Medicare is bad business … A doc’s POV

[bik0]

The fact that the only thing keeping me accepting M/M (Medicare/Medicaid) is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care. The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system. I am personally willing to continue on this course as long as (it doesn’t get too much worse) but I have complete sympathy for PCP’s who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP’s (Primary Care Physicians). PCP’s keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital. The system is just holding on with the PCP’s we have; decreasing that number would be devastating and perhaps fatal to the system. It’s a very bad sign when the best business model for PCP’s is to do something that, if done by all PCP’s, would wreck the system. Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors! They have to earn less money! They have to actually have a conscience! What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle, and live by my conscience. At this time, most PCP’s accepting M/M are doing the same. But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish. Pushing down M/M payments for PCP’s will make a bad situation worse.
That’s bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

http://goo.gl/8xmW

[sharesunited]

1. We need to properly schedule and fund reimbursements. AND...

We need to federally preempt state licensing of medical professionals.

Accepting Medicare and Medicaid patients must be a condition of licensure.

[bik0]

3. That's a very heavy handed proposal..

In that case, let's force all grocery stores and convenient stores to accept food stamps. And while we're at it let's force all businesses across the country to sell any product to the federal government at prices dictated by the government. When has the government EVER dictated to a private business that they must be a supplier to the federal government as a condition to doing business?

[sharesunited]

7. Well, I did say properly schedule and fund. If we can't do that, then you're right.

[ProgressiveProfessor]

5. So mandating insolvency as a condition of employment sounds good to you?

Every practitioner who wants to do quality work with an M/M patient loses money on them. Solve that and no mandate is required.Its not just the allowed fees, its the hassle behind it. M/M is much for difficult to work with than most private insurers. I will keep my private insurance with Medicare as the secondary provider since I want quality care.

[liberalhistorian]

29. That's ironic, because, for the patient, Medicare is often far less

of a hassle than private insurers, much easier to deal with. I know few doctors who do NOT curse private insurers and having to deal with them. I'm not saying Medicare isn't a hassle, but private insurers are also right up there with them. And, frankly, most private insurers want nothing to do with people over fifty, even healthy ones, unless they're somehow subsidized also through a form of Medicare. Take away Medicare and most elderly wouldn't be able to find any insurance no matter how much they could pay for it. And then where would doctors be? People wouldn't have the money to pay them.

[ProgressiveProfessor]

32. Medicare is easy, until something unusal comes up...then its a real PITA

very much like private insurers.

My personal experience is that BC/BS is easier for the Docs and no load on the patient. Recently there was an uncovered prescription I had to work out with them, but it was a bit exotic. YMMV

[liberalhistorian]

28. If you're going to go that route, then you're going to have to also

offer loan student loan forgiveness ( many med students graduate with several hundred thousand dollars in student loans and hardly make much money as interns and residents), and subsidies for office setup and overhead (which are huge, just like they are for attorneys). Otherwise, they're just not going to be able to do it.

[ChicagoSuz219]

2. A patient's POV:

Medicare rocks!!

[Yo_Mama]

34. Yeah, well, it won't rock when you can't get treated

We all have to realize that about another 15 million people are going to go on Medicare in the next decade - and when they do, primary care doctors just won't be able to cover their care financially.

This is a very serious issue. The only way for primary care doctors to even come close to covering their expenses on M/M patients is to shortchange them, and in the end that costs us all a lot. So what most doctors do is keep those M/M patients to a certain percentage of their practice, so they can cover their M/M losses with the rest of their practice. Over the next decade, this will end as the proportion of Medicare patients grows.

My doctor usually gets $62.50 per Medicare patient. But he feels he has to spend about half an hour for most of them. That does not even cover his office cost plus his administrative cost. But sometimes he has to spend much, much more time with them - I have seen him spend over an hour. Part of the problem is that Medicare won't always pay for some of the tests he needs, so he has gotten some of the equipment he needs and he runs those tests himself for free, so he won't be at risk of what he considers malpractice. He is not accepting "new" Medicare patients - he can't afford to.

He doesn't accept Medicaid at all any more. It costs him more to treat Medicaid patients than it would to treat them for free. He does treat a lot of charity patients, however, if you are really sick, so in fact he has patients that are on Medicaid but they don't pay anything and he doesn't charge Medicaid anything.

If I walk in there (I'm uninsured) it's going to cost me $90 and hopefully I will be out in 5 or 10 minutes.

So this is about how it works out on a daily basis:
He sees patients for about five hours daily, six days a week.
On the charity/Medicare group he probably spends 2.5 hours daily, which nets him about $200-$250 (eventually).
His entire practice is supported by the other half of his time, and half the insured patients are partly supported by the uninsured patients like me. He has to net AT LEAST $500 an hour for that segment to cover the M/M group. He's always got at least three administrative personnel going.

And as for working more hours, as some of the snotty uninformed comments in this thread suggest, if he sees patients for five hours, his actual working day is more like 9-10 hours. The rest of the time is taken up with research, referrals, and writing up the records, which he feels is extremely important. He generally takes one to two weeks off a year, and during that time he gets in his mandatory CME.

He's a superb doctor. He's admitted to me that his practice doesn't make any money, and that no younger doctor (he's in his later sixties) could afford to do what he does. I am terrified that he will close his practice, because I have a serious illness and he has made a tremendous difference in my life. If anyone mandates he practice medicine in a way that offends his conscience, he'll close it for sure.

The truth is that Medicare is not really insurance any more. It's semi-insurance, and only the ethics of the medical community is keeping it going. But the whole system is at the edge, and as the number of Medicare patients grows in relation to the non M/M group, it's going to break down. Guaranteed.

The reason I know all this is because I've been working on his computers (for free - it was sort of an accidental thing) and so I have spent a lot of time there lately.

I don't mind at all paying the $90 - it's a total bargain. I have a disease that's considered basically untreatable, and he has restored me to just about normal. But I can't see how the whole medical system can continue on like this - we have got to pay higher Medicare taxes. And the weirdest thing about the situation is that if you are worried about controlling costs for Medicare, good primary care is the only way to achieve it.

[ChicagoSuz219]

42. If/when your doctor retires...

...you'll be grateful that the rest of us were willing to fight for healthcare reform, including Medicare which, by the way, is not free... it's based on a sliding scale.

Lucky for you that you found someone willing to work with you on fees, etc. That only leaves about 46,999,999 others I have to worry about.

And, now that you have a pre-existing condition, even if you win LOTTO, you won't qualify for private health insurance (unless there's healthcare reform), so I guess I have to worry about you, as well.

[provis99]

4. what whiners. Fine, quit your medical practice and work at WalMart.

geez, rich people love to feel sorry for themselves.

[ProgressiveProfessor]

6. Many are

OB-0GYNs are leaving the field in unprecedented numbers. So are primary care physicians. They go to other specialties or just retire. Then the front line of medicine will be the walk up clinics in WalMart. Is that really the route we want health care to go in the country

[SoCalDem]

8. Is the baby boom over?

or are they going into more lucrative fields like in-vitro & fertility clinics?..and even doctors eventually get older and want to retire..

Have we been creating new ones ion numbers to replace them? or has medical school priced too many out of the market?

[ProgressiveProfessor]

11. Interestingly enough there is a small boom in new medical schools

which should help address the needs somewhat. However, the entire system that matches graduates with internships and residencies was normalized based on the existing output. Going to be interesting to see what happens when more graduates flow into the that part of their medical training.

http://www.fiercehealthcare.com/story/new-med-schools-could-help-ease-physician-shortage/2010-02-17
http://www.nytimes.com/2010/02/15/education/15medschools.html
http://www.boston.com/news/local/vermont/articles/2010/01/28/quinnipiac_plans_new_medical_school/

[Donnachaidh]

10. and a lot of them go to work for the insurance companies

and become the *experts* that help these companies turn down treatments to their customers.

No one held a gun to your head to make you become a doctor. The AMA does NOT police the bad doctors yet they still want tort reform to take away the only option for patients crippled by the bad doctors your profession refuse to police.

You cannot have your way on everything. And as the healthcare situation is getting so out of hand and so expensive for the patient with NO ONE willing to take responsibility for the insanity, the government SHOULD step in and regulate and mandate what needs to be done.

If that means requiring doctors to take a certain percentage of Medicare patients in order to be licensed to practice here -- fine. As many other workers are being told in this economic down time -- suck it up and deal. The old saw of *we'll take our toys and leave* has been overused for decades. I'm sure that if we cannot find American doctors who are willing to actually CARE for patients we can always import them from elsewhere. Insourcing can work for the benefit of the long-suffering patients.

[liberalhistorian]

30. + one million!

Particularly on the insurance doctors and tort reform matters. I equate doctors who make huge bucks helping insurance companies deny needed coverage (and some knowingly lie, as one insurance company pediatrician admitted on the stand in a suit brought by a cancer-stricken child's parents against Sanford Insurance in Sioux Falls, SD) and who, thus, have blood on their hands against all precepts of their oath, with the corporate and collections attorneys who use their knowledge and skills to make big bucks fucking people over every day (and I'm in the legal field, so I can get away with saying that, lol).

And don't get me started on the tort "reform" bullshit. My lifelong best friend was killed by a horrible and senseless case of blatant medical negligence; she suffered terribly for a year before finally succumbing. And yet the profession calls her a "frivolous" and "junk" lawsuit. How dare they actually be held accountable! How dare they be expected to have some accountability and liability for the consequences of their negligence. They're more concerned with protecting the negligence of their own, no matter how badly it injures or even kills people, than in helping the injured patients.

[emilyg]

12. My doc quit.

[Hannah Bell]

14. You think doctors is synonymous with "rich people"? Tain't so.

I wish people would get a clue about what "rich" actually is.

[misanthrope]

45. By whose standard? "Rich" is subjective...

...The definition to someone in a middle class suburb is different than that of someone on the poor side of town or of someone in the depths of the Third World.

[rug]

9. Business is bad medicine.

[Liberal In Texas]

13. Just out of curiousity, doc, how much do you charge per hour to give a deposition in

an accident case?

[Dappleganger]

15. Once upon a time, doctors chose their profession

because they actually wanted to help people.

Now, it's all about the money and the next tee time.

[jmowreader]

24. Once upon a time, doctors also carried black bags and made house calls in horse and buggy

Now, they come out of medical school with a student loan burden that resembles the GNP of an average third-world nation.

[gateley]

16. I heard a doctor call in to a radio show saying that even now Medicare is

cutting it close, but if they cut it he will have to stop accepting Medicare PTs because he literally couldn't afford to cover his costs any longer. He said he really really doesn't want to do that, and he's not making bucks off it now, but he'll have no choice if they drop it.

I don't understand -- Medicare isn't free, people pay premiums, right? Why can't we make it work for all involved?

[BeFree]

19. I don't get it

An office has fixed costs. If they have fewer patients then the cost per goes up. If they have more patients it's got to help. Just basic math.

It can't take that much more paperwork to process a Medicare patient, can it?

[gateley]

25. He explained it, and it wasn't the cost to process the paperwork, if I recall.

I don't remember the specifics, just that it would hurt him financially to take reduced Medicare payments. Maybe because instead of Medicare he might instead be seeing a patient covered by an insurance company who reimburses higher? Can't have too many essentially low paying patients and still be able to pay rent, malpractice, etc.

Anyway, I believed him and he sounded sincere so I'm sorry I can't relay the info more accurately. Or accurately at all. 7

[BeFree]

27. Thanks

I was thinking along the lines where an office had a mix of Med pts and Ins pts.

If all your patients are Med pts and you have fixed costs that are not met, you'd have to lower your costs.

[Doctor_J]

35. Stop listening to hate radio

it makes you stupid

[Bitwit1234]

17. My medicare is paid thru Minnesota

although I originally signed in Maryland. I have never had my doctor's office say they had to remind Medicare. I get the copies of the paid bills from Medicare and the longest it takes is about two months.

Now that is good considering my doctor's office the hospital get the bills together send them to medicare they are paid and I get copies saying so. Maybe it is the state Medicare is paid from that is the problem.

[WillowTree]

43. And when you get your copy of the explanation of Medicare's payment...

....what percentage of the doctor's charge did Medicare pay?

The last time my Dad was in the hospital, Medicare covered just over 50% of the surgeon's bill and less than 28% of the hospital's charges and they were prevented by law from billing anyone, the patient or any supplemental insurance or anyone else, for the difference, only for the Medicare coinsurance, which is 20% of the anount that Medicare covered. How would medical care providers be able to go on if all of their charges for all of their patients were knocked down that way and they still had to pay all of their expenses (building/rent expenses, taxes, staff, equipment and supplies, liability insurance, umpty-zillion $ in student loans, etc. etc. etc.) oh, and pay themselves comensurate with their training and the complexity and importance of the work that they do? Not to mention the fact that between internship and residency and all of those student loans, many doctors can't even think about things like saving for their retirement until they're into thier 30s.

Fact is, most doctors aren't anywhere near as wealthy as you think they are.

[w8liftinglady]

18. several of the FP docs I know have gone into "aesthetic" medicine-botox and lip plumping

[gleaner]

20. I can only say ....

That I have not yet found a doctor who feels as you do. Most of them are just plain sick of the hassle of "managed care" and prefer Medicare because it is much simpler to deal with. Medicaid is another matter. My state puts so many limitations on it that many doctors do refuse it, to the detriment of the patients who can't get any other kind of coverage. If Medicare were a single payer option available to most people, run the way Medicare is run now which is simply, I expect that the payoffs to the medical profession would be higher and many doctors, like yourself, who are very concerned with this aspect of your practice would do even better than you are with the mish mosh of private plans, HMOs and PPOs.

I am not baiting you or trying to make you feel defensive, but I still like my doctors to put my care first and worry about that. I have a fine Internist and some specialists and a first rate hospital who think Medicare would be an excellent template to lay a single payer plan over. I know this because they have told me so. They are very interested in their patients and the ability of their patients to find good care. They do not think that the private insurers and managed care is doing that. In 2008 when my husband had blood borne MRSA they managed to save his live against tremendous odds, even after the bacteria dissolved a heart valve and did other damage to his heart, lungs, liver, bone marrow and blood, and took away his ability to walk more than a few steps at a time with a walker. When his private insurance tried to curtail his acute care they helped us with and won the appeals. Not one of them complained that they were not getting enough money, and not one of them has made any real attempt to collect the co pays and other amounts his insurance did not cover. In fact they said it would have been easier for them to function if he had Medicare. Ironic isn't it? One doctor's poison is another doctor's good medicine.

I wish you lots of luck in your future. No one is getting any richer under the system we have. Not doctors, not patients, not nurses who work so very hard and get underpaid much more often than doctors. There are some who are doing extremely well though. That is the private health insurance companies who are profiting from everyone's misery.

I notice that you have a low post count. Welcome to DU. I always refer to the post count because some posters have been members for a long time and choose to read more than they post. I welcomed one of them once and got my fair share of embarrassment. But people don't die of embarrassment. They are far more likely to die of managed care and the greed of the health insurance companies and pharmaceutical companies who are more worried about their profits than sick people.

[marmar]

21. And the insurance companies will make it SOOOO much better, right?

nt

[liberalhistorian]

31. Sure, they would. They wouldn't cover anyone over fifty, no matter

how healthy, so the docs wouldn't have to worry about too many older patients anymore and could concentrate on younger, more lucrative ones. See, problem solved!!!! :sarcasm:

[obxhead]

22. A simple solution would be

to create a new branch of the military. Simply have it be a branch dedicated to medical and open to the public. Instead of people putting out 10's of thousands to go to school to become a doctor, they could be paid a nominal wage to learn and serve our country.

Medical care could become about care, not profit.

btw, kudos to you for not turning the M/M people away as they already have less and less daily.

[Cleita]

23. My personal experience is that since I have Medicare, I have health care.

I never had that confidence before. So I hope this gets fixed. It seems that the Republicans, corporatists and other interested parties want to kill the only way doctors will really make money in the long run. So they should get on board and support the only system that will support them when it all crashes around them otherwise.

[walldude]

26. I've written 4 responses to this and posted none of them.

Nothing seems to be enough to say for these poor Doctors who's jobs are so difficult. I mean this poor guy, he's underpaid and has to jump through hoops at work. It's a good thing no one else has these problems.

[Fire_Medic_Dave]

37. Yeah dropping medicare patients is a much better choice.

[Doctor_J]

33. It's too bad that you chose medicine for your career

if you find it too much of a hassle.

When enough PCP's quit for the more lucrative food service industry, the AMA will have to either

1. quit requiring doctors to graduate $500,000 in debt, or
2. Learn to love members who don't speak English

Seriesly, if you think United Health and Allied Health are the answer to the country's health care woes, it's probably time to get a job on Fox News.

[Fire_Medic_Dave]

36. Who mentioned United and Allied Health?

[jtuck004]

38. In the posts above private ins, is touted as a better alternative

[Fire_Medic_Dave]

39. He responded to the OP.

[Hugabear]

40. Health care should not be about being a BUSINESS or making PROFITS

Sorry if I don't feel too much pity

[bik0]

48. But it is a business because if it wasn't no one would be doing it.

Humans behave based on incentives... it's a biological and evolutionary fact. People will NOT work for free and if you force them to work for free or some fixed salary determined by the gov't they will not give a crap about the quality of care. That has been proven over and over.

[jtuck004]

41. A post below says docs get $62.50 for a medicare visit

What does an insurance company pay for the same service?

I know my doc takes about 15-20 mins, and when we have taken my mother-in-law, it takes about the same

[JCMach1]

44. First, recognize that what we have now is not free enterprise...

there is no choice already built into the system...

Sure, a doctor could refuse m/m patients... Sure a doctor could turn away insurance patients. But, how many does that leave?

As for actually finding a doctor... unless you live in an urban environment, you are left with very few choices.

One thing that has been completely ignored in the health care debate is PRICE CONTROLS. On everything!

Not only that, they should be across the board price controls for all procedures (i.e. should apply to insurance as well as the government programs).

[upi402]

46. Just cut out the filthy insurance companies

We split the difference and I get treated, Dr's get paid.
I've used medical in developing countries and it's great quality care. The Dr's do not go without, they drive Mercedes Benz's. And the care is very very cheap. What we do doesn't work. What other countries do works great, even those we pretend to be superior to.

No media calls BS on the righties scaring folks with one-off horror stories.

[misanthrope]

47. So basically, I'm screwed...

...Due to my disability and the five figure annual cost of my meds, no one will insure me. Even if they would, I wouldn't be able to afford it on my hampered income. That leaves me with Medicare as my only choice. If my pulmonologist cuts me loose or he disappears, I guess I'm free to die.

That settles one mystery, I guess. What a relief...