When the docs in my area began dropping Medicare, their patients had no where to go but to the docs like me who still participate in the plan.
And so, over the past year or so, I began seeing more and more new older patients in my practice. The shift in my practice demographic was almost palpable as these new Medicare patients began filling my appointment book months in advance for routine annual visits. Add in a few retiring docs, and the influx of older women became too much to ignore.
On the day I saw seven new Medicare patients, all coming from the practices that had stopped taking Medicare, I knew that I had to do something.
The Practice Impact
Now I already see more Medicare than most of my colleagues in 0b-gyn. I’m known for managing menopause, and that tends to draw an older crowd to start with, who move into Medicare as they age. Plus, I like the older patients, and almost went into geriatrics at one point.
But this was getting to be too much. The Medicare patients were taking all my new patient appointments.
You see, unlike younger patients, Medicare patients usually call far in advance for their appointments, and fill up my new patient slots for weeks to months at a time. That leaves no room for the 25 year old who just moved to Manhattan and needs her pills refilled within the month, the 35 year old who thinks she is pregnant, the 45 year old with hot flashes who can’t wait till March, the Italian tourist with the UTI or the 16 year old whose mom just found out she was having sex. If I don’t have the slots to see these patients soon, they’ll find someone else who does.
These younger patients provide the variety that drew me to this field in the first place – the opportunity to care for women at all stages in their reproductive lives, with medical problems that change with each decade. My research arena is contraception and std’s, and that means younger patients. I especially love the teens, and ran the adolescent gyn and teen pregnancy clinics at my former jobs. I really missed seeing these patients in my practice as the older patients began taking all the new patient appointments.
What are the financial impacts? Well, if the visit is medically complicated, Medicare pays reasonably well for my time, although it’s still less than half of what I get from managed care for the same services. At current volume levels, it’s not that much of a problem. But if Medicare were to increase much beyond that, it could impact the bottom line significantly.
And finally, I have to be honest and admit that my temperament is not suited to seeing a large volume of elderly patients in one day. I can’t stand having patients waiting in my waiting room because I am behind. Older patients just take more time per visit, no matter what the reason. I can handle a few Medicare patients a day, no problem. But more than, and I am guaranteed to get behind on schedule. And that stresses me to no end.
In response to this rapid change in my practice demographic I advised my staff that if a non-Medicare patient called, for whatever reason, she got offered an appointment immediately, even if it meant adding her onto the beginning or end of an already full day.
I thought that would solve the problem.
But after a few months, it became clear that this was not working. New patient slots continued to be filled months in advance by the Medicare patients.
So I put a moratorium on new Medicare patients except those referred by colleagues for a problem. I am continuing to see my current Medicare patients, as well as my own patients who transition into Medicare.
I feel terribly guilty about all this, but it’s working. I’m seeing more and more new younger patients. The Medicare new visits are still coming, but on a more limited basis, and overall Medicare now comprises about 20% of my visits. Which is fine for now. This solution is working for me and for my current patients, as well as for my referring docs.
Of course, it’s not working for those women out there still looking for a new gynecologist.
I’m a social worker who works with seniors here in NYC & I’m just wondering: Why would doctors drop Medicare patients? Seniors are the biggest growth demographic & they are very loyal to their doctor…. and it’s wonderful when we find one for them who understands (and prescribes for)their specific issues.
I can understand your reasons… but if you could fill me in on the “bigger” picture I’d be most appreciative…
ALM-
It’s a good question that would take another huge post to answer. The short answer is that Medicare reimburses low amounts compared to other payors, requires enormous amounts of paperwork,and for docs in primary care, does not come near to covering their costs for providing services.
Just start read other doc blogs and you’ll get the picture.
Thanks for visiting, and for all that you do.
TBTAM, I understand your “feeling guilty”. I opted out of Medicare/Medicaid more than 10 yrs ago when the reimbursement for breast reductions, reconstruction, and mole excision (those were the three most common things I saw for those insurance patients) go so low that I was actually “paying to take care of those patients”. I ran the numbers and my small office couldn’t continue to take them. I’m grateful to my mom’s doctors who do take Medicare. I hope we figure this out.
I think this is an argument for single payer universal health care. With the money saved on bureaucratic salaries, middle management and office workers to process billing, it would have to lead to higher reimbursements. Especially if physicians are involved in writing the legislation, as they should be in areas concerning health.
The last time (7 years ago) I saw my Gyn in the US, without insurance, the office visit was over 350.00.
The same visit here, without insurance, is 30.00 Both numbers are a bit off in my opinion.
Now you have reminded me that I will be looking for a new one again, after the move… Sigh.
Do you make house calls? In France? I’ll feed you….
I think this is an argument for single payer universal health care.
So, Hilary, you are saying that because the single payer universal system is failing in Medicare, it should be used for all patients? This does not make sense.
With the money saved on bureaucratic salaries
Sigh. Apparently you are unfamiliar with the bureaucracy that surrounds Medicare, especially in the physician’s office.
Hiliary, that was an uneducated statement. Medicare is single payer for the elderly. And look where it has brought us. To a doc who doesn’t take it. Unless you are suggesting that by going to single payer docs will have no choice but to accept it. Is that what you are wishing for? Forced servitude?
I’ve worked at staying healthy all my life…diet, weight, vitamins and exercise as well as maintaining a healthy mental outlook. That’s where I spent money. Now, at around 70, things have happened, not too surprisingly. When I relocated to another state, I found a family doc who takes Medicare, saw him the once two years ago. Recent need for specialialists got me a urologist who sees Medicare patients. At the first visit I thanked him for seeing me (no other insurance) and he seemed embarrassed, but I do know, from reading medical blogs, the hardships imposed by the system. I’m ashamed that I did not foresee all this during my working years, raising my family, and prepare better. At least I have savings so that I can pay immediately what Medicare doesn’t pay.
TBTM, I applaud you for insisting on keeping room in your practice for younger women. They are in as much need for you as older women, and it will be healthier for you to have such a varied practice. After all, too, we elders have children and grandchildren who we want also to have the best medical care.
I have written often to my critters in Congress to enlighten them about the damage they are doing to their voters (for now) with this business of squeezing down the Medicare payments to doctors. And I insist that others do the same instead of complaining. I thank God each day for my doctors.
timely post. the last few weeks, since my mother had a debilitating stroke and a series of other serious health problems, i’ve suddenly plunged into the world of geriatric care. long story short, i contacted an old friend who is a geriatric psychiatrist, and he has been telling me about the enormous burden that medicare places on private physicians. he has moved from the area where my mom is, and it appears there are no geriatric psychiatrists left there, and he and his old office-mate know of no local psychiatrists who will take medicare patients.
of course, the insurance picture is bad all around for mental health professionals, i think. a lot of mental health professionals in my area don’t even take private insurance, because the coverage is terrible and the for-profit companies dispute claims all the time.
TBTAM–great post!! Glad you did what you needed to, to retain your sanity. I strongly believe we have to manage our practice panels (of patients) so as to maintain satisfaction, our interest, and avoid burnout.
Unfortunately, I believe things will have to get much worse before our politicians start doing the hard work of devising a different way to pay for healthcare.
A very interesting post.
Since we’ve been discussing Medicare and payment for physicians on thehealthbeatblog.org,
I quoted part of your post for my readers-sending them back here to find out how you ultimately solved the problem.
It sounds like a fair solution–as someone said above, younger patients need you too, and you’ll probably serve everyone better if you have more variety in your practice.
But the larger nationwide problem can only be solved if Medicare revisits its fee schedule, and lets an unbiased panel (say, physicians who work on salary, not fee-for-service) adjust payments.
Medicare does overpay for some services of questionable value (i.e. we’re not certain whether or not they are effective) while undepaying for others–particularly “cognitive medicine”–
talking to and listening to the patient.
I agree with those who say that we
shouldn’t just roll out “medicare for all.” First we need to reform Medicare, making coverage more rational, based on medical evidence.
We need a compative effectiveness institute that provides unbiased head-to-head comparisons of treatments and drugs, to show what is most effective.
Medicare needs to stop overpaying for drugs . . .I could go on, but the bottom line is that if Medicare spent its dollars wisely, then it would make sense to offer it as an insurance option for everyone.
Congress knows it is going to have to do something about Medicare. The recent vote –cutting back on Medicare Advantage and cancelling across-the-board cuts in physicians’ fees was encouraging.
Our US doctors are the best in the world, but they are the worst businessmen. The worst thing they ever did was to turn their practices over to the MBAs, and it has been downhill ever since.
It will not stop until all physicians are employed by the local hospital. And then they’ll control (or attempt to control) admissions and testing through productivity bonuses. You’ll be admitting and testing not on the basis of patient need, but on the basis of keeping your job. And if you think insurance company gatekeepers were bad, wait until your actions affect the hospital’s bottom line.
Don’t like it?
Then change it while you have a chance. The best thing that could happen to the physician profession is the Medicare-for-all plan by John Conyers (HR676). Let’s eliminate the 31% of insurance bureaucracy waste and spend it on doctors, nurses and hospital care instead.
It never ceases to amaze me, the amount of energy that can go into a project just to avoid doing the right thing. The best, simplest, least costly, most effective thing we could do is expand what has been working so well for years, Medicare. You get sick, you get care, and the caregiver gets paid. Nothing could be simpler.
“America will always do the right thing, but only after everything else fails.” Winston Churchill
Jack Lohman
http://MoneyedPoliticians.net