The Medicare assignment controversy: the construction of public-professional conflict.

The conflict between the elderly and organized medicine over "mandatory assignment" and "balance billing" is a significant public policy issue. Considerable ideological importance has been attached to this conflict by both sides, despite the relatively modest proportion of total revenue for physician services received through balance billing in payment for care of Medicare beneficiaries. The positions of these two coalitions are examined as well as the efforts of the Physician Payment Review Commission (PPRC) to craft a public policy response. Three alternative resolutions--those adopted by Congress in 1989 on the recommendation of the PPRC, the Canadian solution, and actions taken on a state level--are then contrasted. The concentrated impact on the elderly of balance billing practices is considered as a problem, especially for elderly of limited income and resources. Justification of the practice is typically provided by the profession on the ideological grounds of preservation of professional autonomy rather than economic gain, which also reflects the current relatively limited use of balance billing; a significant majority of all claims submitted in the United States are now assigned to physicians. A continuation of the gradualist strategy of the PPRC is endorsed as the most appropriate short-range solution to these problems, which diminish in significance with a more comprehensive national health financing scheme.