Over at the” Blog That Ate Manhattan “a NYC physician discusses “Doctors Dropping Medicare: TheDomino Effect” ( http://theblogthatatemanhattan.blogspot.com/)
“When the docs in my area began dropping Medicare, their patients had no where to go but to the docs like me who still participate in the plan.
“And so, over the past year or so, I began seeing more and more new older patients in my practice. The shift in my practice demographic was almost palpable as these new Medicare patients began filling my appointment book months in advance for routine annual visits. Add in a few retiring docs, and the influx of older women became too much to ignore.
“On the day I saw seven new Medicare patients, all coming from the practices that had stopped taking Medicare, I knew that I had to do something.
The Practice Impact
“But this was getting to be too much. The Medicare patients were taking all my new patient appointments.
“You see, unlike younger patients, Medicare patients usually call far in advance for their appointments, and fill up my new patient slots for weeks to months at a time. That leaves no room for the 25 year old who just moved to Manhattan and needs her pills refilled within the month, the 35 year old who thinks she is pregnant, the 45 year old with hot flashes who can’t wait till March, the Italian tourist with the UTI or the 16 year old whose mom just found out she was having sex. If I don’t have the slots to see these patients soon, they’ll find someone else who does.
“These younger patients provide the variety that drew me to this field in the first place – the opportunity to care for women at all stages in their reproductive lives, with medical problems that change with each decade. My research arena is contraception and std’s, and that means younger patients. I especially love the teens, and ran the adolescent gyn and teen pregnancy clinics at my former jobs. I really missed seeing these patients in my practice as the older patients began taking all the new patient appointments.
“What are the financial impacts? Well, if the visit is medically complicated, Medicare pays reasonably well for my time, although it’s still less than half of what I get from managed care for the same services. At current volume levels, it’s not that much of a problem. But if Medicare were to increase much beyond that, it could impact the bottom line significantly.
“And finally, I have to be honest and admit that my temperament is not suited to seeing a large volume of elderly patients in one day. I can’t stand having patients waiting in my waiting room because I am behind. Older patients just take more time per visit, no matter what the reason. I can handle a few Medicare patients a day, no problem. But more than, and I am guaranteed to get behind on schedule. And that stresses me to no end.”
To find out how he handled the problem, got to http://theblogthatatemanhattan.blogspot.com/ and scroll down to July 13.
(If you’d like, come back here to comment.)
It strikes me that unless Congress does something to raise the amount it pays physicians at the bottom end of its pay scale (while trimming pay for some services in overpriced “grey areas” of medicine where we are not at all certain that the procedures are effective) doctors will continue to drop Medicare patients, and physicians like this one will find too many seniors competing for space in their waiting rooms.
Not a good case. The doctor is conflating personal preferences for the type of practice he runs and the reimbursement rates for Medicare.
Either he likes the variety, in which case the payment issues are secondary, or he is upset about losing income and is using the variety issue as a way not to sound too greedy.
I think standing in front of the mirror for awhile and doing a bit of introspection might help him resolve his true feelings.
Robert–
I think I’d cut him a break.
As a former teacher, I’ve taught college-age students and I’ve taught adults.
After a number of years, you know much of what there is to know about people age 17-21 who attend certain types of institutions.
Teaching adults is refreshing. On the other hand, I wouldn’t want to teach people over 40 full time. Younger students are exciting because they are so fresh. It’s great to watch someone read a truly great novel for the first time.
So I believe him when he says that he prefers the mix of patients. And I definitely believe that older patients take longer.
Some are lonely; others are
fearful. They want to talk.
Many doctors are tempted to just rush the through –especially given the fact that, at this point, Medicare doesn’t pay a doctor to co-ordinate their care, or provide a “medical home.”
Clearly, this doctor doesn’t do that. AT the same time, he can’t afford to let Medicare patients take over his practice.
Overall, he sounds like a good doctor.
As the author of the post in question, I’d like to address the commenters.
Mr Feinman –
The primary motivating force behind my decision was maintaining variety in my practice. The payment issues are secondary, but only at this point in time. I am a salaried physician in an academic practice, and though there is a bit of incentive built in related to practice income,I’ve pretty much maxed that out for the kind of practice I have, which is office gynecology. But I can look into the future and see that if Medicare levels in my practice were to get higher, I might see an impact on income. So while my primary motivation was variety, the fact that finances support that made the decision a much easier one to make. If it were the other way around, I may have just bucked up and lived with a practice mix that was less than ideal in return for maintianing my practice income.
This post was in fact my own standing in front of the mirror – I thought that seemed pretty clear.
To all –
FYI – I’m a girl. 🙂
TBTAM–
Thanks for weighing in–and for writing such an intriguing and candid post.
I’m embarrassed that I assumed that “the doctor” much be a boy.
Maggie,
The doctor commented that while Medicare pays “reasonably well” for the more complex visits, it’s still less than half of what private insurers pay for the same set of services. This ability to cost shift to commercial payers is one of the key reasons why Medicare manages to work for beneficiaries as well as it does. If we had Medicare for all (which I don’t support), this cost shifting would not be possible.
While I agree that Medicare should pay more for primary care and less for some of the overpaid procedures and specialties, I’m not optimistic that this will happen anytime soon given the power of the specialist dominated RUC. Moreover, the recent decision by Congress to back away from competitive bidding for durable medical equipment was especially discouraging. Short of pouring net new money (which we don’t have) into Medicare to pay primary care doctors more, I think the problem is only likely to get worse.
Barry misses the elephant (again):
“Short of pouring net new money (which we don’t have) into Medicare to pay primary care doctors more, I think the problem is only likely to get worse.”
Sorry, we have lots of money, we just have chosen to spend it on the death industries instead of life.
Joesph Stiglitz’s recent book estimates the cost of our latest military adventurism at $3 TRILLION.
Then there is this report on spending patterns http://www.cbpp.org/3-5-08bud.htm
From the The Center on Budget and Policy Priorities.
I’ll only quote one stat:
From 2001-2008 military-type spending went up 7.5% while Social Security and Medicare/Caid went DOWN 2.4%.
Read the report.
I’d really like to know why statement’s like Barry’s are so common. Do people not know the facts and get their information from biases sources, or do they hear the facts and ignore them or do they just have opinions without any facts at all?
It makes a difference: Those who are blinded by ideology are hopeless, while the rest can learn something if the word can only be spread.
Militarism isn’t just killing our soldiers and those in the places we invaded, it is literally kill us at home as well, as vital service are curtailed to feed the insatiable monster of death.
Also, moving to Medicare for all would reduce physician overhead so much that perhaps the lower reimbursement wouldn’t hurt doctors so much. It’s true that Medicare cost shifts in our current fragmented, inefficient and wasteful “system”, but Medicare for all would eliminate so much of that waste that cost shifting wouldn’t be necessary.
Everyone–
Thanks for the comments.
I’ve been travelling–and laptop invaded by a terrible virus.
But I’ll be back to you soon.