A Real "Doc Fix" - NYTimes.com In last week's flurry of budget deals, Congress patched together yet another temporary fix for a flawed formula used to calculate the fees paid to doctors by Medicare. It will hold payments flat for the next 10 months instead of cutting them by 27 percent as the formula required, and the $18 billion to pay for it will be taken from other health care programs. But the fix only lasts until the end of the year. On Jan. 1, doctors will face another big cut unless Congress again steps in. Congress now needs to devise a real fix that would be fair to doctors and make a serious effort to slow the rise of Medicare spending. In the near term, some doctors - highly paid specialists - should be required to accept some reduction in fees. That won't be enough. Congress should also use this moment to wean doctors away from fee-for-service billing, a root cause of escalating costs, into better and cheaper forms of care. In 1997, Congress enacted the "sustainable growth rate" formula, which sets annual limits on how much Medicare can pay doctors in the aggregate. If those limits are breached, as they have been repeatedly, the formula reduces the fees that will be paid in subsequent years for thousands of medical services. The approach sounded sensible. But once the limits were breached and fees were lowered, many doctors made up for the reductions by performing more tests and procedures. That kept driving up Medicare's spending on doctors and often required bigger cuts in fees the next year. As the cuts spiraled, medical lobbyists stepped in to demand relief, which Congress has doled out in temporary doses. At this point, holding fees at current levels instead of reducing them as required would cost some $300 billion over the next decade. The Medicare Payment Advisory Commission, a group of independent experts who advise Congress, has called for a compromise between doctors and Washington. Congress would set a new schedule of fees and find an additional $200 billion in savings over the next decade to help close the fee gap. The other $100 billion would come by cutting the fees for specialists by 5.9 percent a year for three years and then holding them flat. The commission also urged Congress to direct the secretary of health and human services to identify overpriced and overused services such as imaging scans and reduce the fees paid for them. The commission's proposal would wisely protect primary care doctors, holding their fees flat for a decade. Virtually all experts agree that primary care physicians and their assistants are the key to coordinating patient care in our disjointed health care system. The specialists and their lobbyists will fight hard, but most are well paid and can afford it. The bigger challenge will be to improve the way medical care is delivered and paid for in Medicare - and ultimately the entire health care system. The reform law has created a slew of pilot projects, and some experts believe the country should wait to see how those turn out. But the leverage that would come with establishing a new Medicare reimbursement system should not be wasted. Congress should establish a fee schedule that pays doctors more if they leave fee-for-service and form organizations that will coordinate care or take on the financial risk of managing a patient's care for a year at a fixed fee. That will take away the incentive to perform numerous costly, unneeded services. And it would be the start of a real fix for the rising cost of Medicare.