Blog | Friday, June 4, 2010

Primary care doctors and the Medicare boycott

This post by Liam Yore, M.D., appeared at Better Health.

I saw this interesting article linked to from a blog about angry doctors dropping out of Medicare in Texas. As one who shares the universal annoyance at congress' failure to fix the SGR for more than 30 days at a time, I was kind of cheered by this. That's what it will take to get the system fixed, a grassroots, full-scale rejection of the system! Good for them. And the opening lines of the article were encouraging:

Texas doctors are opting out of Medicare at alarming rates, frustrated by reimbursement cuts they say make participation in government-funded care of seniors unaffordable.

An "alarming" rate. Wow. Cool. So how many is that, anyway?

More than 300 doctors have dropped the program in the last two years, including 50 in the first three months of 2010, according to data compiled by the Houston Chronicle. Texas Medical Association officials, who conducted the 2008 survey, said the numbers far exceeded their assumptions.

That's 300, right? Hmm, not too shabby. Not exactly going to topple the state with that, but it's a start.

Hey, I wonder how many doctors there are in Texas, anyway? I hear it's a pretty big state, though I seem to recall it consists mostly of scrubland and swamp. Maybe there are only like 500 doctors in the state to start with. Something is tickling my head about Texas, though, I vaguely remember that they had some nice tort reform law a few years ago that I was pretty envious of.

Oh, yeah, here's the source: Doctors Flock to Texas After Tort Reform:

In the last three years, 7,000 doctors have moved to Texas. So many doctors want to practice there that the state has had trouble keeping up with the requests for licenses.

Oh, 7,000. Actually, this guy suggests the numbers are closer to 16,000 new doctors in Texas. So I'm guessing that the loss of 1% of the NEW physicians in the state won't do much to put a fear in the hearts of the Administrator of CMS.

Now this is not to say that there isn't an access problem, because there is and it's only going to get worse as Medicare reimbursements lag inflation, never mind the funny yo-yo games that Congress plays with our livelihoods. But the writer, Mr. Ackerman, missed the point. The headline is not the 300 who have just dropped out of the program altogether, but the many, many thousands (62% of primary care docs!) who are no longer accepting new Medicare patients.

I have never been shy about dropping out of insurance networks that weren't worth my while, but as a hospital-based doc, Medicare isn't optional. You work in someone else's shop and you play by their rules, and if I hinted at dropping Medicare our group would lose its contract the same day (or, more realistically, I would be tossed overboard by my partners, and rightly so.) I can't take part in the glorious Medicare boycott, but I still like the notion of doctors boycotting Medicare on a large scale. Sadly, I just don't envision it happening on a scale large enough to have the impact that is needed.

What is happening is that access is being restricted and that seniors are being squeezed. Doctors are treating Medicare patients like Medicaid and charity patients, creating a few limited slots in their practice for these money-losing patients out of the goodness of their heart, but not enough to meet the demand. This places seniors (and the disabled) in a very bad place when they are looking to establish care or transfer care or looking for a specialist--there is a serious access problem. But it remains low-level, simmering, bad but just not quite bad enough for lawmakers to need to fix it.

In some deep dark part of my heart I've been rooting for Congress to fail to stop the 21% SGR-mandated cut. It's wrong, and I know it. But it sometimes seems like it's going to take a crisis to force the policymakers to get this right, and something like these catastrophic cuts would be just the ticket to blow things up and force Congress to deal with it once and for all.

Based on the fiasco of a process that brought us healthcare reform this year, I'm not optimistic that Congress would get it right, though. So let's just go ahead and kick that can down the road a couple of years! I'm sure the 113th Congress will be much more enlightened and rational than the 111th, right?

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.