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…doctors out.

For all the fuss I’ve just made about insufficient numbers of physicians (especially primary care physicians) entering the workforce, it’s worth noting that more and more physicians are opting out of Medicare and Medicaid.

Via WhiteCoat comes an American Medical News article featuring a group of physicians across the US who are curtailing their participation in Medicare to various degrees.  The article is short, and it’s well worth reading in full, as are WhiteCoat’s comments at the first link.

The issues with Medicare can be placed under the headings of either “pay” or “administrative hassle.”  The fact (or at least the perception) that some coding errors can result in large fines and possibly prison time doesn’t help either.  Medicare is also particularly restrictive of some aspects of practice management.  Physicians who “participate” in Medicare (more on “participation” later) are not allowed to offer discounts to other patients that aren’t available to Medicare patients; they’re also not allowed to limit the scope of practice for their Medicare population differently than they do for their non-Medicare patients.

There’s a wide range of responses that we see from the physicians profiled in the article.  Some have stopped “participating” in Medicare, some have switched to direct-pay or concierge practice models, some are looking to reduce the number of new or existing Medicare patients in their practice, some are fleeing to hospital-owned practice or retiring early, and one is even considering “opting out of America” by moving to another country.

Medicare has curious terminology to classify physicians.  Having spent far too long looking at Medicare’s regulations and manuals (not the program’s strongest selling point), I can only describe the terminology tentatively.  A physician can accept Medicare “assignment” on a case-by-case basis for most services.  “Assignment” means that the physician will bill Medicare directly, and (as far as I can tell) agree not to bill the patient any amount greater than the Medicare-sanctioned cost-sharing.  “Participation” means that a physician agrees to accept assignment for all Medicare patients.  Participation carries with it some additional restrictions on practice management as described earlier, but also comes with payment rates that are roughly 5% higher than they are for non-participating physicians.

As far as I can tell, there’s no mechanism whereby a physician can bill a patient directly, upon which the patient can seek reimbursement from Medicare up to the amount that Medicare would have paid the physician directly.  I could be wrong (the manual is… dense), but the sense I get is that balance billing and Medicare payouts do not go together under any circumstances.

I’m a firm believer in insurance-free practice for most primary care and routine care.  The article makes clear that some of these physicians are able to continue seeing most of their Medicare patients on a direct-pay/concierge basis, in some cases by providing blanket discounts to some of them (something that likely would run afoul of Medicare regulations for participating physicians).  However, large-scale disavowal of Medicare — something that will be more likely if the SGR axe falls — will leave seniors with dramatically reduced access to care, especially because balance billing doesn’t seem to be available as a middle ground for physicians (please correct me if I’m wrong on this; I very well could be).

Medicaid acceptance among physicians is far worse.  The Happy Hospitalist tells it far more evocatively than I ever could.

Where does this leave us?  There aren’t enough physicians entering the workforce to begin with, but even then, more and more are refusing to accept Medicare and Medicaid.  These programs are intended to be safety nets; however, Medicare isn’t means-tested, and the recent Medicaid expansion is pretty broad.  If society is serious about providing these segments of the population with true access to a health care safety net, instead of insurance-in-name-only, the flight of physicians from these programs is something that needs to be addressed.  Preferably by improving payment rates and administrative practices, not by coercion.

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