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:
- 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.
- Work towards reforming Medicare from within through involvement in the process and by working with your professional associations.
- 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