Will Medicare really lose physicians because of the SGR?

For years, physicians have argued that the specter of annual cuts in Medicare will cause many of them to leave the program, or at the very least, to limit how many new Medicare patients they will accept in their practices. Yet, for the most part, measures of seniors’ access show that the vast majority enjoy good access to care.

For instance, in May of this year, the Medicare Payment Advisory Commission (MedPAC), which advises Congress on payment policies, published the results of focus groups of physicians and beneficiaries. It reported that neither beneficiaries nor physicians believe that there are widespread access problems for beneficiaries.

Views of beneficiaries:

“We heard few concerns about access to physicians in any of the three locations selected for this study … Most beneficiaries felt they could get appointments in a reasonable amount of time as appropriate to the medical situation. For the most part, access issues do not appear to have changed for these beneficiaries over the past several years. Most beneficiaries have no trouble finding doctors, but there were a few more reports of issues with access to specialists than for primary care.”

Views of physicians:

“Most physicians were accepting new Medicare patients, but a few were not. All physicians were required to have at least 10 percent Medicare patients in their practice to be invited to one of our focus groups, but a few reported that they had stopped taking new Medicare patients. A few others have given serious consideration to stopping … Physicians see Medicare as a reliable payer, and appreciate the lack of preapproval requirements.”

The focus group findings mirrored surveys of beneficiaries, also commissioned by MedPAC. “In 2006 – the most recent year for which we [MedPAC] have data from the Medicare Current Beneficiary Survey – more than 90 percent of beneficiaries reported good access to care, regardless of the question asked.” Moreover, Medicare beneficiaries’ reported access was better than for privately-insured persons. The same survey, though, did show that there may be a growing (but relatively modest) problem with beneficiary access to primary care:

“Of the 6 percent of Medicare beneficiaries who were looking for a new primary care physician in 2008, 28 percent reported problems finding one. Although this amounts to less than 2 percent of the total Medicare population reporting problems, the Commission is concerned about the continuing trend of greater access problems for primary care.

Maggie Mahar, blogging in Health Beat, also casts doubt more on the notion that a large number of doctors are boycotting Medicare. Citing the MedPAC surveys and other data, she notes that there is palpable “anxiety” among physicians, “The take-away message is that while the 21% cuts doctors are now facing are an administrative nightmare, they will be fleeting. And reports of a mass exodus by doctors from Medicare are overblown.”

She may be right that there isn’t a “mass” exodus from Medicare – yet.

But something tells me that this time, things may be different. The latest cut and the chaos it creates may have reached a tipping point. An ACP member from Georgia told me that it wasn’t until yesterday that her practice received the first check from Medicare (with the 21% cut included) since the first of the month, and that as a result, her practice is living off credit and having trouble making ends meet. She predicted that she, and many others, will soon have no choice but to close their primary care practices if Medicare can’t be counted on to pay its bills.

But it more than money, I think, that is behind more and more physicians giving thought to what in the past was unthinkable: finding a way to make a living that doesn’t involve Medicare. It is a matter of the government breaking the bond of trust between doctors and the program. Trust that they government will pay them fairly, and on time, for their services, in exchange for physicians honoring their commitment to provide seniors with the best care possible. And as any cuckolded spouse can tell you, once a bond of trust is broken, it is almost impossible to restore.

Do you think the latest SGR debacle will create an access “tipping point” for patients?

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at
The ACP Advocate Blog.

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  • stargirl65

    I stopped taking new Medicare patients 10 years ago. I was ready to leave Medicare when they reversed the cuts. Luckily since Medicare is a small part of my practice I was not severely affected by the cuts.

    But the problem no one initially thinks about is that the private insurers often base their rates on Medicare rates. So if Medicare drops rates 21% then the private insurers will follow in 1-2 years as contracts roll over. If that happens then no primary care physicians will be able to make ends meet with any insurance participation. I am sure most specialists will also have a hard time.

  • http://thehappyhospitalist.blogspot.com THe Happy Hospitalist

    Exiting Medicare should be a stepped process. You don’t even have to start with Medicare. Start with your worst paying insurance. Initiate a stepped up concierge practice by having an open admission process for patients wishing to receive a better level of service. Advertise the heck out of it.

    Continue to calculate the number of retainer patients you need to drop your next lowest payer source. Over time, if you provide an excellent retainer based service, people willing to pay for that service will find you and you will be able to drop insurance in an accelerating process.

    It’s possible. There are people willing to pay for better service. Health care service will get you what you pay for. You have to offer the public a compelling product.

    Eventually, you’ll reach a threshold where the number of folks paying you for your service. Eventually, dropping Medicare becomes nothing more than a formality.

    People who can’t afford to pay extra for good service should petition their government officials for assistance. Perhaps there is an overwhelmed federally subsidized clinic or two they get into

    In 6 months.

  • Primary Care Internist

    I agree – it is the breaking of that bond of trust that will impact current physicians’ long-term outlook. The % of doctors who are just mechanically going through the motions of seeing patients until they have enough resources to retire is going to increase dramatically.

    The big difference between medicare and private payers is that the former is a reliable, generally on-time and hassle-free payer, the bread and butter of a typical internal medicine practice. The latter is generally a big question mark, a risk for a practice seeing a new patient (will i get paid? if so, how much and when?)

    There will be no mass exodus. Unfortunately too many docs can’t survive without medicare. What will happen, and what is happening, is that the gov’t toys with doctors’ trust, and docs will be more quickly looking for a way out – getting out of medicine altogether is probably as likely as staying in medicine but ditching medicare.

  • Doc99

    Third party giveth … third party taketh away. Live by Medicare. Die by Medicare. And from “The Shawshank Redemption,” -

    Get Busy Living or Get Busy Dying.


    It is very concerning to me and my partners as we are >50% medicare. Options will be dire if there is a cut. We may merge with the only other provider in the region and consider Non-par with medicare and run a boutique operation and renegotiate with our commercial carriers. I am beginning the dialogue of the “what ifs” so that we can have a plan in place. I agree with the “trust” piece. Years to build it and only seconds to lose it.

    Wild card if our board of medicine does what Massachesetts is doing by requiring participation in care and caid to have the “privilige of a medical license”. Therefore, cannot bank on boutique.

    • weak and dizzy

      Daughter of Medicare Patient to Concierge MD’s secretary:

      ” My mother just moved to the area and I understand by law all doctors must take medicare patients? Do you take medicare patients?”

      Secretary : ” Yes, we do. Our first new patient opening for medicare patients is nine months from now. Does the morning or afternoon work better for you and your mom?”

      • Max

        I love this and agree with it. They can tell you to take those patients, but they haven’t been crafty enough to put in a time frame, if they could. You can have 3 Medicare slots alloted per month. You can have 1. You can have 100.

  • tex

    I’m a specialist whose practice routine runs about 15% medicare and I will not formally withdraw from the program becasue I will not drop existing Medicare patients or those aging into medicare. I will just stop taking new medicare patients and my % will decline over time. Many of my collegues are saying the same thing. I did the same with Medicaid years ago and now it makes up 1% of my practice. Not to mention both medicaid and medicare patients are less healthy and require more work just to take care of. We should be paid more, not less, for these patients!


    If someone has good knowledge on this subject I would like to know if this is true.

    I have found information that states that if you participate in Medicare you cannot discriminate in any way between medicare patients and commercially insured patients in quality or quantity of care or in access to appointments to your office. That an auditor should be able to audit your charts and not be able to tell strictly on medical reports which patients are medicare and which are not.

    Sounds absurd but I have seen in print ??where?? that in so doing violates provider medicare contracting rules.

    Our state medicaid office in New Hampshire allows broad office policy on whether or not we see Medicaid at all or how many, where from, number per unit time etc.

    Can someone enlighten me.

  • http://drpauldorio.com Paul Dorio

    Sorry to not answer your excellent question, PaulMD. I just wanted to comment on the premise of this post:

    I have heard this question at least twice recently, the first time with a “no way” type of answer. Well, I think that someone is not paying attention if they ask this question and have that kind of answer in mind. Every day I hear more physicians tell me that they are not taking Medicare patients, or are limiting the numbers of Medicare patients. It is already happening and has been happening for many years. The government’s faulty decision-making merely helps spur those practicioners who have not yet made restrictions to do so. When will they wake up? The bottom dollar cuts cannot continue to be sliced out of physicians’ bottoms!

  • Bill Dupon

    Sent in my waiver 4 times…… No response…… but a sigh on the phone when I called to ask why. Icd CPt codes….. Stiff fines when the fraud team visits. Great incentive when you lose money when they walk through the door. Submitting number 5 with a certified letter.

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