Why the Mayo Clinic is refusing to see Medicare patients

Medicare, the government insurance company for everyone over age 65 (and for the disabled) pays fees to primary care physicians that guarantee bankruptcy.

Additionally, 70% of hospitals in the United States lose money on Medicare patients. That’s right, for every patient over age 65, it costs the hospital more to deliver care than the government reimburses. That is why Mayo Clinic has said it will not accept Medicare payments for primary care physician visits. Mayo gets it. Nationwide, physicians are paid 20% less from Medicare than from private payers. If you are not paid a sustainable amount, you can’t make it up in volume. It just doesn’t pencil out.

Mayo lost $840 million last year on Medicare. Since Mayo is considered a national model for efficient health care, if they are losing money it doesn’t bode well for the rest of us who are much less efficient and who have fewer resources for integrated patient care. Instead of Medicare payments for clinic visits, Mayo will start charging patients a $2,000 fee for patients to be seen at their Glendale, Arizona clinic. Much like a “retainer”, this fee will cover an annual physical and three other doctor visits. Each patient will also be assessed a $250 annual administrative fee.

Primary care physicians are on the front line of patient care and senior patients are the most time consuming. The average Medicare patient takes 11 different medications. Just refilling and coordinating the medication can take up an entire office visit, without addressing other health concerns. I grant all Medicare patients a 1/2 hour visit because I would be chronically behind if I didn’t. After paying office overhead, I am broke with Medicare.

I do not welcome the 65th birthday of my patients, but I continue to see them because I love my senior patients. No kidding, I really love being their doctor. They are grateful and respectful and have interesting health conditions. I am able to see them because I make my income from my administrative position and I have private pay patients.

Sad but true. Unless we have true payment reform that values primary care and pays for coordination of care, I fear Medicare patients will not find enough willing physicians who accept Medicare in the future.

Tony Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • stargirl65

    They often talk about Medicare being the lowest payor and losing money on seeing Medicare patients. They also say it can be made up with private pay patients. Currently Blue Cross is paying me less than Medicare. Blue Cross is one of the biggest insurers in my state. So where do I make up this money they promise me?

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    Seattle just spent millions refubushing a hospital, it has a Starbucks, paintings galore, art in every office, and I bet every doctor has a SUV or sports car, WHAT HAPPENED TO BEING A DOCTOR BECAUSE YOU CARE ABOUT HEALING THOSE WHO SUFFER? Cut CEO pay, cut the crap and get back to a nobel prosfession. Has our greedy culture degraded us so deeply that we see no evil? I have a chronic illness, MS. Must I pack for Canada now? Be forced to leave the nation my Irish ancestors helped build? What a cruel, ignorant people we have become.

  • Anonymous

    The average Medicare patient takes 11 different medications.

    A sign of overmedication? Or is this average biased due to the sickest of the Medicare patients being the ones seen most often (while the healthy ones taking no medication come just once every year or few)?

  • PAUL MD

    Buy your apples for 8 cents, sell ‘em for 6 cents and make it up on volume? As a provider I can share this with you. NOTHING changes until you say “NO”. That is just the way the world works my friends. Again, we as physician providers have nothing to apologize for.

  • ninguem

    Who here gets payment from private insurance that’s less than Medicare?

    The inly payors I have that are less than Medicare are Tricare and Medicaid. I take Tricare anyway because they’re our soldiers after all, and my Medicaid leans more pediatric, and one, I want to keep up pediatric skills, and two, Medicaid tends to pay better for pediatric work compared to adults.

    I’b sure as heck not seeing Blue Shield paying less than Medicare, Blue Shield is one of the best payors.

    I’m not sure what’s going on. Blue Shield paying extraordinarily badly, or Medicare paying extraordinarily well?

  • http://fertilityfile.com IVF-MD

    Diane, it’s certainly sad that your health is not the way you want it to be, and I certainly hope you’re getting some help. I’m sure you realize that there are people out there who are willing to go to school for years way beyond what the average American does and sacrifice their youthful years being a medical student and resident, earning less per hour than the average plumber or teacher and working many hours beyond a typical 40 hour work week. They do this so that they can get the skills and knowledge to someday help people who have health problems, such as yours. So if it is really not OK for doctors to have the choice of owning an SUV or sports car, then for whom is it OK to have SUV’s and sports cars? Hair salon owners who provide great perms? Dentists who cure your toothaches? Lawyers who protect accused criminals? Mechanics who fix your brakes? Union bosses who keep the unions running? Teachers who influence your children? Politicians who take your tax money? Rap singers who entertain their fans? Pastors who offer spiritual guidance? Book authors who keep you entertained with their? Software engineers who make your computer run efficiently? Pastry chefs who make yummy desserts? Accountants who do your taxes? Stockbrokers who watch your money?

    It must be frustrating to have MS, but is venting your anger towards doctors really appropriate? I hope you find it in your heart to forgive and not be biased against a certain group of people just because their profession is what you consider to be noble.

  • teach

    I teach part time, the average hour pay for a teacher is $8.00 per hour. Most teachers I know work a minimal of 60 hours per week, and just like the medical professional we don’t bathroom breaks or lunch breaks. Luckily I work in the public school system. The private elite schools, where the doctors’ kids go in my town all make half what I do – $24,000 per year! And while I am at it, do I really know a teacher that has an SUV?? Hum…only one, her hubby is a doctor.

  • Jeff MD

    The conscientiousness of doctors enables dysfunctional systems to remain broken. Medicare is no exception.

    I have an extra board certification in geriatrics, and I’m gonna let it expire…Sad but true.

  • Jeff MD

    I shouldn’t take the bait, but…last time I looked in my 2 car garage I saw the 6 year old average sedan that I bought used along with my wife’s 4 year old minivan. We don’t have an SUV, sports car, second home, country club membership, etc. Yes, and teachers are way underpaid, I agree, but I assume you knew that when you went into teaching.

    But, doctor-bash all you want–it’s not going to change the fact that YOUR health care system is going to completely collapse if there is not a permanent fix to the Medicare reimbursement system soon. If health reform results in an eventual single-payer system, and if single payer is essentially Medicare, then we’re all in trouble, doctors or not. It’s a fact that Medicare payments do not cover the cost of providing care.

  • http://fertilityfile.com IVF-MD

    Haha, Jeff. Smart man. This should not sidetrack into an argument about who is paid more nor who SHOULD be paid more. In a fair moral system, no matter whether you are a teacher, a doctor or a business owner, what you are paid should not be artificially set by any government bureaucrat. It should be set by the people who benefit from your labor. If you produce a better product, then you will be paid more than your peers. If you produce a worse product, then you will be paid less than your peers. This has the beauty of giving people a healthy incentive to work more efficiently or less efficiently based on how much they value their leisure vs how much they want to make. If this type of accountability is NOT present (and I’ll agree that it is not present in our present systems for most teachers and most doctors), then that says a lot about the inherent problems in the system.

  • stargirl65

    I drive a 10 year old minivan. I do not have a vacation home and do not belong to a country club. I have no increased my earnings since my first year out of training over 15 years ago. I went into medicine to help people but the insurance industry has made it necessary for me to be a businessman first. If not then I would be out of business and not practicing at all. Then you could not get my services at all.

    Yes, the Blues in my area (rural Maryland) pay less than Medicare to primary care docs. When I complained, they said take it or leave it. They insure a large majority of the lives in this state, so it is hard to leave it and they know it. I will probably opt out of their plan soon anyway. I am tired of the paperwork they throw at me daily that has nothing to do with providing patient care.

  • MANALIVE

    My staff can look down on the office parking lot. They have remarked many times that it’s the Medicaid patients who drive the 40 thousand dollar cars.

  • Evinx

    I say, let’s hope Medicare crashes + burns. It is a terrible system run that is designed to be actuarily unsound and dependent on the political class. Is that what the medical profession really wants? Is that what patients clamor for?

    Patients want to simple things: Low prices and good healthcare. Is that so different in concept from what they want from other service providers?

    If we get Uncle Sam out of the way, we can get a good deal of both objectives. No entity has driven up healthcare costs more than the Federal (and State) govts – mandates, tax distortions, regulations on who can sell insurance + where, assignment rates, codes, etc.

    Most drs would not pray to god to reform the healthcare system; they should stop praying to Washington also. It makes even less sense. Politics is all about special interest groups and power. Why on earth would you look to that universe to solve your problems.

    Stop taking medicare patients, allow the system to implode, and then maybe we can start to realize why the govt is not the answer (except to what has caused the problem).

  • ninguem

    You bet wrong. 10-year-old Subaru wagon and a four-year-old Honda wagon. We have kids. Neighbors are blue-collar, one other FP on the street. Public schools for the kids.

    Doc after doc here, saying the same thing. “Art in every office, paintings galore”?? I might be in the hospital you described. The art is often up on consignment from local artists. I know ’cause my wife has stuff up in one. Otherwise, it’s commercial “art” you can order en masse. You order the “art” to match the color scheme. I have a few of those in my own office, along with my wife’s pieces.

    Geez, I get sick and tired of doctor-bashing. I’m in a building, among others, a real-estate agency. A few agents driving really high-end cars. So everyone assumes the family doc is driving the Porsche. No, a real estate agent drives the Porsche. Real estate, you know, the “nobel” profession.

  • Primary Care Internist

    All of the private payers in my area (suburban NYC) pay less than medicare. This includes aetna, oxford/united (the worst), cigna, blue cross, healthnet, ALL of them! Have requested for rate increases at least twice for each of them in the last 5 yrs to no avail.

    A couple of other points:

    1- teachers in my area make about $80k/yr to work for 9months and have benefits that a solo pediatrician cannot afford for himself/herself.

    2- diane, doctors generally don’t work for hospitals. And if they’re the ones driving suv’s and sports cars, so what??? don’t they deserve it more than the ceo of the hospital? or a nurse? or a social worker? or a teacher? or a cop? All of these others require far less training, and don’t have night/weekend call, or the degree of responsibility, or the expectation that you work for free (as you’ve so aptly demonstrated).

    I also don’t have a second home, don’t belong to a country club, don’t vacation for a month in europe every summer, or ski in aspen every winter. I have a mortgage of about 80% of my home value, and plenty of debt. I work plenty of hours including nights & weekends, much of it for free as part of the “nobel” charity known as ON-CALL.

    Just like you. Except that I spent hundreds of thousands of dollars and my entire young adulthood training to be where I am today.

    Frankly I’m tired of people expecting me to be apologetic. I’m almost ready to go cash-only. All I need is for the Great One, King Obama & Queen Pelosi, to cut medicare fees by 20%. That’ll make the decision easy. Then, Diane, good luck at your local hospital-based clinic. I hear the care coordination is peachy (don’t worry, with MS you’ll have no trouble at all).

  • Anonymous

    I say, let’s hope Medicare crashes + burns. It is a terrible system run that is designed to be actuarily unsound and dependent on the political class. Is that what the medical profession really wants? Is that what patients clamor for?

    Patients want to simple things: Low prices and good healthcare.

    Patients want someone else to pay for their medical bills without (obvious) rationing, or where someone else (doctors and hospitals) bear the burden of the rationing as it happens behind the scenes. Which is why Medicare is one of the more well liked medical insurance programs by patients. Also, most Medicare recipients are probably not worried about any possible fiscal disasters 30+ years in the future.

  • ninguem

    Hey, sure enough, here it comes.

    http://online.wsj.com/article/SB10001424052748704375604575023192006417362.html

    “…….White House adviser David Axelrod, appearing on ABC News’s “This Week,” said the president didn’t want to abandon several elements of the current bills. These include extending the life of the Medicare insurance program for the elderly, which the bills propose to do through payment cuts to health providers, and issuing tax breaks to help small employers provide insurance. Medicare will become insolvent by 2017 without more funding or payment cuts……”

    Sure enough. Wondering when the gun was going to get pulled out. Soon to follow, is mandated acceptance of the insurance as a condition of licensure.

  • http://lockupdoc.com Lockup Doc

    The inadequate reimbursements are quite significant but only part of the problem. The bureaucracy is the other significant problem.
    Another psychiatrist blogger (over at Shrink Rap) recently posted about how she moved to a different office location, and she has to fill out a 27 page form just to change her address. That’s completely ridiculous! No change of address form should be more than a single page. That form, though, is just one symptom of the larger problem. It’s why I’ve chosen to piece together a couple of different positions as an employee. It has its drawbacks, and I’m not naive enough to think that whatever reimbursement cuts affect others won’t trickle down to me, too. But health care is so over-regulated in this country right now that if you’re not part of some mega-system, you can’t possibly follow all the proper rules and regulations and make everything work.

  • http://curbside.posterous.com Nuclear Fire

    My wife and I are both doctors. We have one 2001 Honda Civic. We have 300K in debt from student loans, only from med school. I don’t want anyone to feel sorry for us but stop saying we’re rich and selfish. You’re not even the one paying us.

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    Wow, I hit a nerve. Why don’t you doctors get together and stop all the paper work? Medicare patients with expensive cars? Yeah, that happens a lot. I think I do pay you. I believe doctors should be funded more, school loans wiped clean after a certain number of years of service. I have only had Medicare for a few years, paid into Blue Cross for about 25 years before that and never used it ONCE. I also paid into Soc Sec, worked 30 years, don’t use any drugs for my MS that I don’t pay for. ME, And I receive SSDI.Doctors, nurses, teachers, you ALL deserve better pay, but be real, no Dr. will trade his salary for a teacher’s or nurse’s. You have an assoc, right? Or lobbyists? I bet they stick up for you. (I will win that bet) (I think)
    I guess I would like to trade lives with you doctors, maybe then we could figure something out and understand each other’s frustrations. You are college educated—what is the answer for both of us? MY family Dr rides his bike to work and says he is doing fine with what he is paid. (I don’t think he is 40.) He loves practicing medicine and helping people.

  • Vox Rusticus

    I suspect that if the SGR “formula”-based reductions planned for this year (March 1, last I heard) become implemented, we will see very shortly the collapse of Part B. It will only take a fraction of the primary care docs presently accepting Medicare to drop it and for another slightly larger fraction to stop taking new Medicare patients for the tipping point to be reached. If even three quarters of the primary care docs do nothing at all, and the remainder withdraw, that is all it will take.

    Congress and the administration are unable to take any effective action; like social security reform, Medicare is a third rail no one will go near, and payment cuts are far easier than excluding by code, which is a more effective way to cut costs, but is undeniable rationing, and something no one can bring themselves to do. Too bad. Instead of some well-planned trimming and shaping, the whole tree will fall to the ground.

  • jsmith

    My wife and I are both family docs. We shared a practice in Roseburg OR for two years in the early 00′s, taking over a mostly geriatric practice from a doc who said he was leaving to move closer to his extended family. He might have left out a few details.
    We were on salary for two years. Most of our pts were Medicare. We worked like dogs and gave good care. Every month we got the financials from the group, and every single month we lost money. We simply could not make a go of it with Medicare, and we left when they wanted us to go on production. We now share a salaried position in a group that does not take Medicare and is financially stable.

  • Heather

    Most doctors refuse to take Medicaid patients too. My sister lives in a medium sized city that has poor public transportation (budget cuts). She’s permanently disabled and on SSDI with Medicaid. Not one doctor in her city will treat her for her disability because they refuse Medicaid patients for the reasons you describe here. The closest clinic that accepts Medicaid is 45 miles away and inaccessible to her. So, she goes untreated and is suffering. No one seems to care. You only get good care in the US if you can afford to pay the premium rate. I’m not a socialist but this situation makes me question the me-me-me attitude. And she’s just a drop in the bucket. Everyone should be allowed to make a living. But if a patient is supposedly “covered” by Medicaid or -cal then shouldn’t doctors see these patients irregardless? It leaves such a bad taste in my mouth that the doctors offices automatically deny access to patients only because they have don’t have coverage “acceptable” to the doctor. Doesn’t this defy the mandate to do no harm?

  • Lily

    The Medicare Trust Fund subsidizes GME during residency to the tune of 9 billion dollars a year. And the teaching hospitals get a cut of this money too. If doctors and hospitals stop taking Medicare patients, maybe this taxpayer subsidy should stop as well.

  • Anonymous

    Folks…..were I come from you have the HAVE and HAVE NOTS….and the same goes for the physicians. The specilaists have the expensive cars, 4 car garages, exotic trips and so on while the primary care physicians struggle, work more, get paid less and drive the same simple car for years. And soon (if not already), the HAVE physicians and the HAVE NOT physicians will no longer play well on the playground – so John Q Public suffers. Sad sad sad…….

  • Vox Rusticus

    Heather:
    Having Medicaid and being “covered” are not the same things. I used to take Medicaid (not in CA). It was a demoralizing and frustrating program to deal with. The state frequently did not pay claims, and neither did their managed-care contractors. The rate of payment for a service that when paid for by commercial insurance might pay $150 would be paid by Medicaid at a third of that. Well below my costs. Sorry, but that kind of plan does not work. In primary care around here, the only practices that can afford to accept Maryland Medical Assistance are federally-funded outpatient clinics. Medicaid is such a bad reputation and is so unrelaible that a federally-funded entity has to be created that will accept it.

    Worse, many Medicaid recipients are, putting thing charitably here, not so easy to deal with. When I did take Medicaid, which I did for years, I tracked the no-show rate for my Medicaid population. It was 40%, week in and week out, You can’t schedule a workday when 40% of your appointments are going to be wasted. Nothing makes up for that unless you double-book. Whenever someone made a ruckus about not having verified coverage, or when they didn’t obtain a referral document they were told to obtain well ahead of time, it was almost always someone with Medical Assistance. Verbally abusing staff and me, disrupting the waiting room, threatening behavior. I had enough of all that. When I dropped Medicaid, I found it was easier to anticipate a well-attended appointment schedule, I could expect to be paid, and I rarely had to deal with unpleasant patients. No one has to take abuse.

    And no, neither the Hippocratic Oath, nor any other ethical compact requires that a doctor’s office accept a particular insurance carrier. It is a free country. Doctors are neither your slaves nor your drones. Just as you don’t have to work for an employer you don’t want to work for, neither do I.

    Lily:
    The Medicare Trust Fund gets some of the best-trained and cheapest labor you can get to work the worst and longest hours for peanuts with its present system. They couldn’t possibly get a better deal and they know it. Find me any other field in the USA where you can get a highly-ranked college graduate with a doctorate and a couple of years of additional post-doctorate education to work 80 hours a week for $40,000 a year and poor or no benefits.
    Any takers? Didn’t think so. Go ahead, eliminate GME support, then you can really see what it costs to pay for round-the clock physician coverage every day of the year. Hospitalists don’t work for resident rates.

  • Primary Care Internist

    diane – our “association” or “lobbyist” group (presumably you mean the AMA?) does not stick up for us, rather they are self-supporting image-mongers who have done nothing but destroy primary care medicine for years.

    And for those you feel doctors should take all comers into their office practice, even medicaid, see my first post about the expectation of working for free. There is still this thing called personal freedom. You should direct your feelings toward policymakers, to improve medicaid rates. The vast majority of doctors want to help people, but if you’re taking a loss on office patients, at least the systems in place should support that process being easier. Imagine trying to give money to Haiti for relief, and the American Red Cross makes you complete a 16-page form in order to donate, and to maintain all sorts of certifications, and then as you’re donating they don’t take american express? Ridiculous, right? Well that’s what medicaid is like, and that’s what many feel medicare will become.

    heather – i don’t have to see patients “irregardless” (please verify that’s word you meant to use). But if you feel that strongly, then just go ahead and invest the next 12 years of your life and about $300,000 – become a primary care doctor and do all the charity work you want. It’s easy, isn’t it?

  • Primary Care Internist

    One more thing –

    hospitals and doctors’ offices function, to some degree, as a safety net for those people who are at the edge of being able to support themselves. For many years, the situation described by heather above has been true, doctors’ offices not taking medicaid. Now major medical centers are dropping out of medicare. And in the last few years we even see in my office (suburban NY) last minute saves between hospitals and their contracts with major commercial insurers.

    This means, clearly, that none of our policymakers or the fat-cat insurance companies has listened to physicians FOR YEARS. Isn’t that clear to you people?

    And instead of addressing this, Obama and his trial lawyer buddies (e.g. Sebelius) would rather beat the drum of the uninsured & pre-existing conditions over and over again, and ultimately set up an expensive system to give people a
    useless “coverage” card a la medicaid.

    Wake up!

  • gerridoc

    I really cannot stand reading about how the public thinks that doctors (including primary care) are supposedly so well off. The only thing we have going for us is job security. Why doesn’t anyone rant about how much athletes and entertainers get paid? People are more willing to spend $$$$ on tickets to sporting events or other entertainment than they are willing to pay for doctor visits or prescriptions. On a particularly exasperating day, a patient complained about being dissatisfied with her visit, I reached into my pocket and gave her $5 (my lunch money) and said: “Here’s a refund for your copay.”
    Wake up, America!

  • Fray

    1. People that spend $$$ on sporting events and SUVs probably don’t have Medicaid. They probably have good insurance and are willing to pay for their medical care.

    2. If money is an issue, you should bring your lunch from home instead of paying $5 at a restaurant or cafe.

    3. If someone is unhappy with a visit, perhaps you should find out why. I was unhappy with care I received and was naive to think the doctor would be willing work it out and our relationship would be stregthened as a result. Instead I was ignored and I chose to transfer my care to a naturpath.

    4. You don’t need a lot of money to buy an expensive car. (Maybe not now since the banks are not lending.) If you don’t have a fancy car, you are probably reasonable and prefer not to take on unnecessary debt.

    5. If I am paying extra to help cover the cost of Medicare and Medicaid patients, and the practice stops accepting Medicare and Medicaid, will my fees for medical care go down?

    6. That medical center in Seattle charges hospital fees for any procedures done it its clinic. It’s easy to but up a multi-million dollar building when you charge 5 times more than a doctor in private practice.

  • joe

    Wow, the non-medical people here really are clueless. The simple fact is every medicaid patient I see, I lose money on. Every medicare patient I see, I may break even on. I still see both, but for simple economics I have to limit my practice. Non-medical people, every doctor who sees these government insurers does a percentage of “charity” or “free” care EVERY day they work…period. Can you say the same? How long would your business survive if you gave people rates for services that didn’t even cover costs? For non-business owners, how would you like it if your employer starting just cutting your paycheck because there services had gone up? Or making you pay them to work? Trust me, most of us docs didn’t enter this field for the money. There are heck of alot easier and educationally shorter ways to make a buck.
    PS: Anon 9:01. I am a specialist. My ford became a teenager this year. All isn’t roses on this side of the fence.

  • Vox Rusticus

    Fray:
    1. Don’t be so sure of that.
    2. I don’t expect someone to subsidize my lunch, nor do I think that with my investment in my career that buying lunch should be an issue. I certainly do not think it is the right of anyone else to ask me to brown-bag if I don’t want to just so I can accommodate crappy-paying insurance plans or people who won’t pay for their care. That goes for you, too. I paid my way and still do.
    3. Fine, But there are limits here, too. The customer isn’t always right and I am well past the point in life where I worry about pleasing everyone, particularly those who don’t pull their weight. And good luck with that voodoo naturopath when you need real treatment (although if your wallet is causing you sciatica, I suppose he could thin it out for you.)
    4. Yeah, I guess you could just steal an expensive car.
    5. What makes you think you are “paying extra?” If you have an insurance plan, that carrier has already negotiated a substantial discount off the posted fees. If you have some like United HealthCare, they really have discounted your payment, and if you have Medicare, they have done so even more. Don’t go thinking that because you aren’t covered by Medicaid that somehow you are paying a surplus. You aren’t.
    6. The medical center in Seattle is not a private doctor’s office. If it has a clinic in its facility, it is lawfully supposed to code for the facility where the services are provided. If it is allowed to charge a facility fee, that is reasonable and permitted. As a surgeon who operates at a hospital, at surgery centers and in my office, I get paid less for the operation I do in the surgery center or hospital than if I do the case in my office.

    And what they “charge” and what they are contractually allowed to collect from the carriers and co-insurance are not the same, usually not even close.

  • gerridoc

    Right on Vox Rusticus and Joe! The majority of my patients were well off, had non-Medicaid insurance, and still complained about the co-pay. They expected their insurance to pay for EVERYTHING. I also carry my lunch, but I keep some cash in my pocket for extras. Excuse me for calling it “lunch money.” And I had already apologized to the patient for whatever it was that was wrong, but she decided that SHE shouldn’t have to pay her co-pay for the visit because I was running late. We cannot waive co-pays for people because they are dissatisfied. I am really glad that Fray is not my patient. Hope the naturopath takes great care of you. And how do you pay for the visit???
    And what the heck does it matter what kind of car I drive???

  • jsmith

    Heather, We didn’t bring up Medicaid because it’s not even a consideration for a lot of us in primary care. In a lot of communities Medicaid outpatient care means the poverty clinic (aka the Community Health Center) or nothing. Sad but true. Want good health care for the poor? Try moving to Canada.
    Lily, If you don’t subsidize residency training, then you will have a doctor shortage that would be most impressive. Not sure the USA wants to head in that direction, with the baby boomers retiring and all.

  • Paul MD

    Mandating provider participation for licensure has always been a concern for me. I would be curious as to the legal issues (if any) that would involve.

    I am a specialist, I still am paying off an enormous educational debt and aside from that, what I do with my money is my own business.

    I am being honest in saying that I did not get into medicine or my field “for the money” but I certainly would not have done this to myself had there been no money.

  • P

    Evan: >>Patients want two simple things: Low prices and good healthcare.>>

    One basic rule of business: good, cheap, fast. Pick two.

    Vox Rusticus: >>Find me any other field in the USA where you can get a highly-ranked college graduate with a doctorate and a couple of years of additional post-doctorate education to work 80 hours a week for $40,000 a year and poor or no benefits.>>

    Veterinary medicine. But, we don’t accept Medicare/Medicaid, either.

  • Lily

    Vox Rusticus,

    So you feel your Medicare funded terrific training should only benefit your private patients. I’m on Medicare with a second insurance. The second only pays their share if Medicare is accepted. I have no choice over this method.

    And if you resent being used as cheap labor in the hospital during training, how do you think the patient feels being used as your practice prop. We don’t get any discount for that. Take your beef about your long hours and cheap pay to the hospitals who are the real beneficiaries of this sacrifice.

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    THe AMA doesn’t stick up for you? Do you pay dues? Why let them get away with that? My nuerologist (I have MS)(my ONLY dang health problem, or like my 103 year old aunt I would NEVER go to a doctor!) gets $350 a 10min visit, I wait 30 min (even when I am first at 7am), the knee guy, again $350 and DID NOTHING, my primary care Dr. is the best, always on time, I WISH I could just see him and I would gladly pay him on the spot. I KNOW he is getting shafted and I hate it. So far, Medicare has done nothing for ME, but take my money. I, like you, am losing money. I have it in case of a catrastrophe, so I don’t end up on the street. I doubt ANY of YOU fear living on the street due to losing money at your practice. You have equity in homes, those aged cars, and why do I feel you could always get a job SOMEWHERE? Your lack of sympathy for those who have NO CHOICE but to be on Medicare is appalling.Those patients act up? Could there be a reason? You think they WANT to be in a doctor’s office? THEY ARE SICK. I’m sure they are not the only unruly patients you come acrosss. SURPRISE! Every job has them! Ask your friendly barista.
    You sound so pathetic, and I don’t mean that in a mean way, I feel sorry for you suffering, poor, doctors with sack lunches and old, old, cars, huge loans, and no support from AMA or our government. I can’t IMAGINE what your staff must suffer through. You have cheap art in your hospitals, I see your points. It sounds like an awful situation. Maybe you could become a vet? I understand now why so many doctors take kick backs from drug companies to supplement their income. Long hours, no time off, sounds terrible. Oh, here is the Seattle “clinic” I referenced (I was wrong to call it a clinic, forgive me I am just a disabled, former civil servant (talk about low pay and long hours and vulgar customers, but they needed me and stupid me, I took a bus and stayed 18yrs)—The Swedish Neuroscience Institute is based on the Cherry Hill campus of Swedish Medical Center, although neuroscience services are provided at locations throughout the Swedish health system.

    Swedish/Cherry Hill was formerly known as the Providence campus of Swedish, after Providence Seattle Medical Center strategically aligned with Swedish Medical Center in 2000. Since then, the campus has undergone more than $100 million in new construction and renovations.

  • A Practicing Physician

    The Peoples Republic of Massachusetts already requires participation for licensure. Certainly this is unconstitutional and should be litigated all the way to the Supreme Court if necessary.

  • ninguem

    Why don’t you doctors get together and stop all the paper work?

    Because our magic ray guns and secret decoder rings are on the fritz.

    I think I do pay you.

    If Medicare, no you don’t. You didn’t “pay into” Medicare or Medicaid. You paid the Medicare and Medicaid of the recipients receiving benefits at the time you were working. Assuming you are not working now, or working some low number of hours. Your current Medicare and Medicaid benefits, as applicable, are paid by current workers. Same with Social Security and SSDI.

  • ninguem

    Fray: That medical center in Seattle charges hospital fees for any procedures done it its clinic. It’s easy to but up a multi-million dollar building when you charge 5 times more than a doctor in private practice.

    Now you’re onto something. Yes, many of the bog box places you find around Seattle, many other towns for that matter, they get themselves designated part of a hospital, or an Urgent Care gets designated an emergency department by the WA Dept. of Health.

    Then they charge ER fees for every trivial thing in the clinic. Been there, done that, seen it with my own eyes. Worked in an Urgent Care for a while. Going to see a patient in an exam room, notice, in the waiting room,say for example, a lady in a blue dress with a bandaged hand. Finish seeing the patient, look in the waiting room, it’s empty.

    “What happented to that lady with the blue dress and the bandaged hand?”

    “She left”

    “Why?”

    Turned out lady showed up for suture removal. Cut hand camping out of area, got sutured at country hospital, now back home to get stitches out. Receptionist is tired of being yelled at, so she took it on self to let patient know the cost upfront. Multi-hundred-dollar fee to take out sutures. Suddenly office FP looked way better.

    Typical scenario, saw multiple variations on the theme, every day until I quit in disgust.

    Now I’m office FP. I made sure I didn’t have a noncompete in my employment agreement. These big box places survive by charging enormous fees, hospital or ER fees for office practice. They exploit the doctors. But if they leave, a noncompete is invoked, and the doc has to leave the area. Drag spouse, kids out of schools, or face a long commute.

    I negotiated mine out only because I caught them desperate for a warm body.

    Oh, and receptionist who got tired of being yelled at is no longer there either.

    I’ve seen…….reported in the newspapers…..more than one case where physician noncompetes were invoked in rural communities, the affected doc left, and the community suffered from lack of physicians.

    Oh, and another thing. If we were lawyers entering a Washington law firm, to put a noncompete in a lawyer’s employment contract would be the unethical practice of law. This is true in Washington and all 50 states.

  • BLG

    I can’t believe I just read all these responses. Found this site by accident. I can say from my perspective, I have never taken exception to a physician’s salary. It’s none of my business much like it is no one’s business how much money I make or what type of car I drive or where I choose to live. I am somewhat shocked at the expectation that physicians provide service below their cost or even at cost.

    A friend of mine has voiced the same complaints that I see here but does not blink an eye at paying the exorbitant prices for season tickets to a ball game nor has he voiced any complaints at the outrageous salaries ball players make. Because of his diabetes, he HAS to see his physician regularly so he is obligated to pay. However because he is not obligated to purchase season tickets and can therefore choose not to make that purchase, there is no complaint. He owns his own business (provides a service) and once I commented “don’t you charge as high as the market will allow you for your industry?”

    Why do we really care what kind of a car a physician drives or the price of their home? I am reminded of an incident when I paid a lot of money (approx $2,000) for a vet bill. I just about fell over when I realized how much it was going to cost but I chose to have the vet begin treatment. I was taken to task by an acquaintance for spending so much money on an animal when I could have taken that same money and donated it to feed the hungry. My response was “how I choose to spend my money is not your business.”

    Just like any service I hire, they are entitled to be paid and make a profit. I have no expectation that a physician that I see provide me care at his/her expense or cost or live within an economic guideline that I deem to be acceptable.

  • ninguem

    Heather – Most doctors refuse to take Medicaid patients too. My sister lives in a medium sized city that has poor public transportation (budget cuts).

    http://www.in.com/videos/watchvideo-cmu-ces-mdecins-qui-refusent-leurs-soins-1816084.html

    http://www.liberation.fr/societe/0101577343-trop-de-medecins-refusent-les-patients-pauvres

    French Medicaid is CMU, Couverture Maladie Universelle. They see the same thing. Like many problems (obesity comes to mind), their problem is less than ours, but they’re catching up fast.

    In the video clip, they show Médecins Sans Frontières doing projects in their impoverished areas because the local docs aren’t doing it.

    Lest you think it’s unique to the USA.

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    UPS good, cheap and fast
    US Postal Service good cheap and fast
    Pizza good cheap and fast
    Midas Muffler G,C, and F
    Geek Squad G,C,F
    Google G,C,F
    Flip your light switch, G C F
    A well run company CAN be all those things. And I DON’T ask or expect “cheap” just affordable. $60,000 hospital stay and I had to BEG them to release me, I felt better and they could find NOTHING wrong with me. I believe I was simply dehydrated, but they ran every test they had. That is NOT MY FAULT. What we NEED is to work together, you and I, to try and acheive BOTH of our goals. How did we get to this place? You admit that once doctors made GOOD money, and once it was a nobel profession and once you did not start with hundreds of thousands of dollars of loans—where did we all go wrong? Why can Canada do it and we can’t? WE WANT to look up to you again, but we will never look at you as Gods again. How do we work together on this? You don’t seem to feel you are in any way responsible for this mess. If we both are innocents, who did this to us? We do seem to agree on one thing: You don’t want to be doctors anymore under current circumstances and WE don’t want to be sick.

  • http://dj-astellarlife.blogspot.com/ Diane J Standiford

    Lily, so true, isn’t it fun to be treated, observed by students? The car thing—just an example of, hey, you can afford that, not me, I don’t complain that I don’t make enough money. My point was, you are making a good income, I can’t believe you deny that fact. Most college students pay back loans, you will too. I was poor enough to gets grants for college and I did work study jobs. Are doctors mad at patients or the govt or Obama or Democrats or just the lack of money? What do you want? Next you’ll say you have trouble getting dates…we KNOW that’s not true, even in rural areas. Wait, divorce rate is high, drug use, stress, why DO you want to be doctors? And who will doctor YOU and your family if you get sick? Are you not, in reality, patients just like us? Your parents have/had Medicare? Are we really so different? Or…will you pay for private ins. because you can? How about your parents? This has been a great discussion, I’ve learned a lot. (I stopped paying for movie/opera/Disneyland tickets long ago.) Looking forward to a post about dentists!

  • R Watkins

    Ms. Standiford:

    I think, in your last post, you’ve hit on the truth. The current system is designed for the benefit of big insurance, big pharma, and big government. It is abusive to both patients and docs. I think the abuse will only get much worse before we seen any real movement for change.

  • ninguem

    Physicians got training subsidized by the government. So does everyone else in higher education, with the exception maybe, Hillsdale College and the few others that accept zero guovernment money. Probably half my class got their medical training well paid for, courtesy of the military or the Public Health Service.

    Is there an expectation for you to do charity work all your life? Why physicians? Is the military hitch not enough? The four years on the Indian reservation? How long in the physicians life do you feel you have a claim on their expertise?

  • Fray

    “The customer isn’t always right and I am well past the point in life where I worry about pleasing everyone, particularly those who don’t pull their weight.”

    And you wonder why we patients are bitter. My issue wasn’t about who was right. I paid a lot of money and didn’t get the care I needed. You imply I didn’t pull my weight. I walk into a doctor’s office and this is what I get. Judged.

    My voodoo naturpath has the abiltiy to prescribe medication. Instead of being judged, I was able to find the right medication in the right dose. I also discovered a food allergy, something my MD was never able to figure out.

  • Vox Rusticus

    Lily,

    I don’t owe you or anyone for my medical training except the banks I borrowed money from. Just because I worked at a hospital that received support from the CMS for supporting resident training does not mean I owe a debt, morally, legally or any other way. Resident training is not a marker you have a right to call in when it suits you.

    And to correct your misperception, it is illegal for a resident to bill you for your care. The supervising attending is permitted to bill, provided he/she actually provides care, but a resident cannot. You did not pay for a resident’s care except indirectly by way of your federal taxes, the same taxes I and everyone else that earns income has to pay.

    P:

    $40K for veterinary medicine? If that is true, you are doing something seriously wrong. The practices I know of, especially those with after-hours emergency veterinary capability are able to buy CT scanners and all sorts of toys. They take payment with this stuff called “cash” and also with these stiff pieces of plastic called “credit cards”, which apparently allow them to earn an income an order of magnitude greater than $40K.

  • joe

    Wow ignorance is bliss.

    Lily those residents treating you are MD’s. At a teaching hospital they are at your bedside at all hours writing orders, making decisions, and keeping people alive. You are far, far from some practice prop. If it was so bad for you, go to a community/non-teaching hospital. I guarantee you in the wee hours there will be no doctor at your beck and call unless you are about to code. Then you get the ER doc or maybe a hospitalist if the hospital has one. As Vox Rusticus correctly pointed out, Medicare gets much much more bang for it’s buck supporting GME than not and they know it. Frankly, I think them not supporting GME would be a great idea. Then ignorant people like you would know how much it really costs to have the equivalent in hospitalist’s 24/7 coverage. Discount Ha.

    Diane:
    Read my post. I see medicare/medicaid patients EVERY day. I limit my practice to them not because I don’t like them (actually like Dr Brayer, I find my medicare patients the most personally rewarding in my practice), but because my pratice would go under….period. Then who loses? I guess as a “civil servant” you have never had to keep an eye on books to keep a business afloat. It is not easy. I am not going to argue with you, you don’t know what you don’t know and I truly am sorry for your diagnosis. But one point to the illuminate to others just how far out in left field some of your statement are:

    Your neurologist’s 10 minute (presumably f/u) visit at $350.00 X 6 visits/hour X 8 hours/day X 5 work days/week X 50 weeks/year (lets give him a two week vacation) = 4.2 MILLION DOLLARS.

    The reality is a neurologist makes 5-10% of that much money. Welcome to the real world.

  • http://rebeldoctor.blogspot.com/ Michael Rack, MD

    “Are doctors mad at patients or the govt or Obama or Democrats or just the lack of money? What do you want?”

    I’m personally mad at Obama and the Democrats.

    What do I want? I want medicaid to leave me alone and not send me any more 20 page questionnaires to fill out regarding the policies I have in place for accomodating the disabled.

    I want medicare to stop treating doctors like potential criminals- no more medicare recovery audit contractors:
    http://www.racaudits.com/Medicare_Fraud_Services_SKD.html

  • Anonymous

    Now I’m office FP. I made sure I didn’t have a noncompete in my employment agreement. These big box places survive by charging enormous fees, hospital or ER fees for office practice. They exploit the doctors. But if they leave, a noncompete is invoked, and the doc has to leave the area. Drag spouse, kids out of schools, or face a long commute.

    One advantage of being in California is that state law deems almost all employee non-compete agreements unenforceable. Indeed, employee non-compete agreements are unreasonable except in the narrowest of cases; certainly there is no reasonable reason to get a primary care doctor to sign one.

  • Anonymous

    A question for the primary care doctors here: if someone were turning 65, would it be better from your standpoint if s/he used traditional Medicare or some “Medicare Advantage” plan? Assume that the 65 year old person is in good health, and does not need any medication or other ongoing treatment besides typical checkups, vaccinations, and screenings as recommended by the USPSTF or similar organizations.

  • http://lockupdoc.com Lockup Doc

    There is already a huge geriatric medicine and geriatric psychiatry shortage in the U.S. (I’ve previously written about this topic.) It has been getting progressively worse in recent years, and now, if Medicare reimbursements get cut, nobody will be able to afford to treat elderly people.

    After 4 years of medical school, a one year of internal medicine internship, and 3 years of psychiatry residency, I completed a one year fellowship in geriatric psychiatry. (Not trying to impress anyone in any way–my physician colleagues know that that is not an uncommon training scenario, but I’m spelling it out for those who may not understand how many years it takes to become a practicing physician.)

    My point is, after all of those years of training and especially after spending an extra year learning to treat the elderly, I have spent only a small fraction of my practicing career seeing this population. Why? Well, as other doctors have mentioned, I too, greatly enjoy working with seniors. After my training I even considered starting my own geriatric psychiatry practice. I did not do so, not because I wanted to make a lot of money but because I did not want to set up a practice that was sure to fail financially. I graduated from medical school in the early 90′s with about $125,000 in med school loans. I spent many years paying $2,000/month to finally get rid of them. I did not go into medicine to be rich, but I didn’t go in the hole that far, spend 5 more years making just enough to pay rent on a modest apartment and make payments on a crappy car so that ultimately at age 31 I could live a pauper’s life either.

    If Medicare payments are allowed to be cut as scheduled, all patients and doctors should be very concerned. Our health care system will not be able to sustain this blow. If you’re a nurse or other non-physician health care worker and think this doesn’t apply to you, then think again, as nurses and others are going to be cut, too.

  • R Watkins

    “I want medicare to stop treating doctors like potential criminals- no more medicare recovery audit contractors:”

    Dr. Rack, why do you blame Obama and the Democrats for a policy that was established under Bush and the Republicans?

  • http://www.mayoclinic.org/healthpolicycenter Nora O’Sullivan

    Dr. Brayer,
    Your point about the financial ramifications of Medicare payments to primary care providers is spot on. If providers are not able to cover their costs of providing care, it is ultimately the patient who will suffer.

    Thank you so much for mentioning Mayo Clinic in this blog post. To clarify one of you points, the Medicare Opt-out is in effect at only one of our off-site clinics in Glendale, Arizona. It involves only 5 primary care physicians, and it’s only for the primary care office visit. This pilot program was implemented on January 1st of this year. The outcome is yet to be determined.

    Thanks again for the Mayo mention, and for your thoughtful post.

    Nora O’Sullivan
    Mayo Clinic Helath Policy Center

  • Lily

    Vox Rusticus,

    Look, I don’t believe in anyway that you should give away your services for free. And I’m appreciative and acknowledge your hard work and skill as I’ve been a grateful recipient many times. And I don’t care how much money you make, none of my business. But if you deny me care because I’m on medicare thus negating my second
    insurance, you’re backing me into a corner. Then my gut reaction is resentment that you took from me when you were in training (financially and clinically), then closed the door when you made it. The senior vote will eventually trump the powerful medical lobbies in Washington and bring mandates that nobody will like. Maybe patients and providors should both stick their fingers in the wind and make adjustments before this comes to pass.

  • VoxRusticus

    Lily:

    It hardly matters what seniors will vote fro, really. You can vote for low prices and low Medicare premiums and anything else you want. That does not mean someone will work for you on those terms. That road was trod by all the east bloc countries before the fall of the Berlin Wall. Sure, there was the state clinic that provided “care” and had “doctors,” but the quality and availability of materials was infamous. If you wanted serious care, you either had to be a Party member who got access to the special polyclinics, where people got paid for their work, or you tapped your informal network and paid someone on the black market, or you did without.

    State price fixing below the cost of production never, ever works, unless you want slave-labor camps to provide that for you.

  • ninguem

    Then my gut reaction is resentment that you took from me when you were in training (financially and clinically), then closed the door when you made it.

    “TOOK. FROM. ME.”

    Quite a high opinion of yourself. The taxes paid for Federal support of higher education goes to ALL fields. Why are you singling out doctors as the people who somehow owe you something? And you went to the teaching hospital with the housestaff BECAUSE of a good reputation, and it has that good reputation BECAUSE of the house staff.

    The dentist that benefitted from the same higher education funding likely is not in Medicare at all. Are you forcing the dentist to participate with Medicare?

    For that matter, do I have a claim on your labor for the government funding of your higher education?

    WE’RE backing you into a corner? It’s Medicare rules that require us to be 100% in, or 100% out. We either accept Medicare as payment in full, or we get nothing. British docs, the consultants at least, have NHS and private clinic hours. They can choose to provide some services privately and others under the NHS.

    Apparently Mayo has found a way to do that as well, in a way, with some Mayo docs and clinics participating, others opted-out. I wouldn’t mind knowing how that works, while keeping clear of Medicare fraud and abuse rules. Don’t know how a solo doctor could do that.

    Depending on the country, Continental docs can balance-bill. Canada, well, good luck finding a primary care doc at all.

    Doctors should be able to choose to balance-bill patients if they so choose. The original Medicare legislation in 1965 allowed that. No surprise, there was a bait-and-switch with Medicare, physicians promised one thing, and promptly taken away. It’s argued that the original legislation was not repealed, docs should still be able to balance-bill as they see fit. Far as I know, it hasn’t been tested in court. How about fighting against the government that created the Ponzi scheme that is Social Security in the first place? How about fighting against the rules that forbid you from paying privately for services you want?

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