Tuesday, September 29, 2009

Medicare for All = Healthcare for None

Doctors Are Opting Out of Medicare

By JULIE CONNELLY

EARLY this year, Barbara Plumb, a freelance editor and writer in New York who is on Medicare, received a disturbing letter. Her gynecologist informed her that she was opting out of Medicare. When Ms. Plumb asked her primary-care doctor to recommend another gynecologist who took Medicare, the doctor responded that she didn’t know any — and that if Ms. Plumb found one she liked, could she call and tell her the name?
...
Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them. Some doctors — often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists — are no longer accepting Medicare, either because they have opted out of the insurance system or they are not accepting new patients with Medicare coverage. The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.
...
Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare, according to the hospital’s Web site.

Two trends are converging: there is a shortage of internists nationally — the American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs — and internists are increasingly unwilling to accept new Medicare patients.

In a June 2008 report, the Medicare Payment Advisory Commission, an independent federal panel that advises Congress on Medicare, said that 29 percent of the Medicare beneficiaries it surveyed who were looking for a primary care doctor had a problem finding one to treat them, up from 24 percent the year before. And a 2008 survey by the Texas Medical Association found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.



29 percent of Medicare recipients can't find a physician who is willing to take them as patients. That's huge. How high would that number go if most of the country became Medicare or Medicare-like recipients? How high will this number go if the federal government's scheduled 21% cut in Medicare payments to physicans comes real (on January 1st, 2010)?

Yeah, give everyone free coverage, but don't be surprised when you can't find anyone willing to accept it.

28 comments:

Anonymous said...

Very troubling.

Holy Hyrax said...

Next step:

Force doctors to accept ALL insurance. The argument, of course will be, that if healthcare is a right, who is a doctor to deny that right.

Anonymous said...

Next next step: people stop becoming doctors.

Nice Jewish Guy said...

"Not accepting Medicare" is not as rebellious as it sounds- if a doctor agrees to see a Medicare patient, then whether the doc is 'par' or not, he/she still has to submit a claim on CMS-1500 to the Medicare carrier. The doc is also limited to the 'limiting charge' on all covered procedures/services and can not balance bill the patient for non-covered services unless the patient signs an Advance Beneficiary Notice (ABN) waiver, agreeing to be charged- and the doc then still has to bill Medicare for the non-covered services, with a modifier that indicates that the doc knows that the services are non-covered. So there's still plenty of paperwork for not being par. Maybe more.

The only way to avoid dealing with Medicare altogether is to stop seeing Medicare patients.

Garnel Ironheart said...

There is a simple solution to the health care shortage: cap malpractice awards at a reasonable rate and make it harder to sue on a whim. Accompany that with primary care reform that gives family doctors decent reimbursements and multiple resources like dieticians, counsellors, etc. to work with.
Up in Canada 15 years ago everyone was going to the US because it was the Goldene Medinah. Now the Canadians are coming back, especially the family doc's because the government is expanding what primary care does.
If Obamacare goes through forget about internist shortages. Where are you going to get all the FP's you'll need?

Orthoprax said...

"Accompany that with primary care reform that gives family doctors decent reimbursements and multiple resources like dieticians, counsellors, etc. to work with."

Sure, sounds simple. Who's paying for it?


"Where are you going to get all the FP's you'll need?"

By reducing quality one way or the other. Going with NPs and PAs taking over for FPs seems likely.

Garnel Ironheart said...

Up here the government is paying for it. Several major cities have developed something called a Family Health Team. Various physician groups then join the Team. The Team gets the money for dieticians, counsellors, etc. from the goverment and doles it out to each member practice based on number of rostered patients.
For example, my practice gets a social work 1.5 days a week and a dietician 0.5 days a week. We also have a nurse 4.5 days a week, all paid for by the Family Health Team.
The other side of the story is that we are expected to increase our roster sizes because now that I don't have to do counselling, Paps or diet education anymore, I have more time to see more patients.

avian30 said...

Orthoprax,

"29 percent of Medicare recipients can't find a physician who is willing to take them as patients. That's huge."

This interpretation is not correct. The article says that "that 29 percent of the Medicare beneficiaries it surveyed who were looking for a primary care doctor had a problem finding one to treat them." But the fact is that in the same report, MedPAC says that 95% of respondents said they already have a primary care physician (see page 9 of this report).

avian30 said...

Orthoprax,

"How high would that number go if most of the country became Medicare or Medicare-like recipients?"

This is mostly a red herring in the context of today's health care reform debate. Some people (such as me) would like to see Medicare-for-All, but Congress is not considering that proposal.

"How high will this number go if the federal government's scheduled 21% cut in Medicare payments to physicans comes real (on January 1st, 2010)?"

This is also mostly a red herring in the context of today's health care reform debate. You can see on page 113 of this health care bill draft from the Senate Finance Committee that Democrats intend to ensure that this cut does not take effect.

avian30 said...

I wrote:

"But the fact is that in the same report, MedPAC says that 95% of respondents said they already have a primary care physician (see page 9 of this report)."

but I see that is not quite right. To the question "Is there a particular medical person or clinic you usually go to when you are sick or for advice about your health?" 95% of respondents said yes, but not all of them are necessarily referring to a PCP. Anyway, my main point -- that it is 29% of a fraction of Medicare recipients and not all of them -- still stands.

Orthoprax said...

Avian,

"Anyway, my main point -- that it is 29% of a fraction of Medicare recipients and not all of them -- still stands."

Why is that relevant? For every new person going on Medicare and who wants a PCP who'll accept the program, ~>29% of them will have trouble finding one. That number is only likely to grow as more people go on Medicare or some Medicare-like program comes to be.

""Is there a particular medical person or clinic you usually go to when you are sick or for advice about your health?" 95% of respondents said yes"

Sure - the local ER.


"This is mostly a red herring in the context of today's health care reform debate. Some people (such as me) would like to see Medicare-for-All, but Congress is not considering that proposal."

Not now perhaps, but any "public option" would be largely the same as simply expanding Medicare.

"This is also mostly a red herring in the context of today's health care reform debate. You can see on page 113 of this health care bill draft from the Senate Finance Committee that Democrats intend to ensure that this cut does not take effect."

Yeah, that's nice, but the government is filled with little disappointments regarding what the politicians intend.

You may also want to see here:

http://orthoprax.blogspot.com/2009/05/physicians-perspective-medical-practice.html

avian30 said...

Orthoprax,

"Why is that relevant? For every new person going on Medicare and who wants a PCP who'll accept the program, ~>29% of them will have trouble finding one. That number is only likely to grow as more people go on Medicare or some Medicare-like program comes to be."

On page 6 of this MedPAC report, you can find some more data. You can see that for the 2007 data, MedPAC was referring to 29 percent of the 9 percent of Medicare beneficiaries looking for a new PCP in the past 12 months. And for 2008, the numbers are 28 percent of 6 percent.

On the same page, you can see that younger people with private insurance have marginally less problems getting an appointment with a new PCP, and marginally more problems getting an appointment with a specialist.

And further, the CMS under Obama report they intend to increase payments for primary care services as recommended by MedPAC.

This is not the crisis you present it as. And though it is a problem, the government has recognized the problem and is working on fixing it.

And further, it is really hard for me to imagine how asking elderly people to pay the first $5,000 will provide elderly people in general more access to primary care. I would expect most people to be more reluctant to go to a physician if all expenses of that visit will be paid out of their pocket, even if an appointment would really be in their interest.

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badrabbi said...

As they say, there are lies, damn lies, and then there are statistics.

The facts are as follows:

1. Medicare is a relatively generous insurance plan. They pay over $140 for the initial doctor's examinations, and about $80 for subsequent visits. Medicare pays for most procedures, hospital stays, and surgery. Medicare pays 80% of the bill. There are no copays (other than the initial $150 for the year), there are no referrals needed for specialty exams and procedures, and there are no major denials of coverage.

2. It is true that some insurances pay better and are more comprehensive than Medicare. However, there are some that are less comprehensive. Medicare is average.

3. The VAST MAJORITY of physicians participate with Medicare. Only in very narrow enclaves, such as, for example, upper west side of Manhattan, where people are wealthy and can afford to pay case, do physicians opt out of Medicare.

4. If every one had Medicare, then every one would have relatively good insurance. Furthermore, the cost of Medicare per patient would be reduced as younger healthy patients would be infused into the system. Currently, only the old, the infirm and disabled -people who utilize healthcare the most - are in the Medicare program.

OK?

badrabbi said...

Also, we are arguing against something that not proposed. No one is suggesting that everyone join the Medicare system.

In the present Obama proposal, a given person can choose from a number of insurance plans.

Orthoprax said...

BR,

The facts are that Medicare reimbursements are not too hot and they make it very annoying to treat patients with all sorts of government-type red tape nonsense and general poor running of the organization. Many doctors would easily prefer to not deal with Medicare if they thought they could maintain sufficient patient volume without it. This is not present in just a few wealthy "enclaves."

The evident consequence of this is that many specialists are leaving Medicare, as well as generally the better doctors who can command more demand from clientele.

If everyone had Medicare and doctors felt trapped in how they practiced and who they treated and how much their time was worth, then many would reduce the size of their practice or quit medicine altogether. Hence, everyone would have "coverage" but you might have a difficult time finding someone to accept it.

"Also, we are arguing against something that not proposed. No one is suggesting that everyone join the Medicare system."

Incorrect. It has been proposed. That's what the Single Payer people are arguing for. Thankfully congress hasn't gone as socialized as that.

badrabbi said...

Once again, we are arguing apples and oranges.

If a physician had the choice between a rich patient paying cash, versus billing Medicare with all its bureaucracies, I agree that the physician would take cash.

No one is disputing this. I like cash more too. Cash is even better than credit card payments!

As insurances go, though, Medicare is a relatively good one. Its requirements are mild. As I said, there is no referral required in Medicare. No "pre-authorization" is required for a procedure. There is no "in network or out of network" shenanigans. The moneys to be paid out are well defined and there are rarely surprises.

The reimbursements are not hot, as you put it, and I agree. But comparatively they are also not bad.

You say that the good doctors can demand better fees. I have no problems with that.

Frankly, I think that the Medicare rule that compels physicians to accept ALL medicare patients once ANY medicare patient is accepted is crazy. This means that if Bill Gates went to a physician who took Medicare, and if Mr. Gates had Medicare, the physician MUST take Gates' insurance. Even if Gates wanted to pay the physician, he is not allowed to do so. Obviously this rule must go.

badrabbi said...

You are correct that the "public option" was in fact an option in Obama's healthcare proposal. I did not realize that you wrote the blog post in September, so a few things have changed.

But realize that the public option was to be just that - an option. An option among many other options.

Do not get me wrong. I am not a huge fan of Obama's plan. There are many problems with the plan. That tort reform was never even considered spoke volumes about the priorities of this administration.

That after all this wrangling there will still be millions of people without insurance still bothers me. That after all this it seems that the insurance companies are set to make out like bandits is shameful. That physicians and hospitals are increasingly bearing the brunt of health care inadequacies is not lost one me.

But if we are going to complain, it is good to realize what we are complaining about.

Orthoprax said...

BR,

"As insurances go, though, Medicare is a relatively good one. Its requirements are mild. As I said, there is no referral required in Medicare. No "pre-authorization" is required for a procedure. There is no "in network or out of network" shenanigans. The moneys to be paid out are well defined and there are rarely surprises."

And? At the end of the day it is still the case that many doctors have no interest in taking part of that system because of the headaches and low reimbursement rates.

"But realize that the public option was to be just that - an option. An option among many other options."

An option that with the help of the federal government could unfairly outcompete private business and subsequently dominate the market.

"That after all this wrangling there will still be millions of people without insurance still bothers me. That after all this it seems that the insurance companies are set to make out like bandits is shameful."

I agree that private insurance companies are in many cases pretty rotten, but that doesn't mean that building a new monster to keep the smaller monsters at bay is the right idea. I say that we work towards ensuring people have access to care rather than access to "insurance." If the government sponsored free clinics, public hospitals and so on designed to serve the needy that would make more sense. That plus a generally available high deductible indemnity plan would makes the most sense and keep costs in check.