With the public focused on the increasingly loud debate over health care reform, a very big Alaska problem is getting lost by politicians and partisans on all sides. Thousands of Alaska seniors can't get a doctor to see them. While our office has worked on solutions to this problem, our major effort suffered a huge setback this week when federal officials issued an opinion saying legislation to provide a fast and temporary fix probably can't be implemented without a change to federal law.
We've got a lot of work to do. So, calling your opponent a "Nazi" isn't going to solve this one. Digression alert, digression alert. Calling your opponent a "Nazi" - an offensive tactic being used in the federal debate - isn't going to solve any problem.
But read on - if you want to know about the state policy on this problem. Officially, it's called - "Ducking Our Heads in the Sand." With a deserved exception for a few legislators (Reps. Lindsey Holmes and Sharon Cissna & Sen. Hollis French among others) and lots of community members who are trying to find a solution, the official State policy that's been implemented so far is this. Very little.
No Doctor In the House
A recent UAA Institute of Social and Economic Research study confirms what roughly every other Alaska senior will tell you. Most doctors will not take in new Medicare general practice patients. The ISER survey of 75 doctors found that only 13 will take in new patients, 42 will only take those who were patients prior to turning 65, and 20 will only take you if you pay the bill yourself, without seeking Medicare coverage.
Years ago I assumed doctors were making money on Medicare, but just not enough. I was wrong. We've put a lot of time into holding hearings, conducting meetings, and learning that, in Alaska, doctors and nurses, and likely physicians assistants, frequently lose money by taking Medicare patients. The problem is most acute for office visits with private practice doctors. Specialists tend to receive better, though not great, compensation for surgeries and technical procedures. And Medicare pays a higher rate to community health centers, and public hospitals. But the rate paid to private general practice providers is often far too low, even with a Medicare reimbursement rate increase former Senator Stevens garnered in 2008.
Medicare and This Week's Bad News
Last year our office and others began holding hearing to find a solution to the problem. The solution isn't easy.
First, federal law, to keep providers from overcharging, prevents the state, patients or insurance companies from paying any more than the Medicare re-imbursement rate. So, none of us can supplement the inadequate federal payment to attract more providers. Second, we already have a shortage of primary care practitioners - though a fair re-imbursement rate would immediately bring existing providers back into Medicare practice.
One long term solution is to increase publicly and privately funded community health centers - though in tight budget times, and in a state with a majority of conservative-leaning legislators who've resisted this on a large scale, this solution isn't close to being implemented. While community health centers cost money - they result in an inexpensive delivery of medical services, and Medicare pays these centers a much better rate for taking in patients.
Also - right now some in the medical community - notably Dr. George Rhyneer, and officials at Providence Hospital, are scoping the possibility of privately funding clinics like this, but the proposals so far, while exceptionally needed an helpful, are not likely to meet the need for physicians. These clinics will likely not be big enough to fill the needs we face, but will be important parts of a solution.
Facing this reality, our office introduced legislation House Bill 178 last year. The bill was aimed at fixing as much of the problem NOW as possible. It aimed to get existing medical providers to take in private patients. We would have offered a bonus to doctors who provided over 200 Medicare patient visits a year, a bigger bonus for those who saw over 400 and 600 patients a year, and calibrated the bonuses with help from private practitioners (thanks to the staff at Medical Park Family Care!). We felt our language legally avoided the "supplemental payment" provisions of the federal Medicare law. Well, this week, after receiving some tentative support from federal officials, they opined that our effort would likely require a change in federal law. So, back to the drawing board.
Next Step
In March, when I visited our Congressional delegation, I discussed this problem with Senator Begich and Senator Murkowski and their staff. In their defense, I know it's like moving a mountain to pass legislation in Congress. We will continue to work with them to talk about federal solutions. Frankly, I think federal law should be amended to allow states in high need areas, where the Medicare Rate isn't adequate, to supplement the federal Medicare reimbursement rate. But "thinking" this is far from "getting" a federal law passed (some states will oppose any law that might cost them money; and the nation is looking at an overall health care fix that won't allow much attention to individual state needs like this in the immediate future).
We'll work with our delegation to see whether this is a reality, and at a minimum, we'll try to get the debate started on how the federal government might help with this local problem. It may be that increasing the federal re-imbursement rate in states where the rate is too low (it is fine in most states) is more saleable. And it may be that there are other federal solutions our delegation is working on.
It's also clear that part of the solution is to work within Medicare, and the state will have to take a role in finding solutions. That means bigger community health centers, which can bill Medicare nearly twice the rate that private practitioners can. I've always supported increasing the availability of neighborhood health clinics. Not only do they provide needed care, but they are cheaper than sending uninsured patients to the emergency room at quadruple the cost. And they are cheaper than denying people care so that conditions worsen, and the public then pays for more expensive procedures under Medicaid. Pooling private and public funds to achieve this goal is necessary.
And - here's where this issue parallels the national debate over health care reform. You might disagree with me. I might have missed something. There are other solution aspects that I haven't had space to mention here. If you think I have missed something, let me know. If you think I'm wrong or right, let me know. Given the quality of my readers(thanks for all your thoughtful e-mails!), I don't expect our debate will devolve into the name calling that's been seen on the national level. But on the far off chance that anyone equates finding medical care for seniors with "fascism," or the Nazi mass killing of people based on race or religion, I might pull a Barney Frank. In truth, I've never received an e-mail like that from any of you. So - Thanks!
As always, let me know if I can help with anything, and please share your thoughts and concerns.
Les Gara is an Alaska State House Representative. This column appeared in his email newsletter, and he can be reached here.