WASHINGTON —  Lawmakers worked behind the scenes Thursday to reach agreement on Medicare legislation that would have a major impact on the bottom line for doctors, nursing homes, insurers and hospitals.

Before adjourning for the year, Congress looked for ways to avoid cutting doctors' pay for treating Medicare beneficiaries. Doctors get paid for about 7,000 different services when they treat older people and the disabled. On average, the reimbursement rate for those services will drop by 5 percent next year.

About 600,000 doctors would be affected by the scheduled cut.

Doctors are warning lawmakers that many physicians will quit seeing new Medicare patients if the change goes through. But eliminating the pay will cost billions of dollars. An array of proposals considered by the Congressional Budget Office in September projected that doing away with those cuts would cost $13 billion to $58 billion over the coming five years, depending on the fix that lawmakers selected.

Lawmakers are struggling to find ways to offset larger payments to doctors without increasing the deficit. One place they are looking at is a fund established for insurers providing managed care. The fund was supposed to be available beginning in 2007; lawmakers want to push that date back to 2012.

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The delay would save about $6.5 billion over five years, officials said.

Health insurers had lobbied against such a change. Mohit Ghose, a spokesman for America's Health Insurance Plans, said the industry would work with Congress and the administration to keep managed care programs competitive. Many offer lower costs and better benefits than what seniors can get through traditional Medicare.

The legislation also calls for the government to hire "recovery audit contractors" that would identify incorrect payments made to health care providers around the country. Lawmakers believe the contractors could help save the Medicare program billions of dollars annually.

The legislation also heads off an attempt by the Bush administration to reduce the maximum tax that states could charge nursing homes and certain other health care providers.

Many providers willingly go along with the tax because the money collected is returned to them _ along with matching federal dollars _ in the form of higher reimbursements. The extra dollars mean additional staff and resources for patients.

Under current rules, a state can tax up to 6 percent of the revenue of a hospital or nursing home. The administration wants to lower that rate to a maximum of 3 percent. That would save about $3.1 billion over five years.

But lawmakers sought to head off that change by approving a maximum tax rate of 5.5 percent.

The bill also would head off changes proposed for physical and speech therapy after a stroke or hip replacement. Under current policy, Medicare will pay up to $1,740 for therapy. It will pay more only when beneficiaries show medical need.

The legislation would allow that particular exception to the cap to continue.

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