Physicians who live and die by the vagaries of Medicare policies and reimbursement are doing more dying than living. For their frail elderly and disabled patients, managing their care is increasingly under-reimbursed and over-complicated. These patients, by definition, have multiple needs and they are typically on several drug regimens that Part D allows the preferred drug provider to switch in many cases every two months without notice. Getting them a wheel chair or power mobility device requires a face-to-face review, submission of chart notes and other documentation and incurring a paper review by a regional CMS bureaucrat who hasn’t seen the patient. We could go on and on, but you get the picture.

There is an underlying pattern. When the Congress won’t make what are obviously politically tough choices, the regulators are left to take up the slack. They trim and cut by rule and oversight. Tightening down on frail elderly patients’ mobility support needs is just one manifestation of a concerted effort by CMS to rein in what the government calls, euphemistically "entitlement" spending and doctors call medically necessary care. The budget hawks, who see Medicare not as a complex delivery system, but rather a cost center full of red-inked line items, approach this by excising the outliers with cuts to reimbursement (outpatient diagnostic imaging) redefining appropriate care terms(ESRD), price rollbacks (power mobility devices), and retooling the complex reimbursement methodologies (geographic cost indices and non-physician workforce component).