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ZOMG! Doctors are leaving Medicare in _droves_ !1!!eleventyone!1!!

Somewhere in comments, lambert asked about this post at a doctor's blog, about an article in the NY Times, Doctors Are Opting Out of Medicare.

NYT:

Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them. Some doctors — often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists — are no longer accepting Medicare, either because they have opted out of the insurance system or they are not accepting new patients with Medicare coverage. The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.

Dr Reece, blogger:

I have a prominent friend, a staunch friend of doctors and long a leader of organized medicine, who has often told me words to this effect,” If it weren’t for Medicare, doctors would have supported single payer a long time ago.” Many doctors simply can't stomach Medicare's policies.

This bodes badly for the future. Some 78 million baby boomers will start becoming eligible for Medicare in 2011; a shortage on internists is developing and is expected to reach 35,000 to 45,000 by 2025; 29% of Medicare beneficiaries are already having a hard time finding a doctor; and only 40% of primary care doctors now take new Medicare patients.

The root problem is that Medicare pays less, usually 20% to 40% less than private plans, depending on the state and region of the country and the paperwork is time-consuming and distracts from care for other patients. For practices having a hard time making a go of it, new Medicare patients are simply not worth the trouble or the expense. Given the current Medicare fee structures, many doctors feel a single-payer Medicare-for-all would put them out of business.

If it weren’t for Medicare, doctors would have supported single payer a long time ago.

Ouch. That doesn't bode well for our chances, nor do I have a good feel for just how true this might have been in the past. But lots of doctors have said recently that yes, they do want single payer now. What gives?

The shortage of doctors taking Medicare, this I've learned a little about recently. This problem has, like many problems, multiple facets [zomg! another hydra!].

Taking the obvious one first, doctors' pay. Dr Reece says that privae insurance pays doctors 20-40% more than Medicare pays. The 40% sounds a bit high maybe [well, maybe not] but according to the Lewin Group's recent report on the much-vaunted "public option" Medicare pays doctors only about 80% of what private insurers pay doctors.

The trade-off is that Medicare hassles doctors much less [don't have to spend hours on the phone haggling over pre-authorization, for example], has less evil paperwork, and pays much faster than do private insurers, thus cutting down on doctors' overhead and providing them with a dependable cash flow. And sure enough, if you tootle around the docosphere, you'll find doctors who are quite happy with Medicare [apologies for the lack of linky goodness].

There are glitches, though.

One of those glitches is [surprise, surprise] Medicare Advantage, aka Medicare Part C, the privatized part of Medicare. Not only is Medicare Advantage costing the taxpayers more than traditional Medicare costs, it's costing doctors more too, and paying them more slowly to boot. And some patients are leaving their Medicare Advantage managed care plans, often citing inability to get care as one of the reasons [that, and costs]. Can't blame doctors for not accepting Medicare Advantage if they think their patients are getting short-changed.

But even traditional Medicare has been causing some problems recently.

One of those problems is my favorite pet peeve, government automatically awarding contracts to the lowest bidder. You do get what you pay for [up to a point]. Medicare has recently redone their contracting [they contract out the administration of their insurance, actually]. Some of the new kids on the Medicare administration block appear to have bitten off more than they can chew, have been overwhelmed, and have been very late paying their doctors, to the point where doctors have taken out loans just to stay in business.

At roughly the same time, Medicare was assigning all their doctors new ID numbers [don't ask] and had drastically tightened the rules for submitting claims, moving their practices to a new address, some other stuff that both the doctors and the brand new contractors were somewhat blindsided by. In this case doctors were again getting paid slowly because of inept contractors, but even worse, doctors were unknowingly violating various of the new rules and getting kicked out of Medicare altogether, often for months at a time.

Dang, after a few experiences like that, I'd believe that government can do no right and storm off in disgust and fury too, but let me just point out that the new ID numbers, new contractors, and new rules are all products of the Bush regime.

It strikes me that if we had Medicare for all, if the pols all had to get their health care paid for by the exact same system as the rest of us, that maybe, just maybe, they'd fuck with it less.

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Salmo's picture
Submitted by Salmo on

I was talking with my brother-in-law, a doctor and clinic administrator, last night about almost exactly that. His state has switched its extended Medicare for kids contractor, who has arbitrarily decreed that the pediatricians have to take a 25% pay cut for about 40% of their practice. Just like that! Well, his rural clinic has already had a vacant position for about a year, which it has been unable to fill because rural areas' doctors salaries don't compete well. This would make it impossible. From the state's perspective, cost go down, but they do so in a way that is arbitrary, capricious, and still obscenely profitable to the insurance company that is getting its lion's share. He suspects that the deal between the insurance company and the state is that they will share what they can squeeze out of the clinics. My guess is that my brother-in-law will do exactly what your doctors are doing, tell the Medicare contractor to take a hike. If the other clinic does this too (and he thinks they will) that will leave about 40% of the Valley's children without pediatricians. That is deeply troubling to him. The business decision is clear, my conversation with him was about his personal and professional response.

As you note, Medicare has a track record of doing this sort of thing. I have had similar conversations with my brother, a doctor in upstate NY. Believe me, saying that doctors hate insurance companies is not an exaggeration. They understand better than almost anyone what part of the health care budget goes to insurance. Because they see both what goes to the insurance company directly, and what it costs to do the billing and negotiate treatments, they generally ascribe a cost for keeping insurance companies as the middleman at around 50% and they almost always add the cost to their patients for truncated medical care. Those 100,000+ excess deaths per year are felt personally by the doctors whose patients they were, and the damaged patients whose lives go on are much more numerous. So, with that background, our discussions about what a single payer plan would look like almost always begin and end with, "Yes, but it can't be Medicare because an arbitrary and capricious government rate setting will destroy my business."

I don't have an answer. We need one though, because not only would widespread support by doctors make the politics of single payer easier, if we actually succeed in getting a single payer system (or even a public option) passed, we will need a better rate setting mechanism than Medicare has used to make the system work.

a little night musing's picture
Submitted by a little night ... on

His state has switched its extended Medicare for kids contractor,His state has switched its extended Medicare for kids contractor,

That would be Medicaid, no?

Not that it matters, in the end; but since Medicaid is just for poor (read: undeserving) people, politicians have felt free to frack it up since almost day one.

Salmo's picture
Submitted by Salmo on

It's actually a state program that extends the coverage for poor kids, and the state Medicare (?) program contracts with an insurance company to administer it. His clinic is already one pediatrician short, they are already overstretched, and the patients are already paying substantially less than others. As I wrote, my role was to be a sounding board while he worked out his options and his feelings about how truly awful were his choices.

Submitted by hipparchia on

medicare originally hired insurance companies to administer their traditional program [basically just write the checks to the doctors and hospitals], and the federal govt is fairly generous in what it will pay for, and how much it will pay.

the privatizers weren't happy with this small concession though, and managed to get medicare to also offer medicare advantage programs, which is where the federal govt buys private hmo insurance for some people, if they choose that. some of the medicare advantage plans are pretty good [though more expensive than traditional medicare], but some are really crappy.

the states are generally very stingy. even their regular medicaid [run kind of like traditional medicare] isn't quite as good as regular medicare, and many states have medicaid plans that border on junk insurance.

Submitted by hipparchia on

if it's about kids, and the states are involved, then what he's probably talking about is medicaid, which is the program for poor folks, instead of medicare, which is the program for old folks.

medicare is a federal program, and fairly uniform wherever you go in the country. it has some glaring flaws, but it's a model of sobriety and stability compared to medicaid. this is the program the hr 676 would shore up and expand to include all of us.

medicaid, otoh, would be allowed to die a quick death [and deservedly so] if when we get john conyers' vision of medicare for all.

the intentions behind medicaid were good -- healthcare for the poorest among us -- but it is literally a ghetto. so easy to demonize the poor for being too lazy to get rich, doncha know. medicaid is a combination federal/state program: the states pony up some amount of money for healthcare for the poor [and they get to decide that amount], then the federal govt gives them some matching funds and sets a few [very few] ground rules on how the $$ is to be spent.

giving states their heads, and the freedom to experiment with public/private partnerships [yay! let's experiment on poor people!] has been such a success. not.

tennessee has long been the poster child for epic fail, and florida recently exported their 'expertise' to louisiana. there are lots of other such experiments, all basically abject failures [except for a few insurance company ceo fatcats who got even fatter].

Those 100,000+ excess deaths per year are felt personally by the doctors whose patients they were

yep. there are a few bad apples everywhere, but people generally become doctors because they want to help other people. the insurance industry [with some help from the for-profit hospital industry] has greatly distorted actual care over the past couple of decades.

Submitted by lambert on

Link, please. The highest figure I heard was 17,000. Where did this number come from?

Submitted by hipparchia on

the 17,000 [18,000 or 22,000 or 25,000 or _____ depending on whose estimates you go with] is the number of deaths because people don't have insurance and therefore don't have a way to pay for needed medical care.

the 100,000 is the number of preventable deaths overall, and can be from lack of access to care, or from medical malpractice, or from poorly run hospitals with too few staff, etc. the countries that have true universal healthcare, whether single payer or multi-payer nonprofits, have fewer preventable deaths than we do, waaaay fewer. there are various hypotheses as to why this is the case.

i'll go look up a cite or 2 for ya.

Submitted by hipparchia on

don mccanne, of pnhp, is my go-to guy on all things healthcare. the article he links to in his commentary is now behind a paywall, but here's the abstract. don mccanne --

Those who still claim that the United States has the best health care system in the world need a reality check. Of the nineteen OECD nations studied, the United States has the highest rate of deaths that “should not occur in the presence of timely and effective health care.”

basically, the argument is that changing the way we fund healthcare would materially improve our ability to deliver timely and effective healthcare.

and here's something with charts! [keep in mind that the commonwealth fund is basically pro-private insurance]. from the commonwealth fund commentary on the same article that don mccanne references --

Many Lives in U.S. Could Be Saved

The researchers estimated the number of lives that could have been saved in 2002 if the U.S. had achieved either the average of all countries analyzed (except the U.S.) or the average of the three top-performing countries. Using this formula, the authors estimated that approximately 75,000 to 101,00 preventable deaths could be averted in the U.S. "[E]ven the more conservative estimate of 75,000 deaths is almost twice the Institute of Medicine's (lower) estimate of the number of deaths attributable to medical errors in the United States each year," the authors say.

Salmo's picture
Submitted by Salmo on

I am related to a lot of doctors. We talk. I am not sure that I will have what I need the next time, but I appreciate the information, particularly from hipparchia.

Submitted by hipparchia on

[i'm related to one doctor and a handful of insurance industry insiders. surely between us, we ought to be able solve all the problems of the world. :-)]

i'm a big believer in making things work for the users of those things. computers ought to do what people tell them to do, cars ought to run, doctors ought to be left alone to practice medicine, patients ought to be able to count on their doctors for care [and on their insurers, whether companies or the govt, to pay], etc.

what your doctor relatives have to say about what works and doesn't work for them is hugely important. thanks for reporting, and i'd really like to hear more. please do come back and tell us what they have to say after your next conversations when you get the chance.

basement angel's picture
Submitted by basement angel on

He had the grades and has some of the best people skills I've encountered - he's very patient and can explain anything to anyone. Every doctor he talked to told him not to waste his time and that they all regretted becoming physicians. They liked the doctoring part of it quite a lot but they all felt that the insurance industry was destroying their ability to take good care of their patients. Not a one of them complained about Medicare, though I know Medicare C is driving a lot of them nuts.

It's really sad. I wonder how many other talented kids got driven away by the doctor's nightmare tales?

Submitted by hipparchia on

we really need kids like him to grow up and become doctors.

i hope he's finding/found something else that makes good use of his talents and that he likes doing [or that he'll revisit his decision once we get single payer!]

Submitted by hipparchia on

yes, that would be cool, getting first-hand reports. i love surfing the internet but it's a bit of a jungle for finding real information.