Encouraging Medicare Protection

The American Medical Assn. has temporarily blocked the implementation of new rules to encourage doctors to accept fixed fees for services under Medicare, the national health insurance for those 65 and older. The rules are good ones, and their object is important. But the delay may have been inevitable, because some of the fee data for the new program were not available when doctors faced decisions on enrolling.

A federal district court in Texas granted the AMA a 10-day stay of the rules. They were to have gone into effect Jan. 1. A hearing in federal court in Dallas has been set for Friday to hear detailed evidence and to decide whether to extend the stay of the new rules.

The new rules on payments for doctors are designed to encourage more doctors to accept assignment and to participate fully in Medicare--meaning that they would accept the specified Medicare fees for all their services to Medicare patients. As of last May 1, only 28.3% of American physicians accepted assignment under Medicare. Most other doctors accept Medicare coverage for less affluent patients but continue to bill other patients at higher fees. Medicare pays 80% of fees fixed by the federal government and requires a 20% co-payment from the patient for the balance. Many Medicare patients buy supplementary insurance, called Medi-Gap, to help cover the co-payment. The AMA says that 75% of all Medicare patients are charged fees less than are charged other patients by doctors even though the majority refuses assignment under Medicare.

In a move to encourage more doctors to accept Medicare as payment in full, Congress passed, and President Reagan signed, new regulations last October. Doctors’ fees were to be in the 75th percentile of customary and prevailing fees, and were to be increased annually in accordance with the Medicare economic index--set at 3.2% for the beginning of 1987. The AMA argues that Medicare fees are unfairly low--one-half to two-thirds of fees normally charged by doctors. Under the new legislation, doctors not participating would be penalized for the first time, receiving 96% of so-called prevailing Medicare fees. Many preferred-provider private insurance plans have similar penalties for non-participating doctors. But the AMA asserts that this would be unfair and perhaps unconstitutional for a federal program.

The issues of principle that the doctors have raised do not appear to us to provide the basis for the courts to substitute their authority for that of Congress and the President. The doctors have sought to portray the new regulations as a denial of freedom for patients to choose a doctor freely--an argument that appears exaggerated to conceal a more fundamental concern that the AMA seems to have about loss of income to doctors as fee controls are imposed. Doctors certainly have a right to stay out of the program if that is their wish. But the government has a right to create incentives to enlarge participation by the medical profession.

Older Americans need the assurance of Medicare protections that can be guaranteed for the long term only when there are reasonable controls over the charges made by all health-care providers participating in the program.