The Corner

A Few Doctors Weigh In




The providers have been maneuvering to deal with Medicare reimbursement for several years now. For example. I am a member of the American Geriatric Society, physicians whose patients are all Medicare beneficiaries. I was at the national convention in Chicago last month. 


Most geriatric medical programs are subsidized by academic centers since Medicare reimbursement isn’t enough for a physician to live on considering overhead, etc. Practice management consultants recommend that internists have no more than 11% Medicare in their practice. 



There was a woman physician at the convention and I attended a small seminar session with her. She is the only geriatric fellowship trained physician in central Iowa. She is also one of the very very few in private practice. She had dropped out of Medicare as a provider and now charges a cash fee to see patients. She is doing fairly well, so far. I called Senator Grassley’s office and suggested they find her and get her input on the “reform” bills. Her objection t Medicare wasn’t just the fees, low enough, but the harassment she was getting about seeing patients more often than Medicare allowed. There have been a couple of prosecutions of physicians in the east for seeing Medicare patients more often than Medicare guidelines, whether they needed it or not. You cannot take Medicare payment for some visits and cash for others. That s illegal. So more and more physicians are just dropping Medicare completely.


I know of orthopedic surgeons in Orange County, CA, where I live who are now dropped out of Medicare and practice on a cash basis with Medicare patients. One, the busiest hip replacement surgeon in Newport Beach, charges $1200 for a hip replacement cash. NO Medicare. The patient can use their Medicare for the hospital, as long as hospitals continue to accept Medicare. For years, physicians have treated Medicaid patients for free, deeming the billing not worth the payment. 


Naturally, they don’t advertise this fact but it will bite the system when they put all these people into the new program, whatever it is. I suspect there is free care totaling in the billions being given to avoid the hassle of Medicaid billing and poor reimbursement. I know of other orthopedic surgeons who are just dropping out and practicing for cash.


Another trend is “boutique practices” in internal medicine. The physician will charge a monthly fee for unlimited care as needed during the year. That allows them to treat a smaller number of patients, say 600 total, and provide personal care. Once again, this will be only available for the affluent. Soon, to see a good internist, a patient will have to pay cash.


We may actually be seeing some evolution to a market system for doctor’s fees. Of course, the poor, as usual, will get screwed because the good surgeons and internists will not be in the system. There will be mills, like the workers comp mills, for those who rely on Obamacare.


My partners and I are urologists in California.  We bailed out of Medicaid years ago….not only were the payments insultingly low, but some civil rights office either at CMS or Justice decided that patients were entitled to healthcare in their own language.   This meant paying $4.00/minute to an ATT operator for an office visit that paid about $25.  Medicaid fraud is rampant because, absent fraud, you go out of business.

 Although it would be difficult to do without Medicare or other insurance in our urban locale the same cannot be said for most of the country.  About 1/3 of counties in the US are without urologists.  The urbanization trend occurred for a lot of reasons, not least being the economies of scale in single specialty practice and improved quality of life partners afford. Doctors moving into those communities tend not to accept insurance.  They, for now, accept Medicare, but it would be simple enough to quit.  I doubt that any sort of “reform” will save overall costs, they will just be redistributed more evenly throughout the country.

 The question is how bad does it have to get?  The answer I believe will vary by specialty.  Pediatricians and OB are dominated by younger  part-time women practicing as second incomes.  They will take what they can get.  My field is pretty old (I think the median age is over 50) and predominantly male.  My observation is that urologists, and surgeons in general, quit when the lifestyle drops below the haute bourgeouis. 

 When they do leave, it tends to look like a cooperative phenomenon.  The hospital administrator wakes up one day and there aren’t enough surgeons to cover the ER, so a service the hospital was provided gratis now costs $1,500/day (general surgeons) or as much as $4,000/day (neurosurgeons) and is provided by doctors with no local allegiances.


Another e-mail:


I can back up your physician emailer’s point about refusing to take Medicaid payments because of the hassle.  My dad is a dentist (still working at 70), and he’s never taken a dollar from Medicaid.  God only knows how many patients he’s treated for free over the years instead, but he’s never turned anybody who needed treatment away.  It was never worth the aggravation to get the government’s money (much less having to hire another staffer just to do the paperwork).


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