Bioethics, medical finance, Medicare, politics, public policy

Medicare Pie Cut Thinner

Think of the money that Medicare pays doctors for seeing patients as though it’s a pie called the “Sustainable Growth Rate.” This pie is not going to get bigger unless Congress cooks some more pies by New Years. Otherwise, when more patients join Medicare and more pieces are needed next year, we will have to cut the pieces that doctors are paid each time we see a patient into smaller and smaller pieces.

I wimped out: I closed my office in 2003 because I saw the costs of the requirements for medical reporting and “privacy” coming and I figured that I could work part time for other people and make more money than I was making as a solo doc. (And I hate the business part of medicine.) I’m not sure how many others are making the same decision, but we often read about “boutique” practices and docs who won’t take Medicare or new Medicare patients. Have you noticed how many doctors in your town are adding things like Botox shots, laser therapy and other cash-pay services?

Medicare will cut doctors’ reimbursement by 10% in January if Congress doesn’t act before the end of the year. This cut is separate from the Veterans Administration, Medicaid and SCHIP funding and is written into the current law. Since many doctors have contracts with insurance companies that pay based on Medicare, the cuts will go even deeper.

If you don’t understand the impact that this cut will have, ask the next person you meet who is over 65 years old whether they had to change doctors when they became Medicare eligible. Ask them whether they have any choice other than to use Medicare and how hard it is to get in to see their doctor.

As I’ve said before, get ready for it to become even harder.

10 years ago, financial advisers told us that Family Physicians shouldn’t have more than 20% of our patient population mix made up of Medicare patients if we wanted to stay in business. Since that time, most doctors have worked harder to be more efficient and have cut out any costs in the office that we don’t need. My colleagues cannot afford a 10% cut in pay, while all of our costs continue to go up.

Primary care docs are paid about $160 per hour for office visits by Medicare. We are more likely to see the patients who have 5 or 6 diagnoses, 10 or 12 medicines to straighten out, and who bring in a family member to each visit. These patients take time. If the payment goes down to $155 per hour, most doctors will not be able to afford the cut.

In order to earn that money, we need the office and furniture, utilities, supplies for the patient room and office staff, at least a couple of staff members to check patients in and assist us, someone to answer the phones, those phones, refrigerators for medications, someone to handle the billing and banking, and all of the fees and insurance that normal businesses handle, like property taxes, slip and fall insurance, fire insurance, employee tax to the State, property tax on the building, furniture and supplies, and unemployment insurance, etc.

Then, we have malpractice insurance, professional dues to the County Medical Society and most likely our State and national AMA dues in order to remain “Board Certified,” State licensing fees, DEA licenses from both the State and Federal systems, hazardous waste disposal fees, CLIA (office lab) fees, and the fees to keep our computer systems that are increasingly mandated by law if we want to be paid the full $160. The new electronic medical records can cost as much as $30-$40,000 per doctor up front and several hundreds to thousands per month.

In addition to these costs, Medicare requires the highest level of reporting, risk and red-tape. This year, there was a planned delay of payment from the Federal government for 2 weeks at the end of October built into the Federal budget to make it appear balanced. There were also unplanned delays when doctors began using the new National Provider Numbers phased in this year as part of the Medicare laws. (A lot of that expensive computer software in the office, at the insurance companies, and at the Center for Medicare and Medicaid Services couldn’t handle the numbers.)

Now do you see why I hate business?

For more information and history, read this article or watch this video from the Texas Academy of Family Physicians.

Please consider calling your Representative to the House, your two State Senators, and the White House and ask them to protect Medicare payments to doctors.

About bnuckols

Conservative Christian Family Doctor, promoting conservative news and views. (Hot Air under the right wing!)


8 thoughts on “Medicare Pie Cut Thinner

  1. >What's the situation if you are over 65 but are continuing to work and have full insurance through your employer, the same insurance you have always had? Does anything change just because you turn 65?

    Posted by Lydia McGrew | November 28, 2007, 8:23 pm
  2. >Medicare is still the limiting factor. Doctors cannot charge Medicare eligible patients more than the medicare fee. If you're working, your working insurance is "primary," meaning they pay the deductible in most cases, but Medicare tells everyone how much is "allowable." In the '90's, the law changed so that docs who don't "participate" must still file the paperwork for the patients and actually get less from Medicare. I believe some do it because they are allowed to charge the patient the full Medicare allowed fee at the time of visit and the reimbursement goes to the patient. The cash helps, I guess. However, these docs risk audits that cost thousands (Medicare doesn't pay for the audits, even if nothing is found.) We all risk charges of "fraud and abuse" if we forgo copays and deductibles for even our poorer patients. For the indigent or poor patient, we actually are supposed to get and document some sort of financial statement.

    Posted by | November 28, 2007, 8:33 pm
  3. >After the "baby boomers" retire and go on Government Medicare, doctors will be a little better off than US tesxtile workers- low pay, hard work. The public will suffer. I wonder what the average life span will be after the liberal socialist take over medicine? mAYBE ONLY 65 (OR LESS).

    Posted by billbe | November 28, 2007, 9:28 pm
  4. >Will the doctor tell you, "The reason you can't get such-and-such a treatment is that it would cost more than is allowed under Medicare," so that you can try to find some way to use your own money and get around that problem? Or do most doctors just not mention limitations to your treatment caused by the Medicare-eligible payment limitations?

    Posted by Lydia McGrew | November 28, 2007, 10:25 pm
  5. >Some days I'm convinced that we will be drafted.

    Posted by | November 28, 2007, 11:27 pm
  6. >We have an increasing amount of patients that continue to work past the age of 65 who have BC/BS as their primary and do not use MC as their secondary. Are we supposed to charge them MC pricing even when MC is not involved? Also we are not in the BC/BS PPO plan. These patients continue to come to our physician because they have been coming here for the past 25 years and know they can trust him. As a courtesy our doctor will charge the patient the full price, file the insurance forms for the patient and then write off whatever their companies will not allow but is that the legal way to do this? From what I have been able to see, the insurance companies almost always allow more than MC allows however, they always apply the allowable to the patients deductible because we are not in their network.I would greatly appreciate any advice on this matter, as I haven't been able to get the answer from MC or by doing a Google search.

    Posted by Karen B | September 10, 2008, 3:00 pm
  7. >I'm not an expert – no one is – but as I understand it, any one who qualifies under Medicare part A should be charged under Medicare regulations. For those docs who've opted out, that means you have to make a contract with each patient and the doc can never charge Medicare for their care – or for anything or any one else's care – for 2 years.For participating docs, BC/BS will know that MC is secondary and will pay according to your contract with BC/BS. From my limited understanding, the max legal charge for non-participating docs is 115% of Medicare's limiting or allowable charge.There's some sort of variance for people who belong to HMO's like Secure Horizon. I was told that if I didn't participate with SH, I could charge regular cash-pay fees. But I was too chicken. I stuck with the MC charge.And now, you know at least a bit about why I don't have my own practice any more and work for other people these days.What we end up with is that Medicare is

    Posted by | September 10, 2008, 4:38 pm


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