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A number of factors erode access to specialty medicine, including fair physician reimbursement, penalties to physicians caring for beneficiaries who wish to pay out of pocket, and benefit packages that may limit access in attempt to constrain spending.

Fair Medicare Physician Reimbursement - The failure to provide a permanent fix for the flawed Medicare sustainable growth rate (SGR) formula jeopardizes access to specialty medical care for our nation’s elderly and disabled. Congress must pass a permanent SGR fix. Ideally any system that replaces the SGR would update payments based on the Medicare Economic Index (MEI), allowing reimbursements to be based on the actual cost of providing care. Congress should empower patients to obtain medical services from the physician of their choice by adopting additional Medicare payment options and maintaining access to fee-for-service. [CLICK HERE FOR MORE INFO]

Private Contracting - Congress should enable beneficiaries to obtain medical care from the physician of their choice by passing the “Medicare Patient Empowerment Act” (H.R. 1700/S. 1042). This legislation would permit Medicare beneficiaries and providers to privately contract, in writing, for Medicare covered services without penalty. Currently, patients must pay the full contracted fee out-of-pocket when they seek care from a physician who has opted out of Medicare. H.R. 1700/S. 1042 would allow beneficiaries to use their Medicare benefit to offset a portion of the contracted fee and would not require physicians to “opt out” of the Medicare program for two full years. The bill appropriately protects vulnerable beneficiaries; contracts may not be entered when a beneficiary is facing an emergency medical condition or urgent health care situation, nor may low-income, dual-eligible beneficiaries privately contract with physicians.

Essential Benefits – Ensure that any essential benefits package defined by the Health and Human Services (HHS) Secretary provides adequate access to specialty care and a timely and transparent appeals process to address coverage denials of medically necessary care.

Workforce – The Alliance is concerned that workforce policy focuses solely on primary care and general surgery shortages and fails to recognize specialty shortages. Evidence indicates that specialists achieve better outcomes in the treatment of the diseases they focus on than primary care providers and other specialists.

The Council on Graduate Medical Education (COGME), reported in 2007 that “In rural areas, there is a clear need for specialty care.” The report goes on to say that “Though primary care would be an essential area of medical service and training, subspecialty and surgical disciplines are also sorely needed in underserved areas.” [CLICK HERE FOR MORE INFO]

The Association of American Medical Colleges (AAMC) published an updated physician workforce study in 2008 demonstrating essentially equivalent shortages between primary care and surgery. In addition, the study projects a shortage of 8,000 medical specialty physicians.

Specialists are an integral part of American medicine. As a nation, we pride ourselves on having the best medical care has to offer. Regardless of what insurance product people have, Americans want to know they may see their doctor of choice when needed. However, we cannot take for granted that those specialists will be there. In fact, it takes more than 12 years to produce a specialist.

Regulatory Burden – The Alliance is concerned about the impact of onerous regulations on the practice of medicine and the retention of specialty physicians in the Medicare program. Physicians are well versed in their clinical discipline, but struggle with regulatory compliance. The endless stream of voluminous and complex Medicare regulations pose a serious threat to the quality of patient care as physicians are required to sacrifice valuable time spent with patients in order to monitor and comply with ever-changing rules. The additional threat of penalties makes regulatory compliance even more of a priority, further eroding the physician-patient relationship. While the Alliance agrees that fraud, waste, and abuse must be eliminated in the Medicare program as much as possible, Medicare's rules and regulations must be easily accessible and understood by practicing specialists and their staff. It is equally important that new or revised regulations are straightforward for specialty physicians and their staff to implement in clinical practice and that they do not interfere with direct patient care. The Alliance continues to work with Congress and the Administration to find balance in these activities.

Medical Liability Reform – Support legislation that will help achieve health system savings by reducing the incentives for defensive medicine and protect physicians from unaffordable liability premiums. [CLICK HERE FOR MORE INFO]

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