Conscience prevents doctors from dropping Medicare

There’s lots of talk about primary care doctors threatening to refuse Medicare and Medicaid patients. As some commenters point out, “If you don’t like the system, just drop out.”

Why, then, do so many doctors continue to see patients on Medicare and Medicaid?

Two words. Duty and conscience.

Primary care doctor Rob Lamberts has an excellent post on this, entitled, Good conscience is bad business. He notes how Medicare (and Medicaid, in particular) grievously underpays primary care, to the point where many of its recipients have trouble finding a regular doctor.

And indeed, his life would be made immeasurably if he stopped taking insurance:

If I dropped insurance and charged a fixed amount, I could:

1. Cut my billing staff nearly to zero (someone would still have to do bookkeeping).
2. Increase my payment per visit, which would allow me to see less patients per day.
3. Document for the sake of patient care, and not for the sake of getting paid.
4. Add extra services like email access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

But it’s his duty to his patients that prevents him from doing so. Calling caring for Medicare and Medicaid patients a social responsibility, he writes, “These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income. So far.”

Medicare and Medicaid exercises poor decision-making to starve primary care and rely on the goodwill and conscience of physicians to keep caring for its beneficiaries. That’s because physicians like Dr. Rob will increasingly be few and far between.

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  • amy

    I believe this applies to all specialties of medicine and not just primary care.

  • Ed

    The real moral question is would patient get better care in the short and long run without medicare. Is it morally right for patients to be seen in the comfort of their home, to stay in close communication with doctor, to have the trust and confidence your doctor is their for you. Is it morally right that doctors actually have the time to properly examine, work up, and talk to their patients. Yes these are the morally correct things. So why are so many doctors stuck thinking that holding up a broken system is the right thing to do. medicare and medicaid will still reimburse patients if the doctor has opted out of the system. Many cash docs charge close to the same price they would be reimbursed for anyway, the extra income come from a dramatically lower overhead.
    Doctors who have opted out can legally provided free and reduced priced services to their patients, which is illegal if you accept CMS payment.
    If doctors were more concerned about morals and duty than locking in a “reasonable income,” there would be a lot more dropping from the ranks of medicare/medicaid

    • storytellerdoc

      health reform is necessary, but we need to address tort reform as well. always frustrating to read about this sort of thing, to me, for some reason. I’m simply a hospital employee who’s paycheck comes regardless if I get my ass kicked or have a slow day…nice post

      • anna

        Tort reform is necessary, but we need to address patient safety as well. Currently, medical providers cover for each other. There is no accountability and absolutely no transparency in regard to provider quality – even to the point of ignoring illegal behavior. Latest example, the Delaware pediatrician who abused his patients FOR YEARS allegedly shielded by the very organization allegedly designed to protect the public FOR YEARS.

        This is an extreme example, and not representative of the majority of medical providers. None-the-less it begs the question – what else is covered up that will never see the light of day? What mistakes – not bad outcomes – those can’t be avoided – but mistakes and poor quality care is covered up. Expose it to the daylight – warts and all. I believe that is the “fruits of your labor.” You know – the consequences of your own life choices. This is part of the personal responsibility that we are all subject to. Medical providers don’t get a pass for their actions.

        No tort reform until there is a credible program – fully transparent to the public – to deal with poor care, the mistakes that providers make – mistakes that should never happen. And don’t say “the public will never understand…” I believe you’ll find we do – we’re not as dumb as you think.

        • jrm

          Well, yes you are. You will never understand the rigors of medical training, which approach that of armed combat at times. You will never give up your twenties. You will never understand that learning the profession of medicine is not at all like graduate school. And you will never understand that, no matter how bright you think you may be, no matter how expert you may be in your own field, you can never approach the knowledge and clinical judgment of even the average physician.

          And yet you spit upon us, condescendingly acknowledging that the alledged Delaware abuser is “not representative of the majority of providers.” You damn us with this faint praise, knowing full well that such incidents represent only a miniscule minority of physicians.

          Physicians demonstrate more personal responsibility for less compensation in a single day than most people do in an entire lifetime. If you don’t believe it, imagine what it would be like to do without us for a month or two. Be careful what you wish for–you might get it.

          • Dr. Mary Johnson

            jrm, that is the best comment/retort from a physician I’ve read on a blog in a long time.

  • Healthcare Observer

    If you were to increase Medicare and Medicaid payments, where would the money come from – and what would that do to the already much higher per capita healthcare cost in the US?

  • Dr. Mary Johnson

    I’m curioius, Ed. Why are doctors always the ones left struggling with the morality and duty of providing care (oftentimes being left alone to flounder in a personal/fiscal hole to do it)?

    In most small towns, you cannot be a Pediatrician these days unless you accept Medicaid. You cannot turn innocent children (who are not repsonsible for their lot) away. Even then, you’re not getting rich.

    So I’ve got to ask you. What about the moral responsibilities of everyone else in this equation?

    • Ed

      My medical oath is to provide the best care for my patients. burning through volume of CMS patients to meet costs, giving them a 7 min visit at best is hardly acting morally and to claim moral superiority because you “accept” these patients is hypocritical.
      Its no wonder that cash based doctors have lower malpractice suits and payouts because they have the time and energy to be real advocates for there patients – many of whom are uninsured, under-insured, or otherwise destitute patients.
      Like I posted earlier, CMS exempt docs can legally provide services at free or reduced costs something I believe is a moral requirement of fulfilling a medical oath.
      A local pediatric clinic charges $110 for a level 3 weight check for which CMS may pay $60-80 and they have to pay for a huge admin staff. A local cash doc charges $40 for a 15min appointment or $75 for a 30 min (CMS will reimburse the patient directly if they mail in the form the doctor gives the). so who is screwing the system and making cost unaffordable: the CMS participant or non-participant?

    • WannabeDoc

      Why are doctors always the ones left struggling with the morality and duty of providing care (oftentimes being left alone to flounder in a personal/fiscal hole to do it)? – That’s easy…they took an oath.

      What about the moral responsibilities of everyone else in this equation? – They have responsibilities to share holders, other policy holders, and their own lot.

      Bottom line – you have to be a champion for the lot that you are in. Until we have meaningful reform in the system which states that care for the patient’s quality of life is the ultimate denominator, everyone will keep playing for their team…until their time comes.

      • jrm

        Well, most of us took an oath, Bowdlerized and politically correct as it may have been. But whatever version of the Hippocratic oath we might have taken, there is nothing in it that obligates any physician to provide care to anyone, compensated or not. Read it. If everyone would, it would eliminate thousands of ignorant blog comments, each braying “What about your Hippocratic Oath?” as a justification for their finely honed sense of entitlement.

        They have their cable TV.
        They have their cell phone.
        They have their refrigerator full of beer.
        They have their untaxed cash income.
        But they don’t have the money to pay for a doctor visit, because that’s supposed to be free.

        If you really are a “Wannabe Doc,” you’re a damned fool.

  • skeptikus

    Barf! Many doctors say they won’t turn away medicare/aid patients because of morality–but it in fact, they they can’t fill their practices otherwise.

    Doctors routinely won’t accept medicaid patients; there’s no morality qualms.

    Further, they SHOULD turn away medicare patients. We, the privately insured, are simply subsidizing their care. Why should I do that? This is America; we’re responsible for ourselves.

  • Matt

    Medicare is so vital for some patients , and your absolutely correct, that Doctors have an obligation to work with their patients. It isn’t about fighting the system. That isn’t the primary reason why Doctors become Doctors, is mainly for their patients.

  • Doc99

    Medical School selected out specific personalities willing to swallow anything – voluminous texts, extensive memorization, browbeating professors, etc – so they could get that degree. Those very personality traits that enabled survival in med school now have doomed doctors to put up with things like Medicare’s declining payments, HMO denials, Prior Approvals, Audits, etc. We have met the enemy and they is us.

    • jsmith

      You’ve hit the nail on the head.Call me Dr. Masochist and hit me again! Gettin’ a little tired though, after 20 years.

  • Leigh Ann Otte—TheDoctorWriter

    Once again, a well-made point. It’s unfortunate that doctors have to make these types of choices.

  • Vox Rusticus

    Doctors continue to accept Medicare largely out of fear, fear that the patients will just go elsewhere where their Medicare is accepted at par and there won’t be enough patients, even at “competitive” rates to make up the income loss. So they settle for the familiar if miserable and continue running on a hamster wheel. There is always the ugly possibility that the opted-out doctor would not have any patients while his departed patients would not be able to find a doctor. CMS knows this and counts on this fear to keep the status quo, while they sharpen their knife for the next slice.

    There are only so many folks both willing and able to pay out of pocket. Large numbers of retirees count on their Medicare benefits to cover their outpatient and inpatient expenses. You can’t blame them, since the government has taxed away a substantial portion of their potential savings in FICA wage taxes that have gone to subsidize current Medicare expenditures. And the government has neither the will nor the political courage to do what will eventually become a forced choice, the wholesale elimination of large numbers of payable codes (enlarging the number “non-covered” services) or engage in some other similar act of rationing. Demographics will make this inevitable as the truth becomes obvious that Medicare is something of a Ponzi scheme. Rationing by CPT code will raise the ire of the denied, but at least it does not run the risk of criticism that age-based cutoffs would have.

    Feeling sorry for your Medicare-insured patients might be a motivator, but I suspect it is minor compared to the fear of the unknown response to opting out, and the possibility of losing all of your practice goodwill.

  • tom

    Our pediatric practice is 50% midicaide. I have over the past several years found that I prefer my publicly funded patients. My income is comfortable, my patient visits are 30 to 40 per day. I treat my private pay patients the same as the medicaide patients. I am so ready for a universal public option!

  • Evinx

    IMO, the moral thing to do is to stop seeing Medicare patients. If enough did that, the system would implode — and that is what is needed. Patchwork fixes can only get you so far – ask any roofer. Medicare is the source of the problem. Kill it by simply refusing to see medicare patients and within a short time, the situation will be intolerable.

    Sound cruel – not if you take a long run perspective.
    Right now, every MD that accepts Medicare is simply a facilitator.

    Say it: My name is Dr X, i accept Medicare and I am a facilitator.

    The first step to the cure is to admit the problem.

  • ninguem

    @ tom February 25, 2010 at 7:38 pm

    It might be apples and oranges. Maybe unique to my area, but I’ve noticed Medicaid pays fairly well for pediatric work, but badly for adult medicine.

  • Susan

    I’m not a doc, but a psychologist and we fall into the same bind. I agree with @VoxRusticus…we’re compassionate and afraid. Also agree w/ @Doc99–the process of graduating medical school (and graduate school) condition us to accept the status quo without question, get approval before doing anything new, and work to be “good” to get approval.
    The health care mess we are in is in large part due to providers giving up all power to outside payers to determine our worth.
    And, putting down the public as ignorant and uninformed makes it worse. They don’t HAVE to be that way vis-a-vis medical payments. They seem to figure it out for life insurance, home insurance, car insurance, the stock market. And they ARE conditioned to get health care for peanuts, but think nothing of buying iphones, Wii game systems, and 4 TVs for their subsidized house. We can’t have it both ways–put ourselves up on a pedestal and say “You’ll never understand,” and then lament “No one understands and won’t pay me a living wage.” They CAN understand and when they do, change may happen.
    In my practice I accept one MC payor because the rest treat me like crap. My clients figure it out–change insurance, complain to the HR depts, petition the state insurance commission, pay me out of pocket, submit their own claims. They get it and want to pay me what I am worth, and free me up to do the work I’m good at while they manage the administrative end. My overhead is way down and quality of care is way up.

    Health care is a business–no matter where you work, someone manages the money. If you pass that responsibility 100% over to an outside entity, they will clean your clock (and they have). Would you give your personal finances up to a stranger? No. But the entire health care profession has done just that by blindly accepting that medicare/MCOs is a “moral obligation” and the way it must be done.

    As a provider, health care is the World’s Worst Business Model: I say lots more about it here:

  • Soul (author: Pay Me What I’m Worth)

    A sense of duty is a double-edged sword. While I completely agree everyone should have the ability to access quality professionals of any kind, if the profession is no loner rewarding or fulfilling for the person offering the service, what kind of service do they really offer?
    From what I gather after leading many a study group regarding one’s calling, if one lacks a sense of joy and gratitude in what they do, it’s very difficult to feel a sense of accomplishment or fulfilled. The goal of my book, Pay Me What I’m Worth is to help uncover how one’s purpose fulfills you – fully, daily, on all levels.
    Feeling fulfilled is one of the most important aspects of our journey on earth. While being financially paid what one is senses to be their worth plays a small part of the overall picture, it’s more than that!

    Do you feel confident that you’re paid the respect you’ve earned?
    What about sense of appreciation? Do patients appreciate all you do? (Do they KNOW all you do to do what you do?)

    Overall, time is the most equal opportunity measure we have. No matter age, culture, creed or calling, time is the same for us all. I sincerely bow in gratitude for anyone who takes the time to help other gain or maintain optimal health – on any level.

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