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A Primary Care Provider’s Dilemma: The Decision to Opt Out of Medicare

We often are asked in our practice, “Why don’t you accept Medicare?”  The immediate answer is simple: we cannot afford to. We opted out of Medicare because the service won’t pay for phone consultations, won’t pay for email consultations, barely pays for an office visit, and does not pay nearly enough to cover a house call.

All of these services are critical to our medical practice. Medicare would require us to hire too many staff, as well as require us to do too much paper work and administration. I cannot afford to invest in either and still manage to operate in the black. Medicare has too many regulations and rules; we can’t understand a lot of them, and frankly, Medicare doesn’t seem to understand them most of the time either.  If I would accepte Medicare, then they have the right to audit our notes and then fine us for non-compliance for infractions that are not readily clear. Their external auditors get paid for every infraction they find which means the temptations for fining doctors are irresistible.

Yet the truest answer as to why we do not accept Medicare is that the service does not focus on what we feel is paramount: practicing effective and efficient medicine in order to ultimately achieve and maintain the good health of our patients. The service’s paltry reimbursement structure coupled with its impossible to-adhere-to regulations doesn’t allow us to offer a complete service to our patients. This complete service includes wellness care as well as the ability to take the time to understand each patient’s unique medical needs and circumstances.

The crux of the issue is that Medicare worries about the forest, in other words, the internal process, money management, reimbursement and policing agreements, data mining, and organizing dozens of internal bureaucracies. These agendas and policing policies help the Medicare service to manage the forest, however these are often in direct conflict with what we feel is key to effective healthcare: taking care of the individual, or each tree.

I do want to make clear that being afraid of audits, punitive actions and the vagaries of no one understanding all the rules is never a reason to leave Medicare — after all, patient care is filled with risk. However, it became clear to me that I, a single doctor voice, dealing with the collective frustration almost all doctors feel when dealing with Medicare (and most insurance companies) had three divergent paths to choose from:

  1. Do nothing. Ignore the conflicts of interest and the lack of patient-centered care and swallow frustration for a paycheck. Just do your best or what Medicare tells you to do.
  2. Work towards reforming Medicare from within through involvement in the process and by working with your professional associations.
  3. Ignore the payers altogether. Work outside the system, returning to the roots of primary care, reforming the business of primary care one person at a time.

Personally, I had to reject Option 1. I was witnessing too many wrongs among my colleagues and for patients. Primary care, a profession I am passionate about and believe in fully, would never have a future under this model. Hoping that things would work out if we just worked harder and harder while blindly submitting to Medicare’s interests and demands meant surrendering my patients’ trust, primary health care’s future, and my soul for a salary. There had to be a better way of making a living.

Working towards Option 2, trying to create reform from within the Medicare system, was nothing but futility on immediate analysis. The ability for me personally to influence the debate for what needs to be done in Medicare for primary care would be a David v. Goliath story without the biblical ending.

In the end I am just one family doctor, that’s what I know, that’s what I’ve spent my life doing and studying. Option 3 chose me. Opting out is financially the riskiest since it requires patients to do something that they have been socialized against for three generations, which is to pay directly for medical services (as they do with nearly everything else in our capitalistic economy). Doctors are well aware that 95% of patients will fire any doctor who refuses to accept Medicare.

This decision meant I might lose my shirt and put my home and small life savings at risk, something thousands of Americans in other professions do everyday. If they could take the risk, then my risk is nothing less than a trivial American story.

The United States was built on this: a country of immigrants fleeing an “old establishment” to build something new. It’s a group of people declaring: “You can’t tax us without representation!” It’s a government that permits us to challenge established norms, challenge power without being jailed or shot. The question today in health care for all of us as patients is will we stampede towards the utopian ideal of  “free care” while ignoring the predictable consequences that nothing is free.

The question put to primary care doctors by Medicare is clear at the moment: Will you let us at Medicare regulate care, dictate “best” treatments and control individual health and choices since we know what’s best. Can you, doctor, be our “yes man?”

Eight years ago I cast my vote and opted out of Medicare. Predictably my journey has not been easy but I have never regretted the decision.

Until next week, I remain yours in primary care,

Alan Dappen, MD


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10 Responses to “A Primary Care Provider’s Dilemma: The Decision to Opt Out of Medicare”

  1. Dr. Bobbs says:

    We stopped taking any more Medicare patients over a year ago. When the government decides to implement scheduled pay increases rather than cuts, reduces paperwork, and stops trying to penalize and criminalize physicians through so-called pay for performance, I'll reconsider my decision.

  2. Dr. Bobbs says:

    We stopped taking any more Medicare patients over a year ago. When the government decides to implement scheduled pay increases rather than cuts, reduces paperwork, and stops trying to penalize and criminalize physicians through so-called pay for performance, I'll reconsider my decision.

  3. whnp says:

    We take Medicare but we are a specialty practice and get paid better rates. Our patients frequently ask for continuing gyn care with our office after their surgeries because they are having such a difficult time finding anyone who takes Medicare.

    Medicare cuts affect our bottom directly as we serve a primarily geriatric population. Having reimbursement cut yearly is frustrating as our staff pay, supplies and rent never head that direction. We'll just have to see how we fare under ObamaCare and any of his future “money saving” efforts.

  4. SpecB says:

    Well, Hallelujah! Medicine the way it should be: Doctor and Patient with no insurance company or government bureaucracy in between. Most doctors' offices have to pay the overhead of a billing specialist to fill out the paperwork to get paid. That just adds to the overall cost.

    One thing you might recommend to your patients is that they get a Health Savings Account (HSA) type of insurance plan. An HSA puts cash in their pockets to pay the smaller expenses without any paperwork, while the insurance is there to pay the bigger expenses.

  5. leishman_md says:

    I was a family doc for 20 years before switching to occupational medicine 11 years ago (board certified in that, too). I applaud any family doc still willing to do it. Twenty years ago, when Medicare outlawed balance billing, I had a luncheon for a few of my more savvy Medicare patients, many of whom offered suggestions, all of which had been forbidden by Medicare. They quickly understood what was going on with Medicare. I continued to see all my Medicare patients but stopped taking new ones. I anticipate a significant shortage of primary care docs should Obamacare take over. Yes, there will be more mid-levels (physician assistants, nurse practitioners)–at least for a while, until they too have had enough. Dr. Dappen, thanks for sharing your thoughts and experience, and kudos for your courage.

  6. fred says:

    density duck

    I'll stop passing my malpractice premiums on to you when you and your fellow voters stop treating me like a lottery ticket

    I have found third world medical practice to be a quantum leap ahead of practicing primary care in the US, I do incrementally much more good and I don't have to worry much about my standard of living or criminal prosecution. In both the US and the country I practice in the overwhelming majority of competant elites elect to use their skills to enrich themselves at the expense of their fellow citizens, the difference is that those few exceptions who apply their gifts to benefit society are appreciated in my little country, in the USA the quacking of density duck is far more common. Not everyone says thank you but in all the years of my practice I have never her the bitterness and entitlement that I hear in the states

  7. johnnhoj says:

    I don't work in healthcare but I really hate to see what the government is doing to the profession. I get the feeling that a lot of Americans don't view the socialization of medicine as the big deal that it really is, which is unfortunate since it could be the difference between life and death. Anytime the government gets involved in the private marketplace it royally screws things up. That might not be a life-threatening deal when it involves food production or the financial system, but medicine is a whole different ballgame. Why anyone would want government involvement in something so essential to an individual's existence is something I will never understand… I just have to chalk it up to pure ignorance concerning the reasons healthcare is so expensive (namely, government interference).

    Also there's no excuse for doctors to be as liable as they are such that they have to carry millions of dollars worth of insurance. Let the free market weed out the good docs from the bad ones. Everyone wins since heathcare becomes cheaper, higher quality, and completely between the doctor and patient as it should be.

    If people want to focus on something “free” then it should be freedom rather than trying to get something for nothing. The latter is just a pure fantasy, while the former is something that all real Americans can sink their teeth into.

  8. drjbowery says:

    We have not had free market “capitalism” in American health care for decades. Certainly not in the twenty years I have been practicing primary care. Supply and demand doesn't work when the federal government is calling the shots.
    An example? Even though we are facing a national shortage of primary care physicians and health care costs have been “exploding”, our real income has been declining steadily. Should a bright young person choose to go into family practice medicine today? Not unless they want to go bankrupt paying back today's school loans with tomorrow's shrinking paycheck.
    Eventually it won't matter what America's doctors decide to do.
    If enough of them opt out of Medicare, the federal government will simply open up the floodgates and allow unlimited immigration by Third World doctors.
    That's how they used to get the cotton picked, remember?

  9. drjbowery says:

    We have not had free market “capitalism” in American health care for decades. Certainly not in the twenty years I have been practicing primary care. Supply and demand doesn't work when the federal government is calling the shots.
    An example? Even though we are facing a national shortage of primary care physicians and health care costs have been “exploding”, our real income has been declining steadily. Should a bright young person choose to go into family practice medicine today? Not unless they want to go bankrupt paying back today's school loans with tomorrow's shrinking paycheck.
    Eventually it won't matter what America's doctors decide to do.
    If enough of them opt out of Medicare, the federal government will simply open up the floodgates and allow unlimited immigration by Third World doctors.
    That's how they used to get the cotton picked, remember?

  10. Ben says:

    I know this is an old thread, but I have to respond to drbowery’s last note. It’s true that we haven’t been operating in “free market capitalism” for years, but the government is only one force that skews the market. The much greater threat to free market capitalism in the healthcare arena is the insurance-model structure of payment. Capitalism is generally a system where the buyer and seller negotiate for goods/services/payment, but we operate in a system where the “buyers” (patients) pay next to nothing for their care and so are incentivized to buy all they can… this means that doctors bill as much as possible and still have a glut of patients. HMOs etc then try to restrain costs by limiting what they will pay for etc and by reducing reimbursement rate… it’s EXACTLY like the Medicare system. Dr Dappen seems to be trying to actually push us into a semi-free-market system (kudos!), but most doctors seem to hypocritically criticize Medicare for it’s anti-market influence while happily accepting “insurance” for even the most trivial of care. The fact is that doctors like money…. they couldn’t care less about the “free market” – which, by the way, would decimate most specialties. Letting more docs in from overseas to compete: that would be free market. Having to issue a bill to your patient for the full amount of your services: that would be free market. Doctors are almost uniformly terrified of the free market.

    Also, while it’s true that the salaries in primary care has taken a beating with respect to most specialists, let’s not cry too hard for our “poor” doctors. The average primary care salary is around $200,000 (for reference, the average med-school debt is $150,000 – so you could roughly pay off your entire debt in one year and still make as much money as the average US family). Doctors deserve to make good money, but they take almost no entrepreneurial risk and have almost no job security issues… so it’s a little hard to hear that they can’t survive on less than 200K.

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