A s a baby boomer physician with aging parents, I have a few thoughts about the horizon for our seniors over the next few years.

As people live longer and increasingly survive illnesses that were fatal in years past, the numbers of people dependent on Medicare for their health care increases. It is very difficult for patients to opt out of the Medicare system regardless of their financial circumstances.

Congress just applied a band-aid to the Medicare payment formula for the umpteenth year in a row. Many providers were poised to stop seeing new Medicare patients had this not happened. Many providers already are cutting back on their appointments for new Medicare patients for financial reasons.

The SGR (sustainable growth rate) formula is known to be flawed but there is not the political will for Congress to do an overhaul - just a painful, year-by-year temporary fix.

Unfortunately, unless a longer-term fix happens, the 2010 fee schedule will have a 21 percent decrease. Many are concerned that these temporary fixes not only contain other provisions that are unfavorable to physicians, but that they borrow against the future, making the problem harder to fix each year.

Other factors make Medicare problematic. The Centers for Medicare & Medicaid Services continues to come up with innovative ideas to cut their outflow of dollars. The most recent is making certain conditions "no pay" to the hospitals. Initially this list included things that everyone would agree should be "never" events, such as leaving a foreign object in the body during surgery or operating on the wrong site.

The most recent list includes things that are going to happen in spite of the best medical care in the country, such as catheter-related urinary tract infections or blood clots in the legs. This might have the unintended consequence of raising costs for screening tests.

The increasing specter of regulatory issues for hospitals and physicians continues to threaten access. This is another avenue by which the government is raising money by going after "false claims" and other alleged types of fraud by providers. Although there are certainly abuses in this area, even the most scrupulous providers find it impossible to be 100-percent compliant with the multiple and confusing rules and regulations regarding Medicare coding and billing.

This later becomes a huge source of revenue for the government in the form of audits, payment recoupment, fines, and other time-consuming, scary processes.

The bottom line is that, because of these factors, many doctors increasingly are reluctant to deal with Medicare. The latest political trend is to expand Medicare and Medicaid so an increasing number of people are covered by government programs. This is a different tack than the "Hilarycare" model of universal health care that was on the table a decade ago.

This creates a "perfect storm" of disincentives for doctors and other providers to care for our aging population. On one hand, we are increasingly under siege from the standpoint of just staying in business. On the other, opting out of or limiting participation in the Medicare program leaves us in the terrible position of refusing to see our own parents and those who taught us work ethic, self-sufficiency and individual responsibility.

Although doctors were celebrating in July when Congress passed the most recent payment fix bill, many think that only when the fix eventually falls through will Congress and the public wake up to the reality of steadily decreasing access for the "Greatest Generation."