I want to expand on the discussion in what I hope will be easy-to-understand terms. Why would anyone who is not a doctor even care what Medicare reimburses their docs? Let me tell you why you might care.
Doctors all have one of four designated categories within the Medicare system:
1) The doc participates and accepts Medicare assignment. The fee for the service is set by Medicare, the patient makes a co-pay and the doctor bills Medicare and gets the rest of the fee from Medicare.
2) The doctor is “non-participating” –which is a deceptive term, because non-participating docs are within the Medicare system. The fee for the service is set by Medicare and is typically 5% less then the fee for participating docs, but the patient pays the Medicare fee in full to the doctor, the doctor files a claim with Medicare, and Medicare reimburses the patient for a portion of the fee.
3) The doctor has formally opted-out. In this case, the doctor charges the same fee that every other patient is charged, the patient pays the doctor in full. No forms are filed to Medicare and the patient receives no reimbursement at all. A doctor who opts out in one setting is opted out in all settings, so one can’t opt out in private practice and also work in a clinic where Medicare is accepted.
4) The doctor never files anything with Medicare. He can not see Medicare patients at all, ever, in any setting. Perhaps he can see patients for free(?), but no money can change hands and no forms get filed. This is not the usual.
The current proposal is for a 30% cut in provider fees for 2012. Oh, we dance this dance every year. But this year, the thinking is that it may stick. As is stands now, the current Medicare fee for a non-participating provider in the area where we live, for a 50 minute psychotherapy session, with medication management, in a non-facility (meaning, for example, a private practice that is not hospital-based) is $120.96. This fee is notably lower than going community rates, and because of this, many psychiatrists who practice psychotherapy have opted out: they can charge what they’d like and they don’t have to deal with the hassles of filing any paperwork. Oh, but it’s not just psychiatrists, some internists have opted out of Medicare. It means that when you hit 65, either you pay your doctor out-of-pocket, or you change doctors.
Currently, it’s hard for patients to find psychiatrists who participate with Medicare, and those who do often limit new Medicare patients. A doctor can come highly recommended, and you may be a multi-millionaire, but that doesn’t matter, because once a doctor is in Medicare as either participating or non-participating, the fee is set by Medicare and being rich doesn’t buy you in, because all Medicare patients pay the same fee.
If the fee drops so that an hour of work is reimbursed at $84.67, a 30% decrease, more psychiatrists will opt out. From the doctor’s point of view, they kind of win: if they can hold on to a big enough patient base, they can charge their usual (generally higher) fees and they don’t have to hassle with claims. From Medicare’s perspective, they definitely win: patients are forced to get care outside the system and they reimburse nothing. It’s not like going out-of-network with your private insurance where they will still pay for services, perhaps at a lower rate or with a higher deductible, but they do compensate for a chunk of the care. Those doctors who remain in the system are those who can make it work for them— they see patients for Pharmacologic Management with a code that does not have a time requirement and cram as many patients in as fast as they can see them. But as SteveMD has pointed out in his comment, when fees drop by 30%, even the workhorse psychiatrists who can go at an exhausting pace of 4-5 patients per hour will be making much less money to provide one-size-fits-all 10 minutes-with-a-shrink care.
From the patient’s point of view: they lose. Suddenly their doctor doesn’t accept Medicare. They now get hit with a much higher fee and they get no insurance reimbursement. This is why you should care.
*This blog post was originally published at Shrink Rap*