I love old people, but I will not accept Medicare

I love old people, but I will not accept Medicare

I love caring for patients — young and old. And though I may not accept your insurance, I will always accept you. I’m still happy to care for Medicare patients even though I opted out of Medicare in 2006. Why don’t I accept Medicare? Let me fill you in.

I do not accept Medicare because:

Medicare treats physicians as criminals — guilty until proven innocent.

Medicare warns patients on their billing statements to turn their physicians in for suspected fraud.

Medicare demonstrates no transparency in the flow of taxpayer money through their program.

Medicare may reimburse physicians so little that we lose money with each appointment forcing doctors to go bankrupt (or run Medicare mills with ramped up volume and quickie visits to make ends meet).

Medicare claims are more complex than any other insurer with more billing codes and rules and regulations that require hiring a team of staff to remain compliant or else  …

Medicare regulatory codes by which physicians must abide is 130,000 pages long! (US Tax code is only 75,000).

Medicare requires compliance with more unfunded mandates and administrative trivia than any other insurer.

Medicare penalizes physicians financially if we don’t use a Medicare-approved computer system and electronic health record.

Medicare penalizes physicians financially if we don’t electronically submit prescriptions the way Medicare demands.

Medicare threatens doctors every year with all sorts of financial penalties if we don’t do what they (non-physicians) think we should be doing.

Medicare audits may suddenly destroy a medical practice and a physician’s life as described by Dr. Karen Smith:

Medicare abuses and bullies doctors.

This is no way to treat people who have dedicated their lives to helping others.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears. Watch her TEDx talk, How to Get Naked with Your Doctor

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  • QQQ

    Since were on the subject of big daddy government run insurance, lets put this in about Medicaid.

    Many people have found that they can now get on Medicaid but are not
    aware of the “Medicaid Estate Asset Recovery Act” that came about in
    1993. From the government web site: “State Medicaid programs must
    recover certain Medicaid benefits paid on behalf of a Medicaid enrollee.
    For individuals age 55 or older, states are required to seek recovery
    of payments from the individual’s estate for nursing facility services,
    home and community-based services, and related hospital and prescription
    drug services.” So your kids can kiss good-bye the inheritance they
    thought they would be getting.

    • Lisa

      And what is wrong with that? Is it appropriate for the government to pay for a person’s medical care so their child’s inheritance can be protected.

      • QQQ

        Nothing is wrong with that! Its just many don’t know about it!

        • querywoman

          Ha! Ha! And too many people think that the government can always seize everything!

      • querywoman

        Is it appropriate for health expenses to eat up one’s fortune? This is socially new!

        • http://www.idealmedicalcare.org PamelaWibleMD

          The % of income paid to taxes in Europe is quite high for health care. That eats up a large portion of one’s fortune. They get ya coming or going.

          • querywoman

            Absolutely! I commented somewhere else about how socialized medicine does have an insurance, the government that collects its taxes.
            I don’t doubt that you make an adequate income with no employees and not having to go through all the insurance hassles. You say you don’t turn people away. I believe that.
            I like you requesting charity work for care and giving people seeds.
            I assume you had to work a while and save up money, though, to be able to get this kind of practice.
            Concierge where I live is quite expensive, but I’ve seen signs on the bus about one practice that had maybe $40 office visits with a small retainer. I call that “retainer,” because it’s like a legal fee.

          • http://www.idealmedicalcare.org PamelaWibleMD

            I’m generally pretty frugal. Paid off my small little house and my med school debt as soon as I could. For years did not own a refrigerator or a car. I favor a life of voluntary simplicity which for me is voluntary sanity.

          • querywoman

            I’m learning to be frugal. Trying to get rid of bunch of stuff so I can move. I don’t have a car. A fridge may not be all that necessary.
            I drink a lot of diet cola, and am learning to carbonate water, the old fashioned way with yeast. I have a SodaStream and a Primo soda maker, but I can do do it with yeast and sugar.
            I just got to keep down the sugar content in 2 liter bottles of water if I’m going to make equivalent of diet soda.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Why continue diet soda anyway. You can make your own natural flavored water easily and cheaply without sugar: http://greatist.com/health/flavored-water-healthy-recipe

          • querywoman

            It’s the carbonation I crave. Supposedly 5 tbsp sugar will carbonate 2 liters of water. I’ve not had the best luck with that.
            However, a little bit of concentrated grape juice with touch of yeast carbonates well with nice bubbles.

          • querywoman

            Carbonation, the bubbles, are an early stage of the fermentation process, alcohol. As the yeast eats the sugars, the yeast pees it all out, and makes B vitamins.
            So it’s an excellent source of B vitamins. A tad of a citrus fruit in carbonated water taste great.
            Like I said, concentrated grape juice carbonates easily, much more so than cane sugar. I think I can carbonate 2 liters of water with 2 tablespoons of concentrated grape juice, but I never measure.

          • Jewel Markess

            “A fridge may not be all that necessary.”
            Not owning a fridge is not frugal. Fridge can save you a lot of money. For the records – I am over 50 and have sizeable savings and a paid off home, so I am not exactly stupid when it comes to money. If you don’t have a fridge you either eat out which is more expensive than eating at home or you buy and eat immediately. Add to eat that sometimes certain things are on sale, so buying a chunk of meat on sale and throwing it into a freezer, than cooking it later on can save you money too.

            I also cook my own lunch and take it with me to work where I warm it up in the microwave. Aside from the fact that my own cooking tastes better to me, it also is a lot cheaper. So not owning a fridge is not frugality. It’s wastefulness.

          • querywoman

            I have been Xploring fridge free living. Fridges also lead to hoarding and spoiled food.

          • http://www.idealmedicalcare.org PamelaWibleMD

            YES!!! That is So true!

          • rbthe4th2

            Since when? We rarely ever throw things out in my family.

          • querywoman

            My mother and grandma let foods rot in the fridge. I’ve got food I need to chunk now.

          • rbthe4th2

            Oh wow. We come from really poor folk. So we learned how to budget and can/freeze/etc. and food is not as wasted at our house. At the most we buy for a week. When the boss lady had a membership to a place for a few years, she bought the paper products and washing products every time there was a coupon. There were a lot of coupons. She stopped once she lost the membership, and we’ve been living off that for over 2 years. Possibly 3 for some stuff. We had that stuff in the storage area and in the bedroom. LOL. Hey what can I say? She’s saved me $$$$ because prices have gone up, we are paying off a big ticket item that should be done in about 6 months, which is when we probably will start needing things.

          • querywoman

            I’m also one person. I live in apartments, so I have a fridge. I recently bought a small one. When I move, I may shut off the big one and just use the small one.
            When I think about, the small one is about all I need. I recently bought a countertop ice maker, which I’ve not used, also.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Very smart. Actually a refrigerator that is mostly empty is a real energy suck. I think if you have a large refrigerator and freezer you save more money if you keep it filled.

          • rbthe4th2

            I’ve got some single friends, and only the guys use the fridge for beer and cold pizza. Most of them depend on the girlfriends for anything else. LOL. Sorry – must be a Baptist habit.

          • querywoman

            Heh! Heh!

          • http://www.idealmedicalcare.org PamelaWibleMD

            I cleaned out my dad’s fridge and found 4 jars of partially eaten pickles – all outdated. And lots of those little marinated onions for his mixed drinks. I mean about 6 jars shoved way in the back on shelves etc . . .

          • ninguem

            No Circus Peanuts I hope.

            I still have nightmares.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Being a vegan is very cheap. No fridge needed. Beans and rice a great staple.

            I live in Oregon. Oregon is a refrigerator most of the year. Why heat a box (your home) in a cold state and then put another cold box in the house You could just store stuff outside.

            I saved 20% or more on electric bills without a refrigerator. How is that wasteful?

          • querywoman

            I have too many food intolerances to be vegan, like the whole legume family. But, I can keep tinned meat and milk, and also dry milk. I can also keep nuts like almonds.
            Our ancestors made due without refrigeration through other means like drying, fermentation, and salting.

          • Eric W Thompson

            Our ancestors made due without vaccines and most other health care – with life expectancies below 40. I won’t say it is wrong, but not for me.

          • querywoman

            Nor me. However, drying and fermentation change foods. Some nutrients go away, then others appear.

          • rbthe4th2

            Oh yes, we’re in this boat too. However, I use a huge huge freezer as I go to farms and agritourist my way to cheaper food.

            The female half had a drying & fermentation type of class. I think that is the hint I’m getting for Christmas …
            :)

          • Ava Marie Wensko George

            Ah, vegan. Now the no frig makes complete sense. There are a lot of ways to save money without a frig. Grow your own garden (even if it is growing in pots), eating beans, and supplementing your protein needs with quinoa and other high protein grain alternatives.

          • http://www.idealmedicalcare.org PamelaWibleMD

            And quick cooking thin red lentils are a amazing staple food! It’s like instant soup without the top ramen noodle crap.

          • Buzzy123

            Smart-It might not be as good of an idea in Florida or Texas though :).
            Question Pamela. How do you make arrangements for patients that are on medicare? While you can charge lower fees for your services (to make up for the lack of Medicare cost) patients often need lab and other services which can get pricey. Do you always refer these out ?

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yes, I refer those out and all else is covered by Medicare. The only thing patients pay out-of-pocket at 100% is my fee (which is 30% off if they PATOS = Pay At Time Of Service)

          • Sheri

            Very nice.

          • Buzzy123

            Yes, probably a lot better than diet coke but remember too much carbonation might be harmful.
            I am curious. How do you control the taste of a yeast water sugar mix? I would think the taste of the yeast would dominate everything

          • querywoman

            I don’t think too much carbonation is harmful. Remember, our ancestors drink beer or wine, not pure water, usually mildly fermented. It was safer than the water.
            Use a tasty yeast, like champagne or ale. You can get it on ebay or at a wine making supply shop. It’s cheap.
            I just put a pinch in, not a spoonful or half a spoon.
            If you throw a grape in, washed, and it doesn’t have to be organic, it starts fermenting on its own. I’ve never had off flavors from that. I suppose crushing the grape some helps, which I do, but the natural yeast is still there.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Carbonated soft drink are also high in phosphorus which is not great for the bones. Creates a hypercalicuric state. Peeing out your calcium. Not sure the other detriments of phosphorus.

          • querywoman

            Commercial sodas have acids like phosphorous. I’m sure a tad of concentrated grape juice fermented in some water is quite healthy. It’s really quite good on its own. Squirt of citrus helps immensely.
            Fermented honey is very helpful, but takes longer to ferment.
            The masses could save a lot of money doing it my way.

          • Sheri

            Diet soda is really harmful stuff. Use fruit juice added to your carbonated water instead of aspartane.

          • querywoman

            “Diet soda” is a catchall term. You have no idea what kind of stuff I’m drinking. Fruit juice in carbonated water is great.
            Stevia is an excellent sweetened. I like the taste; some don’t.

          • Dub

            Are you not aware that we, in this country, pay more taxes for healthcare than any other country?

          • http://www.idealmedicalcare.org PamelaWibleMD

            Really? I am not aware of that via taxes. I know per capita we spend a heck of a lot with not-such-great outcomes. Where’s your data Dub?

          • Dub

            Have read it in several publications regarding medical costs. Google it. Also know it costs us approximately $2800-2900 more for medical costs than any other country per person. Admire your stance on Medicare. Have a brother (doc) I set up his practice as a membership or concierge practice. How you guys allowed and participated in HMOs baffles me. Insurance companies and Hospitals are managing to ruin the Healthcare system.

        • Lisa

          Well, I don’t think it is socially new for health expenses to be a problem. As one person on this thread indicated, that is why medicare came into being in the first place.

        • Suzi Q 38

          Yes, that is what the money is for. If I earn money and have the sense to save it, I can use it to pay for my insurance and the health care that my insurance does not pay for.

          I don’t think this is socially new….would you please expand on your comment?

          My father in law had 3 major strokes.
          His medicare and medicare supplement insurance paid for his medical bills, but he had to pay for his own custodial care, which was a nurse home with him for 6 hours a day, 5 days a week, a monthly housekeeper, adult day care two days a week, medical supplies, etc.

          We did not empty his bank accounts, transfer his property to us, or spend down in order for him to go on medicaid so that his custodial care could be paid for by the US government.

          We didn’t want to do that, because we went to visit some of these nursing homes, and were not impressed….in fact we were saddened at the lack of cleanliness and the way the elderly lived as opposed to a private facility which charged double and the residents were well taken care of and entertained.

          It is not appropriate for health expenses to eat up one’s fortune, but that is what it is there for, IMHO.

          • querywoman

            Very expensive medical care is culturally new as well as massive educational debt. Over 100 years ago, diabetes, for example, was untreatable.
            Doctors want to accumulate fortunes, and so do we. I think seizing a house is extreme.

          • http://www.idealmedicalcare.org PamelaWibleMD

            true.

          • Suzi Q 38

            “……..Doctors want to accumulate fortunes, and so do we. I think seizing a house is extreme….”

            You are so right. Seizing someones’s home is extreme, and that is not done to my knowledge while they are still living in it.

          • querywoman

            I think inherited homes should be Xmpt. Medical debt is not the only issue.

          • Suzi Q 38

            Not really.
            It depends on who is inheriting it.
            A living spouse? Sure.
            As far as children, no.

            Although in some cases I have heard that a child living with the parent for at least 3 years could inherit the home. Not sure.

            As far as an adult getting to inherit a house outright who did not live with and care for that person, I don’t think so.

            The house should pay for any custodial care performed by a nursing home that is owed.

            Nursing homes are fairly expensive, even if it is only custodial care for the most part.

            My funds should not be protected for custodial care. Since medicare covers medical expenses, I understand that we are responsible to pay for our daily custodial care.

          • querywoman

            I was born with some genetic problems. So , why shoud my parents and I pay more for my life than the healthy?
            I advocate limits to what the government can seize.
            It’s not the central point of our discussion, but whatever happens is dependent on state law. I write from the debtor’s paradise of Texas, where such things are less likely to happen.

          • Suzi Q 38

            Yes, it depends on state law.

            If you live at home with your parents, hopefully you can still inherit their house.

            It is worth looking in to.
            I wouldn’t be assuming that the state of Texas is so generous.
            Maybe with all of that oil, they are better off than we are in California.

            If money gets tighter, who knows what liens and forced sales will occur. Custodial care is just daily care, and is expensive at most nursing homes.

            There are limits based on how much custodial care was used and at what total cost?

            Who paid for Christopher Reeve’s care?
            He and his wife did, as they had the money.

            They are wealthy, but they are not the only ones.

            Yes, we are getting off topic, LOL.

          • querywoman

            I already inherited my mother’s house. It wasn’t worth enough for the state to take anyway, but she didn’t go into Medicaid. My brother got a lawyer. I couldn’t afford a lawyer with a retainer.. I owned half. My brother and the lawyer sold the house without me signing anything! I don’t know if I’ll ever get anything.
            I haven’t spoked to the lawyer in 3 years. He doesn’t return my phone calls. Last week I told his staff I will turn him into the bar for not calling me. He called, but I missed call. He’s really pretty nice just busy. He offered to meet me closer to my home to discuss. I told him to meet me downtoan at the courthouse.
            But, my issue when discussing Medicaid estate recovery, and that’s what it’s called, is not to let anyone scare you. Medical people don’t tend to know the law very well. Contact your state and ask them!

          • Suzi Q 38

            The sate wouldn’t have to take it if she didn’t go into medicaid.

            You should get half, unless your brother’s name was on the deed or she left it only to your brother.

          • querywoman

            We couldn’t find her will. She gave most of her cash to him on bank documents before she died.
            The house and another property were supposed to be half mine. He sold them without me signing anything. Now my name has disappeared from the county estate case.
            I know the state won’t get her money. I just threw this in.
            None of these posts I made here were about fear of Medicaid taking her property. My brother who died had nothing but a crummy little piece of land, with a crummy mobile home. My parents, divorced for many years, inherited it, and signed papers to give it back to whomever sold him the property.
            My post about people at the nursing home griping about, “Medicaid will take your house,” was about people griping but not doing anything about it.
            If you have someone who goes into long term Medicaid care, the first thing you should do, after the person stabilizes, is ask the state about Medicaid estate recovery.

          • Suzi Q 38

            Well, the state won’t get her money because she already signed it over to him and he distributed the assets.

            People do this a lot.
            Was she ever on medicaid?

            The fear is not necessarily Medicaid itself.
            It is just wanting the end of life to be lived a certain way.

            If I want a higher level of health care throughout my life, I have to pay for it.

            Some people are lucky and are able to get decent health care while on medicaid or medicare.

            We used Medicare for my FIL’s medical expenses, but for custodial care, we had to pay cash.

            We sold his home to do so, as his end of life lasted 12 years due to 3 major strokes, a heart bypass, several heart attacks, and several seizures.

            Eventually we needed some cash to use to care for him.

            The money was never “earmarked” for my husband’s inheritance. It was reserved and carefully used for his care.

          • Suzi Q 38

            Silence is agreement.
            Sometimes the property as you say is not worth fighting for.
            Let me guess. He did not share the proceeds of the sale of such with you.

            Why not?

            Asking the state about Medicaid state recovery is a good idea.

            As far as my FIL, he was private pay for his custodial needs.

          • Suzi Q 38

            I am sure different states have different laws, but you were supposed to have been sent a letter stating that you (a daughter of the deceased) could file a claim for the assets of your mother.
            You could then inquire about the worth of the assets.
            Since you didn’t, your “voice” may now be mute.
            It probably wasn’t a whole lot anyway.

            If there is no Will it would be distributed as per state inheritance law.

            Since she had no husband, it would rightfully go to the children, if there is anything left.

            “…..If you have someone who goes into long term Medicaid care, the first thing you should do, after the person stabilizes, is ask the state about Medicaid estate recovery.”

            Good idea about the Medicaid estate recovery questions.

          • querywoman

            We have an estate case. It’s still open. I was listed as co-owner of the house on the county tax rolls.
            I am furious at the lawyer for never returning my calls. I warned him I have always planned on reporting him to the bar. I have written the judge, etc. No response.
            If you got the impression I was worried about Medicaid taking her stuff, I was not.
            I knew Texas law.
            I thought I had edited some of the stuff out of this, as it’s not directly medical related. knew it would still go in your email box.
            Last week I told the lawyer i would report him to the State Bar, and told him I would come to his office if I had to. It’s in an adjacent county. He offered to meet me in my county. The county courthouse is fine with me, and no, I will not scream and yell at him.

          • querywoman

            Hypothyroidism and diabetes are genetic conditions. Allegedly, so is hypertension, which I am not sure is a real disease.
            When a person has to go to a doctor every year to get more thyroid med, that person is vulnerable prey to all kinds of preventive recommendations.
            I have had to pay significantly more out of my pocket to live than people who don’t go to doctors.
            Supposedly, the highest percentage of medical expense in this country is end-life care, interventions in the last six months of so when one is terminal.
            I don’t want that stuff anyway.

          • Suzi Q 38

            I have hypertension.
            I feel it is genetic, because it started when I was 27, during the pregnancy of our first child.

            I am now 59.

          • ninguem

            And FWIW, despite getting arguably the best care money can buy, Christopher Reeve ultimately died of complications of pressure ulcers….”bedsores”.

            That’s one of those complications that’s supposed to be “preventable”.

            Not as preventable as you think.

          • querywoman

            I think states have a certain amount of levity on how they administer Medicaid estate recovery, as long as they follow the minimum federal guidelines.
            Once again, the real purpose of my posts here are to tell people to call their states or go online to find out exactly what happens.

          • querywoman

            Here’s a quickie. I hear people gripe about government medical custodial assistance, “We take care of our own.” Some people who save a little money or trying to take care of their own.

      • Suzi Q 38

        You are so right.
        The child has no right to an inheritance, unless such inheritance was not needed by the parent.

        If the parent needs it for better care, so be it.

        My husband had a 100 year old aunt, and she was “sharp.”
        She was a widow with no children and quite a bit of property and money.
        I told her to not give everything away. Keep a good chunk of it in case she needed it. I did’t care if her nephews and nieces beg for her assets. They will get what she wants to give them soon enough, after her death.

        She did give one house away to a favorite nephew, because he had been living there for decades.

        She gave 3 rental houses to another nephew because he had helped her manage them over the years.

        The rest of it (which was substantial) was kept in her name. When she got sick, she had nurses come in to the house. She never wanted a live in, so three shifts of caregivers would come in. An agency sent them, and they were really good.

        She controlled her end of life and lived very well.
        She died this past year, at the age of 100 and 6 months, never having had to live in a nursing home.

        • http://www.idealmedicalcare.org PamelaWibleMD

          yep. smart cookie.

      • Sherry Reynolds

        Plus” Medicaid” is a means tested program for low income (vs Medicare which is based on age and numbers of quarters worked to qualify)

      • querywoman

        If seizing an inheritance causes the child to go on government aid, that’s not allowed. It may happen, though, and it is simply government cost shifting.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Weird times we live in.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yes. No free lunch.

    • querywoman

      That law has to be read carefully. Texas used to refuse to comply. I have a friend who cared for and co-owned a house with a woman with MS. The MS woman never paid her half, even when she was working.
      My friend co-signed on all the med bills, shortly after filing personal bankruptcy. At the time, the home had zero equity.
      She has always thought that the state would come for the roommates portion after her own death.
      I repeatedly explained to her that the state had a limited amount of time to file a claim with the probate court after her friend died. The friend had nothing, and it never went to probate.
      I recently suggested my friend to call the state and ask them if they were holding a lien. If they are, it should be public info. No feedback yet. If necessary, I’ll write a letter for her to sign.
      It had never occurred to her to call the state agency before.
      She was also always afraid because her friend had a large IRS bill. I figure the IRS was running an annual check on the woman every year and saw that she was on Soc Sec and had nothing else, and finally wrote it off. Plus, my friend has never received any IRS threats about the deceased woman’s estate.

    • Suzi Q 38

      “……So your kids can kiss good-bye the inheritance they
      thought they would be getting….”

      Not all kids expect anything.
      For one thing, elderly parents are living a lot longer.
      By the time death comes, a lot of money, including property is exhausted.
      Some kids have talked mom and dad or other elderly family members to sign the houses over to them.
      That is a huge mistake, IMHO.

      This leaves little flexibility as far as what is needed and ordered for the parent’s care. They can no longer choose the nicer, pricier nursing homes or living facilities; they have to go to the welfare type of nursing homes, which at times are not the cleanest or nicest.

      I have seen adult children take possession of the home and live with the parents, only to have them live in a nursing home sooner than the parents wanted or expected.

      I have seen the spouses of the adult children divorce their spouse in order to force sale of the former elderly parent’s home.

      I have seen soo much more, and the stories are sad and endless.

      I would prefer to pay cash for basic doctor’s visits if possible, and use medicare for hospitalizations, tests, etc.

      if I run out of money at age 80 or 90, I run out, and I’ll deal with it then.

      I told my kids that whatever they inherit, they will be lucky to get. Who knows. It might be as little as $100.00, because I may need it for my medical care.
      The government is not responsible to pay my bills if I want or need more care than Medicare is authorized to provide.
      My assets (if I have any) should be used for that, and not hidden so that my kids can get a great inheritance. Nice if they do, but good luck with how much medical costs are nowadays.

      I tease them and say that if I die, they can split the $100.00 I have left for them in my bank account.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Suzi Q 38, you are brilliant! So common sense. . .

        “I would prefer to pay cash for basic doctor’s visits if possible, and use medicare for hospitalizations, tests, etc.”

        • querywoman

          Medical tests cost much less than insurance negotiated rates.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yes you can get meds and tests for way cheaper than even what you pay via your “insurance.”

        • Suzi Q 38

          Thanks!

      • querywoman

        Suzi Q, if you go the the official HHS site that discuss Medicaid Estate Recovery, you will find out that medical debt is not the most sacred of debts.
        Medical debt does not trump common sense.
        Heirs can plead for an exception in cases such as when the estate is necessary to protect their own income and livelihood and to avert homelessness.
        Medical debt is absolutely not the most important issue in our society! Putting out misinformation causes so much fear!

        • Suzi Q 38

          Your point is well taken. There are those of us who don’t want to “spend down” in order to get medicaid if medicare does not cover it.
          I am saying that if I have to choose between good medical care and my kids inheriting my house, I know what my choice will be.

          Do I want to leave them my property? Of course, but only if I don’t need it to pay my bills…private medical and/or custodial care included.

          • querywoman

            It’s also a common sense issue. Do I feel sorry for someone who deliberately got rid of $300,000 to avoid paying for long-term care? No!
            Neither do the states, and if they know the kids did it, they can’t have an exception.
            I’m still trying to convince a friend that just because some nurse popped off at her and her roommate that, “Medicaid will take your house,” It does not mean it.
            The state never came after my friend, never notified her of anything.
            This same friend somehow agreed to pay her roommates final bills, even though her friend always leeched on her and never paid her fair share.
            When my friend put her long-time boyfriend in a hospital to die last year (they didn’t live together), the hospital wanted her to sign some papers. She didn’t want to, because she feared getting stuck for his bills. They told her she could get a lawyer cheap! H0rse and hum@n hockey to that.
            I would have signed his papers, because I would have read them. He died in two days time, peacefully and mercifully.
            Just don’t get the idea that the doctors, hospitals, and or state and federal governments have the right to clean out a family completely over medical debt.

            They don’t!

          • Suzi Q 38

            We never signed the hospital papers on behalf of my FIL. We always had him write an “X” on the signature part, and told the hospital that he was responsible for his own bills.

            You obviously have not had the pleasure of caring for an elderly relative who was not mobile and needed occasional diaper changes.

            We have, for about 12 years. The right care costs money. Short term illnesses before death (less than 1 year) do not compare.

          • querywoman

            In your situation, your FIL was fortunate. My point doesn’t matter. What does matter is the law.
            Are your children secure? Suppose you had $60,000 paid up house. You went into long-term care. You had one daughter, who was married. She and her husband work hard full time, both of them, at minimum wage jobs. They have 3 small children, and day care expenses.
            I think they should be granted a hardship exemption from Medicaid Estate Recovery and the state would surely agree.

          • Suzi Q 38

            Of course, any of that is worth looking in to.
            I never thought of that. Medicaid is different. We would not qualify for it, and I personally would not prefer this type of living at the end stages of my life, if possible.

            If I needed the house sold for my private long term care, I would do it.
            My husband and I are responsible for funding our own custodial care.
            I don’t want to live in some of the nursing homes I have seen but would not place my FIL in.

            The private pay nursing homes and assisted living centers, or even home health care are much more pleasant.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Wow! I am learning a lot here!

          • querywoman

            I am very glad you are. I hope you will do what you can to abate some of this medical debt scare talk.
            Again, you seem to think I was worried about my brother’s or mother’s assets at the nursing home. Absolutely not!
            I hated that old bag forcefully claiming, “Medicare will take your house.”
            I told the admin I wasn’t coming back because of her, and he said he knew about that kind of negativism and would try to abate some of it.
            Pamela, since you are learning so much here, I briefly worked for the IRS. A taxpayer called in who had had a tax seizure of his SS, probably only 10%. The taxpayer advocate was giving him a refund so he could buy medicine!
            That gives the drug companies priority over the US government!

          • http://www.idealmedicalcare.org PamelaWibleMD

            Ok, y’all let’s stop the medical debt scare talk. Get your facts straight. Caveat: I am no expert on medical debt. Have not gone down that road yet.

          • querywoman

            My friend’s boyfriend had very little money, and she had a little more. He had refused prostate cancer treatment and died quickly and easily.
            Since I do or, did, in his case, both their taxes, I knew what they had.
            And no hospital employee should have told her that she could get a lawyer cheap. Just like nobody should flippantly beat their gums that, “Medicare will get your house.’ Tell them to call the state for more info. Or go to Legal Aid if they can’t do it on their own and are poor enough.

          • querywoman

            Suzi Q, I excerpted this stuff right off an official California site. Other states will have similar clauses. As you can see, it applies mostly to people with higher value homes that are either paid off or have substantial equities. I doubt most states want to assume a mortgage.
            I was tired of home seizure being talked about like it was an airtight, assumed consequence, when it is not.
            However, the amount of recovery is limited to the amount of benefits paid or the value of the beneficiary’s estate, whichever is less. For example, if the appraised value of your home is $200,000 and you left it in joint tenancy with your three children, the State can only collect up to $50,000, which is your part of the estate -even if the Medi-Cal benefits paid to you is more than $50,000. The value of the estate is also reduced by any outstanding mortgages or debts on the home. For example, if the home had an outstanding mortgage of$100,000, this reduces the value of the estate to $100,000 (the appraised value of $200,000, minus the mortgage). This, in turn, reduces the amount of the estate claim to $25,000. (The value of the home($100,000) divided by the four joint tenants.) Deducting the amount of burial costs or estate settlement cost scan also reduce the claim. Remember to keep receipts and submit them.

    • querywoman

      Google these words, “U.S. Department of Health and Human Services Medicaid Estate Recovery,” and you can go to the real horse’s mouth, that of the US Gubbermint, at the top of the listings.
      You’ll find that Medicaid Estate Recovery does not come before other estate claims as prescribed by state law, etc., among other things.
      The world does not revolve around medical debt, and it is never the only issue in the USA.

  • QQQ

    Kevin Williamson: Feds Could Force Doctors to See Medicaid, Medicare Patients by Revoking Licenses

    https://www.youtube.com/watch?v=BugYdH3jMGM

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yep. This is why doctors need to stand up and be unified. The health care system does not work without doctors.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Do you want your health care designed by bureaucrats, politicians, experts, consultants, or doctors (and patients)?

  • querywoman

    Most doctors who post here want to be able to start stockpiling money after the heavy education debt incurred. The rest of us want to save money, also, and not have to spend a huge portion for health care.

  • querywoman

    When my brother was dying in a nursing home, my mother and I went to some family meeting at it. This old bag kept popping her mouth off that, “Medicare will get your house.”
    We never went back.
    It’s Medicaid, not Medicare. When I checked, in Texas, Medicaid might take a house over $100,000. If a disabled adult child lived in it, they wouldn’t take it anyway.
    I’d have to file open records to find out, but if you are paying on a house, and don’t have much equity, I doubt they would take the house and assume the mortgage.
    Plus, what they can do is file a claim in the probate court. I don’t know if the judge would allow them to take it, or whatever. It has to be done in a certain amount of time after death. You might get lucky and the state would forget to file the claim.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Lots to think about when you get sick or have a disabled child.

      • querywoman

        The point I was making is about stupid knee jerking or mouth jerking. I checked the facts, and that woman wasn’t interested.
        How the government works is mostly open. They won’t tell you if your neighbor owes income tax, unless they take it to court. Then it’s public info.
        Don’t listen to your neighbor about the government. Call them!

        • http://www.idealmedicalcare.org PamelaWibleMD

          Yes. Agree. I am a person that loves to interview people and go directly to the source. I’m really an investigative reporter stuck in a doctor’s body.

          • querywoman

            If my brother had a problem in the nursing home, I would email the state and cc the nursing home. I wanted it fixed immediately before the state got there. Yes, they got on it!
            Then the state got there later.
            Once I told Mama that my getting the state out was her birthday present.
            Another night at those meetings, some woman was griping about something and I told her what to do. I offered her a card with state contact listings, and she wasn’t interested.
            So after the bit about, “Medicare will take your house,” I never went back.

  • querywoman

    Well, Pamela, I think you are free to practice as you please another ten years at least. I don’t see the government forcing you to take Medicaid and Medicare before then.
    And, we know that in socialized med countries, lots of people bribe the docs into seeing them first.

    • http://www.idealmedicalcare.org PamelaWibleMD

      At least 10 years. That’s great! Do hope inspired and ethical docs will take the helm before then. Time for real health care in this country.

      • querywoman

        I’d love to get rid of all 3rd party payment systems, but there’s not a snowball’s chance on a hot Texas day of that.
        Not so secret jewel: the status quo is easiest to maintain.
        Some doctors have whined on this blog that, if they have to work for the government, then they want the benefits, job security, etc.
        We might see docs absorbed into a public system with more of the benefits.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Anything is possible. What once seemed impossible became the norm. Womens’ right to vote, gay marriage, interracial marriage. All illegal at one point in time and then . . .

          • querywoman

            The problem here is that there are many corporate giants involved.

          • http://www.idealmedicalcare.org PamelaWibleMD

            And having a country founded on slavery with slavemasters everywhere was not a huge obstacle for black people?

            I think you are underestimating what people can do if they stand up for themselves and stop taking abuse.

          • querywoman

            We shall see. Government and corporations are even bigger now. Also, info is freely available to the masses on the net.

          • http://www.idealmedicalcare.org PamelaWibleMD

            We are entering a great paradigm shift. Exciting!

  • Duncan Cross

    Is the point of this that Dr. Wible sees old people for free? Otherwise, it’s weird that almost all doctors can make do with Medicare, and yet the few who don’t consider it a point of pride that they refuse to help elderly patients who can’t afford their services.

    This article has not a single useful idea amid the gripes and self-justification. Instead it panders to Kevin, MD’s audience, fanning their persecution complex without contributing anything substantive to our understanding of healthcare or Medicare. It is yet more evidence that some physicians are incapable of understanding their patients’ lives and needs outside the clinic.

    Dr. Wible wants healthcare designed by physicians and patients, as if there is ever any symmetry in that relationship. America had that sort of system in the early 20th century, and it was so brutal for old people that Medicare was an easy sell to everyone except physicians. Still, the resulting program was as much shaped by AMA lobbying — by physicians — as it was by elected legislators.

    Dr. Wible might spend a moment to consider that older voters consistently defend Medicare with their votes; the system is at least patient-approved, if not patient-designed. This means that while she claims to love old people, she hates their decisions and resents their ability to make those decisions — a curious and condescending sort of ‘love’.

    Dr. Wible is young enough to have seen medicine (and Medicare) for what it is before she started med. school. If she is dissatisfied with her career, she is still young enough to choose another. Let’s see whether her tune changes when she is old enough to enroll in Medicare.

    • http://www.idealmedicalcare.org PamelaWibleMD

      I do not see anyone for free because health care should not be a passive experience. Those who can not afford to pay, volunteer their services and time to help others. If I provide charity care, I ask patients to volunteer their time helping others (soup kitchen, library etc. . .)

      Many doctors are NOT making due with Medicare. For many, reimbursement is so low that docts are not able to accept new Medicare patients. Approx 36% of docs LOSE money every time they see a Medicare pt. (and 65% LOSE money with every Medicaid pt).

      Docs do not want to refuse to see elderly. It’s a math problem Duncan. You can’t lose money every time you offer a service and stay in business.

      Useful ideas? 1) Cut out the middleman in primary care. I’m sure you have heard of DPC (Direct Primary Care) 2) Put the doctor-patient relationship first and stop catering to those who would undermine it.

      There IS symmetry in the doctor-patient relationship. We want the same things. The patient wants a REAL doctor (NOT a paper pusher, a robot zombie, a factory worker on an assembly line etc. . .) And after doing town halls across America helping patients design their own clinics, I know what patients want. And most doctors want to be the kinds of doctors that patients describe (not the kind of doctors politicians, bureaucrats, CEOs describe). Get it?

      So do you think you can have empathy for the abuse inflicted upon doctors such as Dr. Karen Smith? Walk in her shoes for a day and see what it feels like to be a doctor.

      Dude, we went into medicine to help people not be victimized and terrorized by an inhumane health care system.

      Medicine is a spiritual calling and I intend to honor my calling, my soul’s purpose, my patients, and most importantly—myself. I’m no use to anyone else if I become a victim.

      • Duncan Cross

        Sorry, Dr. Wible — DPC is exactly the system that made Medicare necessary. If patients designed the system, it would look a lot more like Medicare on the payment side than it would DPC.

        • http://www.idealmedicalcare.org PamelaWibleMD

          By the way, any system will fail if unethical people are at the helm. So the name of the system is less important than the ethics of the people involved.

          What do you think of the video of Dr. Karen Smith?

          Would you work for free or better yet—pay to work?

          • Duncan Cross

            What I think — because she says so — is that Dr. Smith is talking about the behavior of a private insurer: Cigna. The AdvanceMed contractors were doing work required by a bill passed by Republicans to hamstring Medicare. Sorry — the people who want to ‘fix’ Medicare do not care about the Karen Smith’s of the world. When her case finally met up with the merciless government bureaucrats at CMS, they… slashed her penalty.

            And I don’t buy the claim that doctors work for free. Losing money on a client isn’t the same as paying to work. But yes: by your math, I have paid to work and will work for free.

  • http://www.idealmedicalcare.org PamelaWibleMD

    “I (as owner of my now-closed practice Queenan Family Medicine & maternity care) just received an invoice from Monroe Plan (the branch of our local Blue Cross Blue Shield that administrate the Medicaid managed care program in Rochester) for $466.99 for 4 well-child visits I provided in my practice (two from 2012 and two from 2013) that they’ve decided they shouldn’t have paid me for. This is the major reason why I closed my practice this past Spring. Fighting to get paid for providing well-child care. Unreal. I’ll never contract with an American insurance company again. I will not allow myself to be abused.” ~ Emily Queenan, MD (just posted to Facebook today)

    • querywoman

      Hmm…write up a claim for small claims court. Sign it, but don’t file it. Send them a copy and tell them you want proof and may cross-sue for debtor harassment.
      I’m sure it violates some statute.

      • http://www.idealmedicalcare.org PamelaWibleMD

        I once was asked to sign an insurance contract that would make me responsible for any legal expenses incurred by the insurance company. That is going way too far. I did not sign my name on that.

        • querywoman

          That’s insane. Even though I often advocate for patients, I know that insurance companies abuse doctors, badly!

          • http://www.idealmedicalcare.org PamelaWibleMD

            BUT (it gets better) even before they would agree to send me the contract to review and sign, They sent a woman down from Portland (2 hours north) to take stour of my office and measure the space between the toilet and the wall. Once I passed that test, they mailed the contract that made me responsible for their legal costs (small print).

            This is usually when ninguem chimes in with a photo.

            Waiting . . .

          • querywoman

            Wow! Did you refuse to sign and they still let you work for them?

          • http://www.idealmedicalcare.org PamelaWibleMD

            No. I am not in-network and if a patient uses an out-of-network doc they are out-of-luck on payment.

          • ninguem

            The compliance reviewer found Dr. Wible’s toilets are in full compliance with Oregon building codes.

            http://hikingnb.ca/Photos/var/albums/Miramichi-River-Valley-Region/Miramichi-City/Millbank/05-outhouse.jpg?m=1371555121

          • querywoman

            Your friend Ninguem posting back at you as you expected!

          • http://www.idealmedicalcare.org PamelaWibleMD

            I know! He spies on me in the outhouse. A true voyeur. :)

          • querywoman

            You should be grateful that he is making quality check ups on you!

          • ninguem
          • querywoman

            Ninguem, I made a post about you that for some bizarre reason never made it past the sin-sers. It was about a diagnostic code that you stated Mrs. Ninguem gave you once. It was for a pain in the posterior area, though I used simpler words.

          • querywoman

            I saw your complete response in my email, thought it’s waiting for the sin-ser here. Come on, Kevin, let it through! It’s sanitized.
            I am sure Mrs. Ninguem has this dx and others memorized for her husband and repeatedly applies them to him.
            We need a code for a mystery doctor who feels compelled to be an electronic practice monitor for another doctor.

  • http://www.idealmedicalcare.org PamelaWibleMD

    A good doctor who really cares is hard to find so when you can find one, it can literally save your life. Kind of like finding the right husband or wife. May take longer than just marrying the first person you go on a date with but it is SO worth it not to settle for just anyone. :)

    Also, cutting out the middle men will lower the price you pay for the visit. It could even be less than your current out-of-pocket using your brand-name insurance. Example: $40 co-pay for 10 minute visit or $40 cash for direct care with a great doc who spends 20 minutes and files no paperwork.

    Hope that helps Kim! Happy to answer any other questions.

    • Jewel Markess

      “Also, cutting out the middle men will lower the price you pay for the visit.” Unfortunately, it doesn’t work this way. Large insurers negotiate prices while uninsured get bills that are often three times as much. Incidentally, I have a PPO that pays 80% in-network and 70% out-of-network which probably works out better than co-payment since one can always get “something”. My periodontist is not connected to any insurer, but they do submit the forms, and the out-of-network reimbursement+difference in cost works fine. I wonder if a doctor who doesn’t take any insurance would at least be nice enough to submit the forms after the fact.

      • Lisa

        Very few doctors in my area will negotiate with patients who are paying cash. And if they do, the want cash or a credit card up front. They will not bill you.

        • querywoman

          Where I live, they want more than the insured contracted rates because the insurance rate is “discounted.”

        • http://www.idealmedicalcare.org PamelaWibleMD

          I’ve never taken plastic. Don’t accept credit card payments. Just checks, cash. And I am willing to barter and I give 30% off for payment at time of service.

          • querywoman

            I’d love to see it illegal to pay for medical care with plastic.

          • eqvet2015

            Why? Is it wrong to use a credit card or Care Credit? Should people who are just scraping by hope they don’t get any sicker before such time that they can pay? My therapist charges an extra $5 (for fees) and takes an extra 30 seconds to use Square to receive payments – is it a immoral to take advantage of that when I forget my checkbook?

          • querywoman

            Will your therapist still see you when you have maxed out your credit? They are encouraging you to take out unsecured debt to help them.
            In theory, the therapist or doctor should not terminate you if you have no more money, but they might. That’s a legal question.
            I ran up serious medical debt on credit cards.
            If they couldn’t take credit cards, they might be forced to work out payment plans.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Docs can legally terminate patient after 30 days notice for reason or for no reason at all. Is it ethical? That’s another question.

          • querywoman

            That probably depends on states.
            Nevertheless, the issue of payment is different. I have researched it. Suing for abandonment is possible.
            If it was made clear in advance that the patient must always pay, then the doctor can terminate for nonpayment.
            I assume that if the patient is in an area where free or low cost care is readily available, lawsuits for financial abandonment won’t go through.
            eqvet2015, Pamela has already stated that she does not accept credit cards. She has other ways to work with her patients. The average doctor doesn’t. She’s not asking her patients to incur unsecured debt to see her.
            It looks like most of her patients have insurance and usually get reimbursed for her services.

          • http://www.idealmedicalcare.org PamelaWibleMD

            I never make my patients decide between food and medical care. If somebody is that cash-strapped we work something out.

          • querywoman

            I attempted a private contact on your web page contacting system. So you start seeing patients at 4 PM, when it is convenient for them. Are you a later riser?

          • http://www.idealmedicalcare.org PamelaWibleMD

            In fact, I have never turned anyone away in 10 years (since opening my clinic) for lack of money.
            I have terminated patients primarily for non-communication. After 2-3 attempts to contact them and I know they are alive and breathing in town, I opt out of the (non-existent) “relationship.”

          • http://www.idealmedicalcare.org PamelaWibleMD

            It is illegal to charge extra for fees when using plastic.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Not immoral. I just do not want to absorb the bank fees on plastic.

          • querywoman

            You don’t like anything that interferes between your patients and you.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yep. You got it. :)

          • querywoman

            eqvet2015, my minister went to some kind of jubilee celebration for forgiving medical debt. That’s debt the providers, usually the hospitals since most docs won’t do it, billed directly.
            If you got bullied into using your credit cards, the financial institutions behind your cards won’t be participating in a medical debt jubilee celebration,
            Most doctors were educated on a buy now, pay later plan, but they won’t give you the same deal.

          • eqvet2015

            Thanks for the clarification. I’m not sure I agree that outlawing use of plastic will benefit patients that much, but I appreciate your response. In the case of my therapist – and I didn’t know about the extra fee being contrary to the merchant agreements, interesting – he is very good at what he does and practices in an area which, like most places, does not have an excess of mental health providers, let alone ones of his caliber. He does offer to work with patients who fall on hard times but ultimately any incentive to do so is out of caring, not because his practice is short of paying patients. Reasons I have used plastic include sheer convenience and so that I could have the liquidity to pay now and get reimbursed later, for practitioners who do not directly bill insurance companies; in both cases, I did not end up paying interest.

          • querywoman

            If the bizarre, wildly varying medical payment systems in this country were straightened out, there would be no need for credit cards as payment.
            You are seeing the greater picture.
            There are people, like my mama’s general surgeon, who use credit cards and pay them off at next billing to earn rewards interest.
            You may be at an income level where you can handle it. I wasn’t. I used credit cards for new patient fees in the later 80s, paid COBRA insurance 18 months with credit card checks, and used credit card checks to pay my rent.
            Then when I had no more credit and no more insurance, I went to the county. In retrospect, I should have gone to the county sooner.
            The county worked well for me for general medical care, but was absolutely horrible for my skin disease.

          • Suzi Q 38

            Good for you and your patients, Dr. Wible!

        • Suzi Q 38

          Doctors have to pay their bills, so I am sure that they have instructed their staff to collect payment after the visit.
          I once knew a doctor who was getting “stiffed” from various patients, so he requested payment up front, BEFORE the visit.

          He was a dermatologist.

          Have you asked your doctor directly (during your private visit) if he would allow you to make payments?

          • Lisa

            The common practice here is to collect co-pays (or cash payment) when you check in. Not after the visit.

            I’ve always had good insurance coverage, so have not had to ask for payments. Many of my friends have not had insurance at all and they had trouble getting medical care pre ACA.

          • querywoman

            Only one doctor here every tried that number on me. I protested. They claimed the insurance company required it, which is a lie.
            I protested. I got out of it. I told the doctor that this wasn’t about making anybody rich. He said, “You won’t be making us rich.’
            He wasn’t getting what I told him, nor was he interested in my ear infection and my need for a referral for an ENT. He came charging in the room with a blood pressure cuff, and that’s all he cared about.
            I paid my copay as I left, called the staff and ate ‘em out, and changed my PCP that very day.
            I was just getting ready to enter law school.
            I got a certified letter a few days later, which I didn’t sign for. I’m sure he was sending me a letter terminating me as a patient. That arrogant manure head seemed to think I’d want to come back.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Because he wanted a co-pay upfront? I always collect co-pays at the beginning of appointments.

          • querywoman

            I had never encountered that around here with any of my docs, though other people said they had.
            I think it was fifteen dollars. He wasn’t worth five dollars.
            I have a repeated history of ear infections. I had just seen a county doctor who thought I needed to see an ENT. I was looking for a private doctor on my insurance to give me a referral.
            He wasn’t interested in my ear infection or history at all. Just my BP, which had been normal at the county, high in his office, not unusual for a new patient.

            He came in with that BP cuff and nearly attacked me with it.
            I do not go to doctors who can’t do anything than play with a BP cuff.

          • querywoman

            I asked an ob/gyn once and he said he was the one to be discussing that with! We had umpteen problems. My mother especially faulted him for not making a followup visit in the hospital for day surgery.
            The Texas Medical Board just disciplined another doctor for the same thing.

      • querywoman

        If they just give me my itemized receipt, I will gladly attach a claim form with a stamp and throw it in their office mail.

      • http://www.idealmedicalcare.org PamelaWibleMD

        I’m talking about independent docs in low overhead models (they pass savings on to patients), not huge big box clinics with high overhead.

    • Kim

      That would make sense for an office visit but if I needed to prepay for surgery with her I would be tap dancing on the corner for spare change.

      • querywoman

        Kim, Pamela is surely a low-tech doc, a GP. She surely knows where to refer her patients for more complex care. My mother had carpal tunnel surgery with a surgeon who would not accept Medicare assignment. He required her money upfront. Then when Medicare paid him, his snotty receptionist told her she couldn’t have an immediate refund. Mama said oh yes I can and got her money promptly.
        She liked his accent. My derm is from the same country with the same accent. He takes Mcare assignment.

        • http://www.idealmedicalcare.org PamelaWibleMD

          hey I did remove a metastatic lung cancer from my patient in office. amazing what a regular doc can do when left alone.

          • querywoman

            Good 4 you! Did you send the patient elsewhere for radiation or chemo if needed?

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yep. To oncology and dies soon thereafter. Amazing how people really want to fight at the end.
            He was so frail. I didn’t think the treatments were the right way to go, but what do I know. I’m just a GP.

          • http://www.idealmedicalcare.org PamelaWibleMD

            And he was just scared. Hard to give up the human body.

          • querywoman

            The big C is scary, even if not one of the more fatal ones.

          • querywoman

            You know your community and EMLTA law.

  • Sherry Reynolds

    Medicare paid for you to become a doctor in the first place via CMS – Graduate Medical Education (over 10 billion a year) and that is the reason you are paid less to care for their patients.

    You were their paid employee – essentially a government employee (paid more than the average salary in the US during your training of 50 to 60 k ) and in exchange for now being qualified to treat some private patients you are paying back US taxpayers the cost of your education..

    If you opt out you should pay back the cost (400k to 1.1 million) plus interest (another 400 k to 1.1 million) plus a penalty as someone else could have taken that slot.

    Without that Medicare/Medicaid investment technically you would be an MD but without a speciality (like family practice).. and probably not able to see or care for any patients. It is a little bit like people who used to get Habitat for Humanity House and then turned around and sold them at a profit.. (took community investment for their own personal lifestyle)

    BTW the average US medicare payment for an office visit is more than doctors in the EU are paid per visit so if you are unable to run the business go to work for Kaiser or Partners or Mayo all of which care for people on Medicare with some of the highest quality and patient AND provider satisfaction scores in the US.

    You made the argument of why doctors should be on salary and not in small practices.. (btw I adore you otherwise but in this case you are wrong)

    • querywoman

      Student loans, etc., are a form of government assistance, even if they have to pay them back. Your view is valid, though I am not sure exactly how Medicare helped pay for her training.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Nobody should agree to be bullied and abused. Whether your abusive father pays for your education, or an abusive spouse, or even the government. Nobody should submit to abuse. I certainly do not plan to do it any longer.

    • http://www.idealmedicalcare.org PamelaWibleMD

      My decision to opt out of Medicare has very little to do with their poor payment and has nearly everything to do with the abusive way they treat doctors and the onerous administrative BS.

      I never agreed to be mistreated when I went to medical school. I wanted to be a healer. NOT a victim. NOT a perpetrator.

      Get it?

      • querywoman

        You had an expectation in medical school, that, if you accepted Medicare patients, you would be paid timely without hassle.

        • http://www.idealmedicalcare.org PamelaWibleMD

          I suppose that I did have the impression that if I did my work and was a good student and doctor that I would be treated fairly.

          Not always the case. Shocking. At least to me.

    • jpsoule@hotmail.com

      Sherry, you are wrong. Here is why. Your argument implies a social or other contract between physicians and the federal government because they partly or mostly funded our training. By that logic every American who attended elementary school, high school or college owes a duty to work for the state AND the feds, as all these institutions of learning are partly or wholly funded by state and federal dollars.
      Unless the federal government requires a contract be signed by each medical student, intern, resident and fellow to accept medicare/medicaid/tricare and any other federal insurance, physicians are FREE (not indebtured servants) to choose their work conditions.
      We all already work for the state and Uncle Sam through the myriad of taxes we pay. But we also maintain the right to choose our work, the difference between freedom and communism.

      • ninguem

        ^^^ what jpsoule said ^^^

        It’s the old argument “You used a public sidewalk. Therefore, you benefit from the government, and we all have a claim on your services, forever.”

        The government spent a lot on Dr. Wible’s education, as well as mine. Therefore, the government has a claim on the expertise we earned, forever.

        The government spent even more to train fighter pilots and submarine commanders and Navy SEAL’s.

        I guess we have a claim on their services forever as well.

        • querywoman

          Yes, you have a right to reasonably priced medical care. Pamela is providing medical care to her community, with reasonable, flexible rates. It sounds like it costs less to use her than Medicare plus copayments.
          I suspect that some people pay her well.
          I hope that, whatever changes come in the next ten years, they will just leave her alone.
          I can see the government or her community trying to absorb her or offer her some help. I do not like to see government meddling too much in my local church clinics.
          I hope they just leave her alone.
          She’s one person, doing what she can.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Isn’t the government really us?

          • querywoman

            Yes, and if all the government will pay for medical care is Medicaid rates, then I should get the Medicaid rates myself.
            Did you expect that?
            Did you see the seen in Dr. Zhivago where the man returns to his home and sees the sign that, “The People,” own it, and he cries, “I’m the people,” and tears it off?

          • jpsoule@hotmail.com

            Excellent example of big Government going too far.

          • http://www.idealmedicalcare.org PamelaWibleMD

            OMG. I do not own a TV. Never have. Did not see the scene.

          • querywoman

            I saw it at the movies years ago. I have a TV, and have not turned it on in I don’t know how long.
            Sometimes I watch video on my ‘puter. I may donate the old CRT tv when I move.

          • querywoman

            Re: Zhivago quote, right off Wikipedia

            A body, styling itself the Yuriatin Committee of Revolutionary Justice, has expropriated my house. In the name of the people. Very well. I’m one of the people too!

            [He picks up a shovel and makes to force his way in.]

          • jpsoule@hotmail.com

            We the People are supposed to be in charge.
            Americans need to remind big government of that.
            Vote.

          • http://www.idealmedicalcare.org PamelaWibleMD

            with your money.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Yes. We need informed consent.

    • ninguem

      “…..if you are unable to run the business go to work for Kaiser or Partners or Mayo all of which care for people on Medicare with some of the highest quality and patient AND provider satisfaction scores in the US……”

      One gets weary of the arrogant ignorance.

      Partners and Mayo and Kaiser have rigged the system where they get paid twice as much as private physicians for the same service.

      They are NOT better business managers, they are better extortionists.

      We got the Patel scandal in Oregon because Kaiser and OHSU (the medical school) managed to exempt themselves from the malpractice reporting rules with the Medical Board. Rules that Dr. Wible and I have to follow, they simply ignored, and then went around crowing about how much better their quality is, compared to private docs.

      For the longest time, the medical school limited their total liability by law, to half a million dollars. I favor tort reform, even I say that’s too low. Then you wonder why lawyers filed fewer cases, and then the medical school crows about their higher quality.

      Oh, and if you don’t pay your bill with the medical center, expect the state revenue service to chase your bill.

      See if I can use Vito to collect my bills.

      Since you bring up Partners, I assume Boston. Here’s Lahey Clinic doubling the bill by “facility fees”.

      http://www.bostonglobe.com/lifestyle/health-wellness/2013/01/27/visit-dermatologist-ends-with-operating-room-and-hospital-facility-charge-lahey-clinic-charges-hospital-fees-patient/OZsc5swPmUO7oCoU6k7gjJ/story.html

      I could pull up the same from NPR, the Wall Street Journal, most anywhere in the country. Saw it with my own eyes, with my own family’s medical care.

      When primary care docs disappear, to be consolidated into big box centers, the cost of primary care will double.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Yes. Let’s use the proper terms here. Extortion.

        “Partners and Mayo and Kaiser have rigged the system where they get paid twice as much as private physicians for the same service.

        They are NOT better business managers, they are better extortionists.”

        Thanks Ninguem for clarifying things.

        • ninguem

          Oregon Medicare once tried to collect an alleged overpayment that was five years old.

          They sent us nasty demand letters. They were going to use the power of government to take it, with interest, and penalties.

          I asked the Medicare carrier what I had done improperly.

          They didn’t know. They just knew I owed them this money, and I should pay it. Now.

          I cannot begin to tell you how nasty they were about it.

          It had to do……I suspect……with a change in carriers. Aetna to Blue Shield North Dakota. I had billed an office visit early in my practice days, brand new patient, brand new office, just moved to Oregon.

          Aetna lost the Medicare contract to Blue Shield, they took over.

          You may or may not have been affected by this, but with the contract takeover, there was an interruption in cash flow that went months. Medicare claims in Oregon were not being processed for payment…….for months.

          This is the “efficiency” of these large organizations. There were internal medicine groups that could not make payroll.

          It had to go to the Legislature for emergency payments, as the doctors were effectively going to :”go on strike”. In this case, meaning bankruptcy. That will stop the docs from practicing.

          At that time, I was new in practice, I had expected low revenue, had the line of credit and all that to get started, but that was just dumb luck timing.

          My billing “error” with the patient? I don’t know to this day. I’ll stipulate as a doc new in practice, I may well have made an error in billing. But I didn’t know what it was, nor did Medicare.

          The old carrier, Aetna, seems to have found some error on my part. But they never told me, as Blue Shield had taken over the contract a few days after the service in question. The error and the overpayment demand sat in limbo for five years, until Blue Shield got around to cleaning out these legacies.

          The dollar figure in question was about a hundred dollars, maybe two.

          I was getting nowhere with Medicare. I went to the Medical Association, with little help, except to give them the story as background for their lobbying.

          Then I went Senatorial on them.

          I’m not in the same camp as Ron Wyden politically, but I have to credit him for constituent service, so he gets my support anyway.

          What I got was someone who would actually tell me Medicare’s rules in that regard. It turns out, Medicare, like the IRS, does have a statute of limitations for good-faith billing disputes and errors. Three years. Fraud, like the IRS, they can go back as far as they want.

          So, Medicare was not following its own regulations.

          Wyden’s office sent me Medicare’s reply, when the rule was pointed out to them. They acted like I was a murderer who got off on a technicality.

          So……yes…….extortion is an appropriate term.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Wow!

  • querywoman

    Why did you bother to go to her?

    • Kim

      I didn’t. I went on my insurance company’s website and found another specialist.He asked if I had a referral. I said I was referred to another doctor but she doesn’t take insurance. He said no problem.

      • querywoman

        Yes, you ran into what happens in my large urban area. They want more, up front, etc., if they don’t take insurance. I’ll have to go back and re-read what happened to you.
        Plus, around here, all the private doctors know they can dump on the county.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Meat pies in larders? I have no idea what you are talking about but that sounds really disgusting.

    Tail coverage is usually about 1.5 x annual insurance premium. I’ll ask her what she did about that. I once owed 18K in tail. Just to leave a job.

    • ninguem

      Meat pies, from British and Northern French cooking, Quebec Canadians and the Canadian maritimes.

      You see a fair amount of that in New England, in the corner stores, to the extent that they still exist.

      “In the larder”, I’m not keeping them more than a day mind you, but they’re on the kitchen table. They’re not keeping for weeks, but they’re on the shelf with meat pies, fish cakes, stuffed quahogs (a big New England clam, around Narragansett Bay to Cape Cod).

      It was the workingman’s lunch, early to mid-20th century. Still around, but rapidly vanishing, more’s the pity.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Speaking of meat pie larders and what happens without refrigeration, I recently went on a house call and discovered a meth lab. Here’s the video:

    https://www.youtube.com/watch?v=2xMAB_788Uw

    • ninguem

      Look behind the face plate of the electrical outlets, see if you can find the vial of ricin.

      I mean I’m just sayin’

  • ninguem

    As pointed out by others, I have to answer a question with a question.

    Where did you go, ultimately, for your urogynecological care?

    Did you go to this person, who did not accept insurance, or did you go elsewhere?

    • Suzi Q 38

      I would go to this physician.

      https://www.youtube.com/watch?v=w2EwD1kykmQ

    • Kim

      I went to another doctor. He asked me if I had a referral. I said I was referred to another doctor who didn’t take my insurance. He said it was fine.

      • ninguem

        Noted, just wanted to be sure I understood the story.

        Why does the doc decline insurance participation? Revenue versus hassle.

        Seems the doc decided the hassle wasn’t worth the extra cost.

        Urogynecology implies a clientele consisting of women of a certain age…..and certain economic means. They may well want to pay cash, especially if the doctor does certain incontinence surgeries that, perhaps, are not ordinarily covered by insurance. And more to the point, ABLE to pay cash.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Are you suggesting a woman in a poor neighborhood wouldn’t say: “I’ve got an appointment with my urogynecologist today, babe.”

          • ninguem

            Now I’m not sure what you’re asking.

            All I’m saying is the patients of a urogynecologist MAY be of a certain age and economic means that is favorable to that specialty.

            Only as a speculation why a doc in that specialty has, apparently by poster’s story, left all insurances.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Aha!

          • http://www.idealmedicalcare.org PamelaWibleMD

            Thinking only the rich could afford to go to a “urogynecologist.” So an uninsured woman in a poor neighborhood would not be able to get an appointment?

          • ninguem

            Surely it is no surprise that there are practices that cater to the well-to-do.

            Botox and all that.

            Harley Street practices in London.

            The urogyn described here would not likely be able to see such a doc……unless that doc deliberately took on such patients for free.

  • ninguem

    For quite some time, the People’s Republic of Massachusetts has mandated that, AS A CONDITION OF LICENSURE, a physician cannot charge a Medicare recipient more than the “Medicare Limiting Charge”.

    So, even if you are completely opted-out of Medicare, you are still stuck in the Medicare fee schedule in the Commonwealth.

    Efforts to make Medicaid participation a condition of licensure, have been bandied about from time to time, so far has not gained traction.

    Sooner or later…….

    • querywoman

      Doctors lose money on Medicaid.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Medicaid pays $11 per visit in California.

        • querywoman

          I can’t click “like” on this comment. I dislike it, but I’m not thumbing it down either.

    • Suzi Q 38

      Bummer.
      Can we buy our doctors rolls of stamps or other things needed in the office as a “donation?”

      • http://www.idealmedicalcare.org PamelaWibleMD

        Yes! You can!

      • ninguem

        It sounds more classy if you call it “fakelaki”.

        It’s what you may need to get medical attention in Greece.

        http://www.bbc.com/news/magazine-20874650

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yep. In Minnesota accepting Medicare is mandatory as a condition of licensure.

    • jpsoule@hotmail.com

      Also known as government price controls.

      Many liberals will never learn laws can not dictate ‘good’ behavior.
      Laws can only incentivise beneficial behavior and punish ‘bad’ behavior.
      As for mandating acceptance of medicaid/medicare or other government healthcare as a prerequisite for licensure…
      We only have to look at the VA. And the old Soviet Union saying about communism: “They pretend to pay us, and we pretend to work.”

      • http://www.idealmedicalcare.org PamelaWibleMD

        And too many laws that punish “bad” behavior (as defined by who?) can destroy a society.

    • querywoman

      The miniscule Medicaid payments will never work for the average doctor.

      • http://www.idealmedicalcare.org PamelaWibleMD

        A quick way to put docs out of business.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Or alternatively they can run a “Medicaid Mill.”

        • querywoman

          The majority of docs didn’t take Medicaid from the beginning. I’ve written before about how Medicaid patients usually go to the public hospitals, where docs are on salary.
          Decent private docs who take Medicaid usually limit it to a percentage of their patients. Sometimes they take Medicaid family members only from their other patients as a courtesy.
          As a former welfare, I don’t think too much of other private Medicaid doctors. They can make money off it, though all kinds of dastardly stuff, like running a gob of tests and other procedures.

  • querywoman

    Inadvertently, this thread has proven something. Medical debt creates a lot of scare. Medical debt is not the only concern in our society.
    I never indicated I was worried about the state going after my brother’s or my mother’s assets, yet some people seemed to read ii that way.
    I knew my state’s laws on both their situations.

    • http://www.idealmedicalcare.org PamelaWibleMD

      “Inadvertently, this thread has proven something. Medical debt creates a lot of scare.”

      Thats for sure! This is why my uninsured patient who had a stroke dealt with it on his own rather than go to the hospital He crawled and hobbled to the outhouse rather than go in to get treatment and risk losing his house and leaving his wife homeless.

      • querywoman

        And we know the EMLTA act covered him. There might have been some government funds to pay his bill. He still should have gone to the hospital.
        Did he?

        • http://www.idealmedicalcare.org PamelaWibleMD

          Nope. He only came to me. Weeks later!

  • querywoman

    I just mulled over a way Pamela could probably keep her practice as is. it sounds like she mostly charges over Medicaid rates and requests some labor in exchange for free or low cost services.
    It sounds like she charges a little under the Medicare rates.
    If, in the coming changes, she can prove to the government that she provides her average payment care in one month that’s less than the average Medicare premium and copayments for a patient in one month, then she should be allowed to practice as she wishes.
    I think this is a fair political solution, and we can advocate for it.

    • http://www.idealmedicalcare.org PamelaWibleMD

      99% of my patients pay either through insurance(80%) or self-pay (<20%). My fee schedule is lower than most docs in town, but it is not under Medicare rates in this region.

      • querywoman

        Whatever. I suspect whatever you make would probably work at as equitable and a fair way to service the public.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Yes. Malpractice rates are highest for primary care docs who do OB in urban sue-happy areas such as Miami or Chicago. So if 30+ K annual malpractice premium (last I heard) then > 45+ K tail.

    Pay to play and pay to leave.

  • jpsoule@hotmail.com

    In 1986, as a senior medical resident in Richmond VA, I was paid exactly 18,000 a year.
    Our program policy forbade ‘moonlighting’, but all but a few wealthy residents did so to make ends meet. And this was before weekly hour training restrictions, so you worked your 100+ hours a week BEFORE moonlighting.
    There are exactly 168 hours in a week.
    I counted those hours many times in training. :)

    • http://www.idealmedicalcare.org PamelaWibleMD

      OMG. Sad. True.

      • jpsoule@hotmail.com

        Life changer for all of us, no matter how many hours.
        My MD sister in law, a psychiatrist, often tells of her internship year on the medical wards.
        I smile at her and she smiles back, just knowing.
        When we were young, we knew no better, we thought it was all normal.

  • Joe

    Hyper-regulation: the cost driver nobody ever mentions.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Too many cooks in the kitchen.

      Too many no-value added intermediaries making a great living off of revenue generated by physicians.

      • T H

        Billing services, coding services, 75% of hospital administration, and 95% of the insurance industry.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Why should a primary care doc providing the same service in a big box clinic receive only 15% of collections when they could keep 85% in a solo small clinic?

          OVERHEAD.

          Overhead is high when no-value added intermediaries (parasites) are running around making a good living off of docs hard work.

          TRUE story: A friend had 85% overhead at a big box clinic in town. My first year in solo practice got my overhead down to 10%.

          Simple math.

          • T H

            Exactly. Though the math is simple… the problem itself is not.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Why not? Boycotts work.

  • rbthe4th2

    Not necessarily. I had a relative who was always thin. Type 2. Go figure. Her father was that way too. Couldn’t figure that one out either. They never did fast food either. Grew most of it.

    Type 2 now is a lot of kids. Then again, our idea of overweight is 20 pounds.

    • querywoman

      Lowering the diagnostic define level has also led to an increase in diabetes diagnosis, and that is good.

      • rbthe4th2

        I am not so sure. I’ve got docs that a lot of them dont treat anything until you are way out of the bottom normal limit. That’s fine if you are a regular person but if you aren’t, and your true limits are above that, you have symptoms, then you are sicker for longer and take forever to get better. More $$$.

        Ask docs: I’m not sure the statins contention is a good thing, as many seem to disagree with the standards.

        • querywoman

          Solid research has shown that diabetic damage incurs at lower levels than thought. There are several four meds for diabetes. A blood glucometer, which most manufactures give away, and the strips, off which, they make much more money, is kind of expensive to supply but very helpful. These early interventions can really help reduce costly and horrid complications.
          Perhaps Drs. Ninguem and Pamela will chime in here.

          • rbthe4th2

            All I can say is that I’ve been low or high at times and the vast majority of things have never been treated. After saying things were a problem, I never do any more. I just get sicker.

          • querywoman

            Have you ever had rising blood sugar? I don’t know if there’s a grey area on when doctors and patients should consider treatment based on symptoms as well.
            I get really sick when my sugars rise a little. A psych told me once that might be good, since it warns me to get medical care and might prevent me from having serious complications.
            I worked with a man who’d had some kind of hand surgery. He told me that they then discovered he was diabetic and the damage had built up for years.
            This would be excellent place for Ninguem and Pamela to drop in.

  • querywoman

    For me, it’s been great.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yep. Most patients seem to like it. Politicians know that the >65 crowd can make or break them so they kowtow to them. They certainly do not seem too concerned about how doctors feel. We are not a large enough % of the voter population. Not that I feel our democracy is working too well anyway. The change we need is unlikely to be delivered through more legislation like Joe mentions above: the costs of over-regulation in medicine are extreme.

      • querywoman

        True. The old folks vote.
        I have been in the hospital four times in seven years, using Medicare, with the same general internist, whose office is next door to a hospital. She has no NP or PA.
        Your own skills are probably comparable to hers, but you might see more children.
        It’s nice to see my own doc in the hospital. So direct pay would not be by preferred choice.
        Sometimes I think of changing because she knows little about skin and isn’t much interested in hearing what my derm does.
        However, my endo in a neighboring building really looks at my skin and understands it better. My derm knows the endo is backing him up. My endo, like my derm, seems the skin disease as autoimmune self-protecting mechanism. I take Vitamin D, and the endo probably is the more appropriate doc for the inner problem.
        My minister liked my internist in the hospital, and, when she met him, she knew I had somebody, since most of my family is gone.

        • http://www.idealmedicalcare.org PamelaWibleMD

          You got a good set up there querywoman. Wouldn’t change a thing if I were you.

          • querywoman

            Yes, I thought you would agree. The fact that my minister likes her is excellent. The hospital gets lousy ratings, but I get excellent care there.
            He liked my care much better than some of his other parishioners were getting.
            Sometimes I think about going to the doc who cared for my brother in the nursing home till he died. He’s same hospital. He was quite good.
            But, I have been seeing her for seven years. She’s foreign. Won’t tell you what Asian country. Small and sweet. I may make private contact with you and tell you who I am and where I am.
            She called my minister, “the parson,” and knew he was my family.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Are you in Oregon? Do we secretly know each other now? Or from a past life?

          • querywoman

            No, in Texas. When you said you didn’t have TV, I really bonded.
            What I hate is being in the hospital with the electronic babysitter.
            My internist saw me drawing in colored pencil the first time in the hospital and was pleased.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yes. should have other activities for bedridden, the sick, and little kids than just TV. Don’t some hospitals still have the cart full of books – that mobile library – rolling around?

          • querywoman

            Not mine. I draw, black ink on paper. When I had serious pneumonia, eight days, quite all, I couldn’t do much but lie there. I finally turned on idiot box out of boredom, silently at first.
            During that eight days, and I finally turned on the noise on the TV, there were two notorious local murders being rehashed! I hate that stuff. I read it on the net.
            When my brother was in the nursing home, sometimes I’d watch TV with them. I liked the nature specials.
            But when the late afternoon news came on, with the murder of the day or other tragedy sensationalized, the newscasters on speed reporting, I’d ask my family, “How can you watch this she-!t?”

          • querywoman

            Don’t you have patients today?

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yes. I work afternoons and evenings. Going in at 4:00 pm.

  • querywoman

    Many of the drugs are cheap and on the $4 med list. And no, most Type II diabetes does not go away with diet and exercise. Diet and exercise control, if they work, will work normally for a max of 7 years.
    Doctors have been encouraged for years to quit just handing out diet and exercise sheets at first dx and start people on a med, usually metformin. Damage starts incurring at slightly elevated BP levels.
    Type II is also autoimmune and associated with getting older. If we died earlier from something else, lots of us wouldn’t live long enough to get diabetes.

  • http://www.idealmedicalcare.org PamelaWibleMD

    WOW jesskazen. Really? I always heard it was kind of like an “all-u-can-eat buffet” for patients.

    • JW

      No. The monthly premium is a lot less, but there are still large coinsurances and deductibles, including the very scary ‘donut hole’ medication coverage gap.

      If they designed the medication coverage gap as a way to get senior and disabled people to stop taking their medication, or ration it, or not try expensive meds their doctor suggests, when it starts to get too expensive, then they succeeded. If they actually wanted to help people who were seriously ill, they failed. It’s being phased out but only by a very small percentage point per year.

      And there is no out-of-pocket maximum.

      One can purchase Medicare Advantage plans which typically institute out-of-pocket maximums and may reduce some or all of the coinsurances and deductibles. They either limit the network (though this may result in an improved selection compared to who will take Traditional Medicare) or cost a lot in premiums proportionately to the fees they reduce, or both.

      I hear that people on traditional Medicare and Medicaid may have trouble getting coverage for what their doctors want to do (though this may be mainly complex patients with poorly-researched diseases and no clear standard of care). Advantage and Medigap plans of course depend somewhat on the carrier (although I think the drug formulary for all Advantage plans is negotiated by Medicare, not totally sure though).

      Disabled people and retired people still have to pay a lot for healthcare. If they also have almost no assets and qualify for Medicaid (by having little to no income), however, then Extra Help may cover some or all of the deductibles, copays, and premiums. But first they have to have basically not enough money for first and last month’s rent. Most other safety net programs go by similar rules. I know someone who was made homeless by this asset test policy, and I’m sure there are others.

      Note that ACA/exchange doesn’t cover the most poor people of all: people with very small incomes are supposed to use Medicaid, and people with no incomes due to disability are supposed to use Medicare (plus Medicaid if no assets).

      • http://www.idealmedicalcare.org PamelaWibleMD

        Wow JW – if it ain’t great for docs or patients, maybe we should try this –> http://www.idealmedicalcare.org/blog/when-your-health-insurer-pays-for-breakfast-heres-what-happens/

        • JW

          I agree that insurance companies have way too much power, and effectively practice medicine without a license(!)… but I’m not clear on how private pay solves the problem for people who are disabled, retired without savings (maybe they were caring for sick family, like my parents, rather than being irresponsible and not saving), or very poor even though they may be working.

          I do agree that it’s a bit silly in many cases to make routine, expected health expenses free while making unexpected expenses prohibitively costly (and seriously, what’s up with ambulance being covered only if you get admitted, while at the same time discouraging admissions? This is one where Medicare is better–there is a simple copay for ambulance.). However, people with little to no income might seriously not be able to afford $60 or more to go to the doctor, especially if, like me, they have to go a lot*, or if they would otherwise qualify for Extra Help.

          Should we pay for them in a similar way as SNAP?** Give the patient a special debit card that can be used only for medical care? How will we know how much to fund it? Some patients are more healthy, and others have more complex (and sometimes expensive) problems.

          *I have no dedicated specialist for my orphan condition–would have to travel about 800 miles to get to the nearest one, which is not possible for me at this time–so my care is spread around multiple specialists who mostly don’t actually know what my main condition is, and my PCPs [last one just moved, so I have a new one], who also don’t know what my condition is, can manage only bits of my care herself/himself.

          **only preferably without the paternalistic restrictions we see in some states; it can be as bad as an insurance company!

          • http://www.idealmedicalcare.org PamelaWibleMD

            I think there is no one perfect “program” to handle 100% of patients 100% of the time, but I do think DPC is the most sensible for most people for most primary care. PLUS there is huge value in keeping the same doc who can advocate for you over your lifetime instead of having to switch docs based on your employment, your insurance plan, your miserable docs escape from their assembly-line job (there is a huge amount of discontinuity due to docs frequently changing jobs and moving out of town suddenly – not to even mention doc suicides leave patients in the dust)

            For the poor, I do accept lesser payments or even no payments and trade for cleaning my office or other sorts of things. Sometimes see them for free.

            Interestingly, I really enjoy seeing uninsured patients best because I do not have to document every little thing on their chart and then submit claim. It’s just so much more fun.

          • JW

            I guess I can’t fault you for not having a solution for specialists and hospitals when you’re a primary care doc. :) You solved your sphere of operation.

            At some point I think all the docs have to revolt against the system, but those of you opting out of insurance are voting with your feet, which has to say something.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Another intersecting issue is how much money is spent developing which drugs. The 1% of people with unusual life-threatening conditions get very lithe funding for help with their conditions, but every other commercial is two people in two bathtubs (why not one?) for Cialis.

    Here’s a version with dogs:

  • http://www.idealmedicalcare.org PamelaWibleMD

    Out-of-pocket at 30% off for payment at time of service with every reasonable fees for follow-up visits. :)

    • querywoman

      They get their expensive drugs off their insurance or Medicare?

      • http://www.idealmedicalcare.org PamelaWibleMD

        They can get their Rx, labs, tests via Medicare.

        • querywoman

          Readers, they don’t have to pay their Medicare deductible out of pocket to see her. If she charges slightly more than Medicare, and she’s the only doctor she sees over a year, the cost of the deductible has to be figured in.
          Does a Mcare doc have to order lab work?

          • http://www.idealmedicalcare.org PamelaWibleMD

            nope. any doc can order labs. Only once did a patient have a Mcare managed care plan that required an opt-in Mcare provider to order.

  • http://www.idealmedicalcare.org PamelaWibleMD

    quick thinking!

  • http://www.idealmedicalcare.org PamelaWibleMD

    in resort towns. why not an adult disney world experience. I like when Patch Adams recommends to patients: “Design a death that you will actually look forward to”

  • http://www.idealmedicalcare.org PamelaWibleMD

    Medicare allows 3 choices:

    1) PARTICIPATING PROVIDER – accept Medicare 100% and everything that comes with that (reimbursement rates, admin hassle etc, . . )

    2) NON-PARTICIPATING PROVIDER – accept Medicare rates, but you can balance bill your patients for what is not fully covered by the generally low reimbursement.

    3) OPT-OUT PROVIDER – don’t deal with any of it and have a direct payment model with patient (who signs a form that they will not try to get reimbursed by Medicare)

    I think there is no way in the world an average guy off the street will properly submit a Medicare claim so if you are #1 or #2 doc you are pretty much obliged to do it for the patient.

    Am I missing anything? Other docs pleas chime in here . . .

    • ninguem

      The original enabling legislation of Medicare allowed doctors to balance bill against their usual fee.

      The “evil” AMA did warn that this would eventually disappear, and as they predicted in 1965, that’s exactly what happened.

      Or maybe it didn’t. There are some medical organizations that would like to see the question settled in court.

      The National Health Service lets physicians see patients in, or out of the system, as decided between the physicians and patients.

      The French allow their physicians to balance bill. Some physicians do, others don’t.

  • querywoman

    We have gotten OT off here, but this thread has some interesting stuff and has risen above being a gripe with no solution fiesta.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yes! We have explored life without refrigeration, what happens when you spiral down on to Medicaid, how the government can take your assets from your grandchildren. . . .and more!

      • querywoman

        Yes, and one point I tried to make that I helped Mama, my brother, and me by getting the state reg people out to his nursing home on our about her birthday. She told me we are meeting with them at the nursing home.
        That was a lovely birthday present!
        We learned a lot from the state people that day, like that many older people lose their sense of taste and food tastes blah.
        Other family members at the meeting weren’t interested in contacting the state, even though I held a card with the local contact people.
        They just wanted to gripe, and I hate that. Really, deep down inside, they want someone else to do everything for them.

  • querywoman

    I do not want to linger.

  • Sarah

    Dr. Wible,

    I think an important part that you are forgetting is that as senior citizens we have paid into Medicare our entire lives…… 6% of our income being deducted from our wages for heath care for our entire working lives.

    I am a cancer survivor and have received nothing but excellent care from the doctors….. and all health care providers…… from the East Coast to the West Coast……who willingly accept Medicare.

    I find your comments to be based on nothing but incredible generalizations and not on any research whatsoever…..just your opinion.

    IMO your blog is a joke.

    • querywoman

      Medicare works best for the specialists.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Some. Not all. Definitely undervalues primary care and favors proceduralists.

    • T H

      No, ma’am, her blog is not a joke. Her blog is an honest attempt to get laypeople such as yourself to understand why over the next 3-5 years, primary care doctors (IM, FM, Peds, Psych) are going to be dropping Medicare insurance from their practice. If your doctors are mostly specialists and surgeons, then you will have few issues… until the squeeze hits them as well.

    • Lisa

      The current rate for the medicare tax is 1.45% for the employer and 1.45% for the employee. There are is no wage base limit for the medicare tax. I think you are thinking of the current tax rate for social security, which is 6.2% for the employee and 6.2% for the employer, with a wage base limit of $117,000.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Sarah ~ I pay into Medicare with every paycheck too. And I have my entire life. This events above are not made up and what Medicare did to Dr. Karen Smith is not “a joke.”

      • querywoman

        Sarah, Dr. Pam, if she gets disabled or elderly and gets her Medicare, will surely use it for any hospitalizations in that future. But, she might also use a pay as you go doc like herself for her general care.
        She also states her patients can get other tests and meds through Medicare and insurance. So, in a way, third party payers help her treat her patients. She charges mostly for her time, and less than other doctors do, because she has no employees, no claim forms, and no wait for payment. The trouble is a lot of doctors want to charge $400 a visit if they don’t take insurance.
        I don’t know if she treats any cancer at all, but cancer does need costly care, and Medicare or insurance helps immensely. But the uninsured can also get quality cancer care!

  • Sheri

    Gee, if I was a doctor I would not take Medicare either, after reading this article!!

    • Suzi Q 38

      Yes, if it only pays $12.00 a patient visit, that is simply not enough to pay the bills.

  • querywoman

    I’m not so sure about that one.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Doctors do not give up the best years of their lives in school and amass huge educational debt for the “money.” The public has misconceptions (often reinforced by the media) about who doctors really are. We are here to care for you. And no, we do not deserve to be abused by patients or the government via Medicare.

  • Jen

    Many people on fixed incomes can’t afford to pay for medical care. Some can’t afford an extra $20. I appreciate that you don’t want the Medicare hassles, however when doctors stop taking Medicare then patients have fewer choices.

    Medicare also covers people on dialysis and with severe disabilities, so you are not just excluding people 65 and older.

    Since University hospitals and transplant centers will never stop taking Medicare there will always be a safety net, but when more people stop taking Medicare the safety net is strained even more.

    I appreciate you are trying to change the system, but without Medicare how could a 66 year old pay for their screening colonoscopy or a cardiac echo and treadmill if they have chest pain?

    I’m curious if you accept private insurance and just not Medicaid or if you are a concierge practice and take no insurance?

    However, if every doctor in a small town stopped taking Medicare then the option would be no care, find money to pay for care, find money and a ride to get to another town to establish care with a physician who does accept Medicare. Those options just seem less ideal for the patient.

    It seems a more ideal way for the patient would be to get involved politically to make changes. Many of your concerns are valid, but I just don’t see how declining Medicare will change the system.

    • http://www.idealmedicalcare.org PamelaWibleMD

      I never turn anyone away for lack of money. So anyone can see me. I accept most insurance and will work with anyone (patient or insurer) who is respectful of me. Unfortunately, some insurance companies are abusive to doctors (and patients) and so I have chosen not to continue contracts with these few insurers (and rarely, yes, I do have to fire a patient).

      It would be fabulous if all insurance companies (including government plans) could upgrade their behavior and be respectful. I’m ever hopeful, but at this point I do have to keep my sanity and my health by not accepting any abuse in my life. I would suck as a doctor if I were a victim. You can’t be a victim and a healer at the same time. I choose to be a healer.

      Oh, I am not a concierge practice. There are no extra fees. In fact, I offer “VIP without the fee.” Red carpet treatment for all . . .

    • querywoman

      She has to keep some basic medical supplies in her office. She knows where to send her patients for procedures she doesn’t do.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Me? yep. I do. I perform minor surgery. I see anyone. All comers. I can handle > 90% of the problems the average person walks in with. This is what a good primary care doc can do when they are left alone to actually care for people not parasites.

        • querywoman

          Tell the masses: and this is an easy one: do you keep flu shot serum? Standard antibiotic shot serum?

  • querywoman

    For our hostess: I am researching Oregon Medicaid Estate Recovery law on and off. Oregon appears to be lax and flexible about it.
    I know you try your best to encourage your patients to get costly care elsewhere that you can’t give them. You can’t make them go.
    I don’t think they have anything to worry about it as to the debt. I doubt anyone will come take their homes. They might get harassed, but that can be handled.

    Now, if someone dies with a really modest home, the public will get it eventually. I feel that the county is more likely to get at $3000 plot for not paying taxes than is the state. Somebody might buy it at tax seizure, if the county gets lucky.

    • Suzi Q 38
      • querywoman

        I research laws, including other states, out of curiosity.
        Even California has generous limits, and the states don’t want to have to pay mortgages.
        You are getting the idea. Just check the laws on the web.
        I’m always astonished at how many people just won’t pick up the phone and call the government agency involved and ask a simple question. You don’t need a lawyer to call.
        As a former IRS employee, I assure you that you don’t need a lawyer to approach the IRS most of the time. If you have hid money or done other deviant stuff, you might need a lawyer. Even a $100,000 debt can be worked out on your own.
        And a lot of people think you need a lawyer to apply for Social Security disability. You ca apply directly the first time and hope you get it. Give as much info as you can. If you get turned down the first time, then you might want to get a lawyer.
        On other stuff I mentioned, I quote you a figure for 300% of the poverty level for two people. Those under that limit are exempt from the ACA. You should get the idea that from 200% to 400% of the poverty level, the ACA is onerous.

        • Suzi Q 38

          “…Even California has generous limits, and the states don’t want to have to pay mortgages….”

          True, but so many of us have homes that are worth over $500K…these are not mansions.
          They are little houses….California is expensive.

          I will have to say that the latter part of this quote intrigues me.
          Why not get a mortgage on a paid off house
          right before going on medicaid? You could use the money to delay having to go into a nursing home in the first place.
          I have seen so many, that I truly do not want to contemplate this eventual reality.

          • querywoman

            Knowledge is power. There’s a way to work every system.
            Taking out a new mortgage on a paid off home makes more sense than doing a quickie title transfer to another person. Not sure of the legalities, but I don’t think a title transfer is ever a good idea.
            I know you don’t like nursing homes, but sometimes they are better.
            My non-compliant diabetic brother, who had three lower leg amputations over ten years, collapsed on a public bus due to strokes and heart attacks, six months after his third amputation.

            When he started snapping out of it, the doctors told Mama he would need 24 hour nursing care and to find him a nursing home.
            In our case, and Mama and I were sick ourselves, we never could make him take his medicine. The nursing home was the only choice.

          • Suzi Q 38

            I am sorry about your brother.

            Yes, sometimes nursing homes are the only choice for patients who are immobile and for caregivers who are not able or no longer able to help out.

            Having some money though, can postpone the inevitable.

          • querywoman

            In theory, someone in a $800,000 should also have a nice nest egg of dollars in the bank. Not necessarily!
            I had a friend, and she was on of 12 children, whose daddy went in a nursing home.
            They all had money due to some major tech companies buying out their daddy’s farmland. So the surviving adult children all chipped in on their daddy’s nursing home bill. They were able to do it till he died.
            I don’t feel sorry for someone in a million dollar paid up home who didn’t contribute to an aging parent’s care, but there is levity written in the laws for that person too. A disabled adult child can keep it. But Soc Sec checks would not cover the utilities on such a home.

          • Suzi Q 38

            Who in the family owned the farmland originally?
            How did they get the money?
            If it was directly or indirectly through their parents, they should “chip in” to pay for their father’s care.

          • querywoman

            Duh? I already said they chipped in.
            A long time ago, land was cheaper in the US. They were poor, but they had land. And the technical contractors grew in that area.

          • Suzi Q 38

            Yes, you did, I was just curious as to who owned the land first.
            Thanks for the info.

  • querywoman

    On using her as a doctor who doesn’t take Medicare – she says she longer has hospital privileges, because the hospitals pays charges her too much annually. She says she will visit her patients in the hospital, as a social call.

    I have Medicare and have a general internist who accepts it. I have been in the hospital four times with this doctor in the past seven years. She has no PA or NP, and her office is in a building next to her hospital. She sees her hospitalized patients herself.

    So my odds of needing a doctor for hospital services are high, and I get to have my own doctor. She works for me. It’s nice to see my own doctor in the hospital. So, no, I would not go to a Dr. Pam if she were close to me.

    If you doubt you will be hospitalized (one never knows!) and just need ongoing, maintenance or sporadic care, a Dr. Pam would work for you.

    • http://www.idealmedicalcare.org PamelaWibleMD

      I did hospital work when I first opened my clinic and LOVED it! Since I only had 2 admits per year and my hospital staff dues were $700 per year, it was a financial loss. Please note that the hospital increased the staff dues ONLY on “courtesy staff” (the 94 docs in town who admit 25 patients per year) at $300. So I was taxed for keeping patients healthy and underutilizing of the hospital. So I decided to drop my staff privileges.

      Btw, my husband was shocked. He asked, “You have to pay an entrance fee to see your patients?

      YEP!

      • querywoman

        I’m not thumbing this down, much as I dislike it.
        Sad!

      • ninguem

        WTF? $700 A YEAR TO BE ON STAFF?

        Which was this, Sacred Heart or McKenzie?

        • http://www.idealmedicalcare.org PamelaWibleMD

          It is Sacred Heart and I arranged a meeting between me and the Chief Of Staff & brought 10 “courtesy” docs with me (mostly men). I watched the fight comfortably from my chair. During the battle, the C-O-S reduced it to $500/yr. I still found this underutilization tax quite discourteous and inhospitable so I withdrew my staff membership.
          This is after RiverBend was built. I guess there was a need for more funds. Go after the courtesy docs.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Divide & conquer is the control tactic of choice. Scare the crap out of people and feed them high fructose corn syrup and other brain drain food and entertainment (bread & circus). Then . . . . shhh . . . while they are sedated, the control freaks run off with the cash. Is this correct maryhirzel?

    My mom, a retired psychiatrist, never accepted Medicare Part B as a physician and so she opted out of it as a patient until age 73 when she would have had to pay a penalty. Guess what? They charged her 26K for all the years she did not pay her Medicare premiums. She paid cash for her visits, did not overuse health care, and this is how she is rewarded. ???????

    A sick, sick system.

    Since she was bored as a retired doc, I assigned her the task of researching how money flows through Medicare. She bought books, she read, she tried her best and could not figure the darn thing out. Zero transparency. Insane complexity.

    Criminals hide out in complexity.

    • Suzi Q 38

      I am sorry what happened to your mom.

      What a system….

  • http://www.idealmedicalcare.org PamelaWibleMD

    Any other docs who have opted out of Medicare want to chime in on their reasons?

  • querywoman

    Looks like you worded it nicely enuf for the sin-ser this time. Dr. Ninguem, I have atopic eczema all over my body. There are two fleshy large symmetrical areas, on my backside, between the small of my back and the tops of my legs.
    Eczema lesions on these two symmetrical fleshy parts can be extraordinarily painful when I sit on them.
    So, I do supposed you can be very painful for your significant other when she has to give you ICD-9 569.42.

  • http://www.idealmedicalcare.org PamelaWibleMD

    I totally get it teo45. Reminds me of the patient profiling story –> http://www.kevinmd.com/blog/2014/02/victim-patient-profiling.html

    I think it’s compassion fatigue that leads health care workers to be callous and judgmental. Obviously this was not our objective when we entered med school.

    You can legally see any “opt-out” Medicare doc without using your Medicare, by the way. But it sucks that anyone would feel trapped and victimized by their insurance.

  • SonnySky

    My wife and I pay over $200 a month for medicare. Plus $236 a month for supplemental plus $96 for drugs, And a doctor shuns me?? Why because they get paid their price even increase it higher when they find out what the supplemental covers which is 100%. Hogwash. Its what Bush did to doctors about medicare back in 2002 that lowered the amount they receive. Political football and the hell with patients.

    Private health care insurance is just as strict and demanding. There is a lot of medicare fraud by doctors and she is full of it with her excuses.

    • http://www.idealmedicalcare.org PamelaWibleMD

      I do not turn anyone away for lack of money. I went into medicine to care for people, not to be abused.

    • http://www.idealmedicalcare.org PamelaWibleMD

      SonnySky ~ I get that you pay so much for your insurance and you should receive quality care for the money you spend, but I’m asking you to look at it from say Dr. Karen Smith’s perspective. What did you think of the video above?

      • Lisa

        I watched the video and what I thought was wow, a lot of the charts pulled for the chart audit had problems. Makes me wonder how she practices medicine and the veracity of what she is saying on the video. I’d like to hear the other side.

        • http://www.idealmedicalcare.org PamelaWibleMD

          And these problems were found not to have merit after further review.

      • querywoman

        The real details are between Dr. Smith and the insurer.

  • querywoman

    I had one doctor who had questioned why I’m getting Social Security. It’s a good thing doctors don’t make the decisions at Social Security.
    Insanity is also a legal issue.
    I’m used to be own skin disease being a mental problem aggravated by picking it. When it flakes off, I get blamed, but it’s part of the process. Now, with digital cameras, I have been able to take pictures over the time that show improvement and prove my point.

  • querywoman

    If you are able and have a back-up system, you should just get up and walk out when they act like that. If you walk, they shouldn’t be able to file a claim.

  • querywoman

    I currently have a painful, itchy eczema lesion breaking up on my left inner ankle. I won’t be calling it, “Ninguem.” I know I will not be getting out of this life with more extra painful ones breaking up higher. I may call those, “Ninguem Uno, Ninguem Dos, etc.,” in honor of you!

  • http://www.idealmedicalcare.org PamelaWibleMD

    Yep Holly. It has gotten really nutty.

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