For the last two years my practice has been significantly in the red, requiring me to spend a considerable amount of my trust and now my IRA to keep it going.

I have decided not to retire. I came close but rather I gambled that relocating my office and other maneuvers would lower my overhead. Also, I feel a commitment to my staff of four, to myself because I love the office, but mostly to my approximately 2,000 patients who have in various ways asked, "You are not going to quit practicing are you?"

In my field of nephrology, a great deal of income was lost when Medicare reduced reimbursements for certain technical procedures, such as kidney biopsies and placement of dialysis catheters for acute dialysis, to the point that the effort required for such highly trained techniques was not worth the time.

Then the interventional radiologists took over because they, although getting the same pitiful money, did biopsies of all organs and all catheter techniques for angioplasties and stents in all sorts of places. So now nephrologists spend more of their time in the office.

What might have worked to save Medicare was the private option, in which individuals who cannot afford private insurance could tie into Medicare at any age at a cheap premium. Those who can afford a higher premium and want the current system, i.e. a private doctor and private hospital, would have that option.

But the Republicans voted that down, too. Ironically, during the Bush administration, his party was in favor of this approach.

Certainly another issue for the practitioner is the current economy. Many of my patients have lost jobs and therefore insurance. They either do not come in when they should, or they pay a small cash fee.

Maybe some of these folks would be able to use the Medicare option and generate more money for Medicare and go to the doctor when they should.

Medicare thinks cutting our reimbursements, thus leading many doctors to stop seeing the people who saved the world, is not a travesty. The above and the pitiful bandages of President Barack Obama are going to do nothing to save bankruptcy of this system.

Mandating insurance or demanding a penalty; making states put more folks on Medicaid (Medi-Cal) and letting parents include their children in their policies until age 26 will actually raise the cost.

In my own field, in 1974 Congress provided the end-stage renal bill that places anyone, regardless of age, under Medicare for life as well as for kidney transplants.

Now the floodgates have opened, so the average age of a dialysis patient is 65, compared to 40 in 1974. The problem: autonomy of decision-making is no longer the doctors' prerogative, but now rests solely with the patient or the family.

So, there are three reasons patients with no quality of life get placed on dialysis and have other highly technical procedures in other subspecialties ? The patient wants it; the family wants it; and, sadly, the doctor wants it.

If Medicare is to survive the above must be reined in, yes, by a committee of doctors, clergy, bioethics experts and legal experts. If you want to call this a death squad, then so be it.

If doctors do not take back the autonomy we had in the '60s, then our children and grandchildren will be paying for Blue Cross, Cigna and such. Right now that is $2,200 a month for myself and my wife.

Golden is a practicing physician in Modesto.

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