Is Medicare the biggest challenge to seeing the doctor of your choice?

Medicare was touted as the social entitlement program that would forever change health care access for our seniors.

But is it becoming the biggest challenge to seeing the doctor of your choice?

For the first time in the almost 50 years of the program more and more Medicare recipients are facing the challenge of finding a doctor who will take their government sponsored insurance.

Sure, there have recently been problems with the over 65 finding primary care physicians. But these PCP’s can be hard for any insurance class of patient to find, though much harder for patients with plans that pay 40 percent of current market rates.

As you have seen from my recent blog posts, we are facing a rapidly approaching meltdown of our Medicare system. With no substantial reimbursement increases since 1997, an expanding older population, and medical costs that are outpacing the rate of growth of GDP, more and more physicians and other health care providers are exiting the market space.

But the current state of affairs is about more than money. A whole lot more.

You see money won’t necessarily buy you access to your physician if you are a Medicare patient.

For most capitalist oriented folks this doesn’t make sense. This land of milk and honey we call America was built on one’s ability to buy anything — including access. Whether it be to the halls of Congress or the waiting rooms of medical specialists, the rich (or even the middle class) in the United States have always been given the golden ticket for access if they could afford it.

But current Medicare rules don’t allow for the normal business relationships that have built the rest of our economy.

This stems from the limited participating agreements that physicians are forced to agree with if they desire to see Medicare patients. And, for laws that restrict the payment of benefits to seniors if they see physicians that aren’t a part of the Medicare program.

Physicians are really given only two choices if they want to get paid for seeing a Medicare patient. They can either agree to be “participating” where they are paid directly by the government for delivering care, or “non-participating” where they agree to see an over 65 patient but the payment is paid to the patient and the physician is then responsible for collecting the fee.

If a physician “opts out,” that is, decides to not be a part of the program at all (“par” or “non-par”), then they can see a Medicare patient only if a complicated set of constantly renewed contracts are completed.

But here’s the catch: the patient cannot receive any reimbursement from the government for the cost of the care.

That’s right, as a Medicare patient you lose your benefits from the federal government entitlement program if you enter into a contract with a physician who is not part of the system. You won’t even get reimbursed for what Medicare would have paid if the physician was a program provider.

Now honestly this has never been much of a problem: most physicians participated in the program and very few were “non-par”, much less opted out. A big impediment to even testing the water of opting out has been the mandatory two year waiting period that physicians must survive before they are allowed to rejoin the system.

That was until the post-Obamacare age we live in now.

Funding the Medicare system has become laughable with a recurrent litany of temporary fixes that now provide only a month-to-month operating budget for the program.

It is this uncertainty combined with the decline in overall revenue that is driving physicians to opt out of the program and into the world of direct contracting.

Is it fair for the federal government to get a free ride on the backs of American seniors by no longer being responsible for providing health care dollars?

If you are an entitled Medicare recipient and you see a physician of your choosing who might not be a part of the system, why shouldn’t you at least be able to get reimbursed for your out of pocket costs to the limits of the allowable Medicare charge?

So I guess the answer to the question is, that for now, the government is not “telling patients they can’t see the doctor of their choice” but they are telling them that they aren’t going to pay for it.

As we move forward into the Republican controlled Congress, and free market capitalism begins to rein supreme, we are almost certain to see challenges to the current status quo. Not only will patients begin to demand the right to see the physician of their choice, Republicans may see changes in the law as a way to limit growth of the program and curb the government’s responsibility for cost increases.

Of course, with these rights patients risk a higher amount of out-of-pocket costs.

It’s unclear if the political winds will blow to enhance the laws surrounding direct contracting — loosening the restrictions on physicians from offering these deals and for patients electing to sign up — but it is almost certain to be a part of the discussion very soon.

Dan McCoy is a dermatologist who blogs at docdano.com.

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  • stitch

    You have some valid points, but you lose me when you talk about the “post Obamacare world.” The vast majority of that legislation has not even begun to go into effect, and the problems of Medicare pre-date even the discussion of healthcare reform.

  • Dr. Liberty

    “As we move forward into the Republican controlled Congress, and free market capitalism begins to rein supreme”

    Really? Since when do republicans give free market capitalism anything more than lip service?

    That is a very dangerous statement to make. Because it leads people to blame free market capitalism for the failures of the republican party…when they are really failures of republican-style socialism.

    • http://fertilityfile.com IVF-MD

      Great point. Sadly, neither party supports limited government. You realize that Burger King and McDonald’s are going to argue passionately that their burgers are better than the other place, but neither would tout the advantages of consuming more vegetables and less red meat.

    • gzuckier

      I’ve come to see this as the Republican Paradox, although in all honesty it’s more Post-Reagan Right than classical Republican: the axiomatic belief that one is entitled to government largesse, be it Medicare or bailout of one’s badly managed financial establishment; coupled with the fervent belief that any regulations or restrictions associated with such largesse are a sign of overbearing government intrusion into the almighty free market, creeping socialism, impending Gulags, Armageddon, etc.

  • http://www.somebodyhealme.com Diana

    Medicare certainly has problems, but to blame them on the Affordable Care Act (or Obamacare, as you and yours like to call it) is laughable.

    • Smart Doc

      So the $500 billion in Medicare cuts in ObamaCare and the complete absence of any correction in ObamaCare of the yearly 25% cuts in Medicare reimbursements have no effect on doctors’ acceptance of Medicare patients?

      Who is being “ridiculous” here?

      Doc McCoy is totally correct.

      • stitch

        The $500bn “cuts” in “Obamacare” are to reduce overpayments to Medicare Advantage insurance providers, who are paid per patient more than standard Medicare patients. What other cuts are you talking about?

        And it is my understanding that the legislation provides for a permanent correction to the payment formula based on the 1997 budget act. Not that the payments under the new system are necessarily going to be good, mind you, but it does correct the ongoing payment cuts.

        The healthcare reform act (I can never remember the placement of letters in the acronym and I won’t use the politically charged term “Obamacare”) has a lot of problems, to be true, but I’ll say again, Medicare has had ongoing problems for a number of years, and we’ve had lots of tweaks along the way. None of them, going back to the institution of DRGs in the ’80s (under the Reagan administration, mind you) have been beneficial to docs, certainly not to primary care providers.

        • http://www.docdano.com docdano

          Stitch: unfortunately the bill did not include a fix in the physician payment formula. That was initially included, but because it made the fiscal note of the Act so large (read – possibly >$1 trillion) it was stripped out and voted on earlier in the year. It failed. So the current legislation does not include any correction of the failed physician payment system. This is probably one of the biggest problems of the bill.

          • stitch

            Thanks for the info. I had read other articles indicating it had been included; I appreciate the correction.

  • Jackie

    When I received the new physicians directory from my insurance plan, I realized that none of my doctors accepted Medicare.

    Frantic, I called the health plan and was offered the Medicare Advantage plan. I do complain about my doctors from time to time, but I know I need the good doctors who have accompanied my cancer journey for many years…

    • Jackie

      When I found out the advantage plan requires no co-payment for my appointment, I joked with my oncologist that “I’m coming to see you everyday!” He forced a smile on his face and told me to come back in 10 weeks.

      Got a call early this morning that the ENT surgeon whom I’m supposed to have a consult with at 9:45 has been out sick… He’s also certified in neurology and is specialized in skull-based surgery. I hope he will get well soon. Wondered if the life expectancy of surgeons is still among the lowest.

      Two of our choir members had passed away unexpectedly almost 10 years ago. One was an audiologist barely a year into his retirementin in his late 60′s; the other an ER Director in his mid 50′s. The system needs to change in order to save our good doctors.

  • Dr Chris

    We get many , many call from patients wanting a physician taking medicare. The stealth methods used attempting to get into the practice indicate a lot of problems finding a doc-it’s too much paperwork and intense medical care, which loses money. Apparently, these patients have been coached -we are told that they take BC/BS, then give their age, and the secretary realizes that they must have medicare.
    It’s against my ethics not to take them all, but we just can’t afford it anymore and stay in business.
    It has nothing to do with” Obamacare”-the system was completely screwed up ten years ago- and there has to be a way to make sure that there is some kind of universal coverage-people are out there working three part time jobs, because no one can afford to hire full time and pay all those benefits, I’m seeing people -and middle class two-job families-lose their houses right and left. One spouse loses his/her job and the system collapses.

  • soloFP

    In my area Medicare is the second best payer and actually has low overhead. Straight Medicare requires no prior auths for CTs/MRIs and simply a piece of paper to see a specialist who also accepts Medicare. Payment is requried within 30 days from Medicare, and all docs in my region are paid the same fee for the same CPT code. None of the HMOs/PPOs meet these standards, and most private insurance companies pay 20% less than Medicare. Most docs in my area could not survive without Medicare, and at least 70% of the hospitalized paitents have Medicare.

    • ninguem

      This reflects different pay rates for Medicare in different parts of the country. You would think the system would be monolithic, but it can vary significantly. I practice in the county I’m in, because if I moved a couple miles over a county line, I’d have a 5% reduction in pay. The cost of living does not really change moving less than ten miles down the road.

      Also reflects different rates for the private payers, but Medicare pay does vary depending on where you practice.

    • family practitioner

      I think medicare is your best payer because you are being underpaid by insurance plans. And that’s the price of being a solo fp; you are a gnat to them, My guess is that bigger groups in your area are getting at least 120% medicare, if not higher.

  • Smart Doc

    Best guest post article of the past year, in my humble opinion.

    I fear that, while 95% or so of doctors still “participate” in Medicare, the accessibility into the practices of the best doctors ranges from “passive-aggressive” to “John Galt.”

    In other words, you will never get an appointment with the top doctors once you are coerced by our totalitaritarian system into Medicare Third Class citizenship at age 65. Such insurance status renders you Persona Non Grata to the scheduling girls.

  • David

    Would certainly like to hear comments/suggestions on what “fix” would actually work for doctors and patients.

  • RedRaider218

    It’s going to be interesting to see what finally transpires with the health care bill. I work in my family’s small business and I watch daily the struggles my father faces in being able to afford to continue to offer his employees medical insurance and keep his business going in today’s economy. On top of that, he turned 65 this year and he’s not interested in having Medicare as his primary insurance if he can help it.

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