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Wednesday, February 17, 2010

Primary Care Physicians Are All One Breath Away From Dropping Medicare

This post by Rob Lamberts, ACP member, originally appeared at Better Health.


I am going to state something that is completely obvious to most primary care physicians: I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business.

In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance. If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit. This is totally obvious to me, and I suspect to most primary care physicians. A huge part of our overhead comes from the fact that we are dealing with insurance. A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge. As it stands, the percentage of my collections that goes to overhead is between 50% and 60% (depending on the month). A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing and documenting. If I dropped insurance and charged a fixed amount, I could:

--cut my billing staff nearly to zero (someone would still have to do bookkeeping),
--increase my payment per visit, which would allow me to see fewer patients per day,
--document for the sake of patient care, and not for the sake of getting paid, and
--add extra services like e-mail access and house calls without worrying about how I would get paid.

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

So why just single out Medicare and Medicaid (M/M)? Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me. There are several reasons why this is possible for insured patients:

--Insured patients generally have the option of filing for their own insurance (there are some that still don't allow this, but that number is dwindling with the decrease of HMO's); and
--Insured patients could choose to just pay me cash if they choose.

Can't Medicare/Medicaid patients do this? No, for several reasons:

--If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files;
--If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered). So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud; and
--If I drop M/M, I cannot sign up for it again for three years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still? Why would I continue to make my life so difficult? Two words: duty and calling. I view my seeing M/M patients as a social responsibility (especially Medicare). These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income. So far.

Plus, I just like to take care of the elderly and the poor. My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need. If I dropped M/M I would reject the calling for personal gain, which is something I can't do in good conscience at this time.

The fact that the only thing keeping me accepting M/M 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 primary care physicians (PCP) 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. 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.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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3 Comments:

Blogger Toni Brayer, MD said...

I totally agree with you, Dr. Rob. I, too, continue with Medicare because I know how hard it would be for my patients if I stopped. It is bad business for me but my dedication to my senior patients is larger. I must admit, however, as those baby boomers have birthdays...I cringe one by one.

February 21, 2010 at 6:43 PM  
Anonymous calgary acupuncture clinic said...

Correct me if I’m wrong, but doesn’t modern day health care just boil down to a choice between a good medical system that only cares for people as long as they have the means, or a poor medical system that takes care of everyone as if they had the means?

August 13, 2010 at 6:08 PM  
Anonymous Health nut said...

The system has proven to be poorly effective, I think that good and well designed policies will bring a better future to the people and physicians.

November 8, 2010 at 2:00 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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