“Hospitals are working to provide high-quality, innovative and effective care to seniors and their communities. Additional payment reductions will make it harder for patients to access the care they need and depend on.”

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When a pharmacy sells the heartburn drug Zantac, each pill costs about 35 cents. But doctors dispensing it to patients in their offices have charged nearly 10 times that price, or $3.25 a pill.

The same goes for a popular muscle relaxant known as Soma, insurers say. From a pharmacy, the per-pill price is 60 cents. Sold by a doctor, it can cost more than five times that, or $3.33.

At a time of soaring health care bills, experts say that doctors, middlemen and drug distributors are adding hundreds of millions of dollars annually to the costs borne by taxpayers, insurance companies and employers through the practice of physician dispensing.

Most common among physicians who treat injured workers, it is a twist on a typical doctor’s visit. Instead of sending patients to drugstores to get prescriptions filled, doctors dispense the drugs in their offices to patients, with the bills going to insurers. Doctors can make tens of thousands of dollars a year operating their own in-office pharmacies. The practice has become so profitable that private equity firms are buying stakes in the businesses, and political lobbying over the issue is fierce.

Doctor dispensing can be convenient for patients. But rules in many states governing workers’ compensation insurance contain loopholes that allow doctors to sell the drugs at huge markups. Profits from the sales are shared by doctors, middlemen who help physicians start in-office pharmacies and drug distributors who repackage medications for office sale.

Alarmed by the costs, some states, including California and Oklahoma, have clamped down on the practice. But legislative and regulatory battles over it are playing out in other states like Florida, Hawaii and Maryland.

In Florida, a company called Automated HealthCare Solutions, a leader in physician dispensing, has defeated repeated efforts to change what doctors can charge. The company, which is partly owned by Abry Partners, a private equity firm, has given more than $3.3 million in political contributions either directly or through entities its principals control, public records show.

Insurers and business groups said they were amazed by the little-known company’s spending spree. To plead its case to Florida lawmakers, Automated HealthCare hired one of the state’s top lobbyists, Brian Ballard, who is also a major national fund-raiser for the Mitt Romney campaign.

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Doctors were told last month that we should stop doing so many screenings for prostate cancer with the prostate-specific antigen test. We learned that sigmoidoscopy is a cheaper, easier and effective alternative to colonoscopy for colon cancer screening. And a study I led turned up strong evidence that routine lung cancer screenings are justified only for people at high risk because of heavy smoking in the past.

Regular mammograms aren’t necessary for women in their 40s and are needed only every two years for women ages 50 to 74, the United States Preventive Services Task Force has decided. For many women, Pap smears are required only every three years, not every year, the group also says now.

This deluge of do-less recommendations results from research into tests and procedures that have been arguably overused. You’d think these pronouncements would bring a sea change in the way patients are treated in this country. But my guess is that little will change. Many doctors, maybe most, will ignore these findings and keep doing what they have been doing all along.

The PSA test will still be ordered as a matter of routine, not selectively administered after careful discussion with patients. Colonoscopy will remain the accepted primary method for colon cancer screening. Radiology centers will continue to offer lung cancer screening to people who are unlikely to get lung cancer.

Why? Health care critics are quick to point to the profit motive. And it’s true that gastroenterologists, radiologists, urologists and physicians of all stripes make money from procedures that may not be necessary. But the real obstacle is not money. It’s the culture of doctors, and that will be very hard to change.

In medical school, I was given textbooks and made to memorize long lists of obscure facts, most of which have never come up in practice. Then I sat at the knee of master doctors. I followed them around. I learned to emulate what they did and how they thought. Over the years, I gained some approximation of their mastery. At times, I’ve even found myself mirroring how they stood and leafed through a patient’s chart.

Subtly, and then overtly, I learned that as long as I trusted my instincts, I was probably going to be right. Because doctors know best.

Ours is a comfortable hegemony, particularly if you do not question it. It has teeth, too. A strong defense to a malpractice lawsuit is that you did what other doctors in your community would have done — the “community standard” test. Citing anodyne research written by faraway experts to back up your actions is a less preferable strategy.

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For decades, the attempts at health care reform have aimed to increase access. The United States is one of the few industrialized nations in the world that does not provide universal health care to its citizens. And repeatedly, those who oppose it have been forced to argue that access isn't the problem some make it out to be. Why?

That, of course, is not true.

It's not even close. Let's start with the idea that emergency rooms must provide you care.

What's important to remember is that you can't be refused emergency care. That's because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that any hospital that takes Medicare or Medicaid must check you for emergent conditions and treat them if they exist. Since nearly every hospital in the country takes federal funds from one of these programs, nearly all hospitals are subject to EMTALA.

But "emergency medical condition" has a pretty narrow definition. It includes active labor for women and acute conditions that would cause death, serious bodily organ harm or serious bodily function impairment if they were not treated right away.

If politicians are meaning to say that women have universal access to delivery care, then I suppose there's an element of truth to that. But there's no guarantee of prenatal care in the emergency department. If they are saying that we have universal access if we're acutely having a heart attack, then I suppose there's truth to that as well. But there's no such access for lipid panels, stress tests or prescriptions for cholesterol medications that might help you avoid the heart attack in the first place. If you're acutely obstructed by massively advanced colon cancer, it's likely you can get emergency surgery to end the blockage. But your cancer is likely too far advanced to cure at that point. Moreover, you're not going to get chemotherapy in the emergency department nor could you have gotten the colonoscopy that might have detected the cancer far earlier.

You can't get preventive care in the emergency department. You can't get screened for a host of disorders. You can't get treatment for your depression there or really for any chronic mental disorders. You can't get help with your child's autism, ADHD or developmental delay. And even if you could, it wouldn't be free.

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Hospital patients waiting in an emergency room or convalescing after surgery are being confronted by an unexpected visitor: a debt collector at bedside.

This and other aggressive tactics by one of the nation’s largest collectors of medical debts, Accretive Health, were revealed on Tuesday by the Minnesota attorney general, raising concerns that such practices have become common at hospitals across the country.

The tactics, like embedding debt collectors as employees in emergency rooms and demanding that patients pay before receiving treatment, were outlined in hundreds of company documents released by the attorney general. And they cast a spotlight on the increasingly desperate strategies among hospitals to recoup payments as their unpaid debts mount.

To patients, the debt collectors may look indistinguishable from hospital employees, may demand they pay outstanding bills and may discourage them from seeking emergency care at all, even using scripts like those in collection boiler rooms, according to the documents and employees interviewed by The New York Times.

In some cases, the company’s workers had access to health information while persuading patients to pay overdue bills, possibly in violation of federal privacy laws, the documents indicate.

The attorney general, Lori Swanson, also said that Accretive employees may have broken the law by not clearly identifying themselves as debt collectors.

Accretive Health has contracts not only with two hospitals cited in Minnesota but also with some of the largest hospital systems in the country, including Henry Ford Health System in Michigan and Intermountain Healthcare in Utah. Company executives declined to comment on Tuesday.

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