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Primary Care Physicians Are All One Breath Away From Dropping Medicare

I am going to state something that is completely obvious to most primary care physicians:  I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business.

In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance.  If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit.  This is totally obvious to me, and I suspect to most primary care physicians.  A huge part of our overhead comes from the fact that we are dealing with insurance.  A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge.  As it stands, the percentage of my collections that goes to overhead is between 50 and 60% (depending on the month).  A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing, and documenting.  If I dropped insurance and charged a fixed amount, I could:

  1. Cut my billing staff nearly to zero (someone would still have to do bookkeeping).
  2. Increase my payment per visit, which would allow me to see less patients per day.
  3. Document for the sake of patient care, and not for the sake of getting paid.
  4. Add extra services like email access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid?  Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me.  There are several reasons why this is possible for insured patients:

  • Insured patients generally have the option of filing for their own insurance (there are some that still don’t allow this, but that number is dwindling with the decrease of HMO’s)
  • Insured patients could choose to just pay me cash if they choose

Can’t Medicare/Medicaid patients do this?  No, for several reasons:

  • If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files.
  • If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered).  So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud.
  • If I drop M/M, I cannot sign up for it again for 3 years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still?  Why would I continue to make my life so difficult?  Two words: duty and calling.  I view my seeing M/M patients as a social responsibility (especially Medicare).  These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income.  So far.

Plus, I just like to take care of the elderly and the poor.  My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need.  If I dropped M/M I would reject the calling for personal gain, which is something I can’t do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care.  The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system.  I am personally willing to continue on this course as long as (it doesn’t get too much worse) but I have complete sympathy for PCP’s who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP’s.  PCP’s keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital.  The system is just holding on with the PCP’s we have; decreasing that number would be devastating and perhaps fatal to the system.  It’s a very bad sign when the best business model for PCP’s is to do something that, if done by all PCP’s, would wreck the system.  Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors!  They have to earn less money!  They have to actually have a conscience!  What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle, and live by my conscience.  At this time, most PCP’s accepting M/M are doing the same.  But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish.  Pushing down M/M payments for PCP’s will make a bad situation worse.

That’s bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

*This blog post was originally published at Musings of a Distractible Mind*

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6 Responses to “Primary Care Physicians Are All One Breath Away From Dropping Medicare”

  1. Gene O. says:

    Here’s a related story out of Wichita, Kansas:

  2. Robert says:

    Very sad that Medicare patients, those who probably need health care more than any other group, are getting dropped due to business and politics. Kudos to you, DrRob, for continuing to accept Medicare patients.

  3. No durable system can require extraordinary decisions made by extraordinary people for its survival. Your present circumstances provide an example of what medical students are choosing to avoid. You might function for a while but our succession planning is problematic.

    This is simply a study in selection pressure and evolutionary principles, not moral principles. Either the rules change or PC goes the way of the Dodo bird.

  4. Rob says:

    Contrarian: That is exactly my point. A system that relies on the self-sacrifice of its participants is destined to implode. If the system does not change, I may just be forced to abandon my principles to take care of myself. If someone like me leaves, the system is dead.

  5. Marlee says:

    Dr. Rob:
    I think you make a very salient point, that is, physicians are suffering personally to uphold what you referred to as a “duty or calling.” Part of what I try do with my clients is to help them bridge the gap between profitability and meeting their calling in the practice of medicine. Do you believe it feasible to run an insurance free practice on the whole, yet accept M/M for a limited number of patients to be a happy medium?

    Much like attorneys allocate a specific number of hours per year to pro bono work, do you think physicians could view accepting M/M as though it were limited “pro bono” (say 750 patients max per year), while offering fee for service care to insured and out-of-pocket patients? Is that something that would resonate well with you? Is there anything prohibitive of that structure? Your insights are appreciated.

  6. Rob says:

    Yes, I think it is possible; it’s really tempting, in fact. But that type of practice can’t become the norm, or the system will fall apart. My choice will impact my patients, but really my choice being difficult is a sign that the system is on the verge of failing. That’s a message Washington needs to hear.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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