By S. SMILEY THAKUR
GUEST COLUMNIST
Physicians have been keeping a secret from you: The practice of medicine simply isn’t a viable business. This reality affects not only the availability of doctors to care for patients, but also the quality of delivered care. After 10 years in full-time clinical practice, I decided to stop accepting Medicare and all private insurance. Such a move seems illogical to physicians and patients, but was made to preserve patient access to quality care. Physicians who don’t come to the same conclusion risk going out of business.
The doctor-patient relationship is suffering. While much attention has been paid to the uninsured and a universal health plan, those are not the core issues. What good is insurance if it doesn’t cover the cost of providing care or if no doctor takes it? What good is universal health care if doctors have left the profession?
Relevant, but beyond the reach of individual patients and doctors, is the larger ethical issue of participating in a government program that expects young workers to pay for the care their elders.
Medicine is a calling. We want doctors who are accessible, good listeners and inquisitive thinkers. Unhurried, on-time visits and house calls, however, all seem antiquated notions as they’ve been dropped from the doctor’s medical bag long ago. How doctors interact with patients has changed substantially since 1966, the year Medicare started. Patients notice the doctor is always late and visits are hurried. Ever wonder why your primary care doctor doesn’t come see you in the hospital? And where have all the one-doctor offices gone? Have you ever tried to find a doctor who takes your insurance but had difficulty?
Patients should be concerned about their access to an adequate supply of physicians. In Washington, 57 percent of physicians either don’t accept new or take any Medicare patients; 45 percent of Washington physicians are older than 50, an age group that is limiting the size of their practice. Some sources estimate the shortage of physicians to be between 96,000 and 200,000 by the year 2020. Doctors are soon to be in short supply.
Medicare and insurers have a coercive relationship with doctors. Physicians must sign contracts with Medicare in order to get reimbursed for services provided to this large patient population. There is no negotiating a rate with the government. When dealing with insurers that cover thousands of lives, the physician similarly has little bargaining power. Physicians are barred from joining together as individuals to negotiate collectively as that is viewed as anti-trust. That impels individual physicians to merge into large groups in order to negotiate with insurers.
Doctors must accept what Medicare states is the value of their services. That is known as price fixing. The amount changes annually. Only face-to-face time is considered part of the chargeable visit. Other essential services to facilitate patient care, such as phone calls, and coordinating care, are considered included and are thus unpaid work that occurs after the patient leaves. Government and private insurance intrusion in the form of documentation, coding and billing requirements, are just some of the unfunded mandates doctors are struggling to satisfy. It is easy to understand why doctors rush patient visits in order to budget time for those tasks.
From a physician point of view, it is difficult to be intellectually curious when time is pressured. Conscientious physicians who ask questions and listen are rewarded with a lengthening workday. Many primary care physicians turn hospital care over to hospitalists, as there isn’t time to manage the office and hospital simultaneously. Thus, how care is financed has a direct effect on how patients can access their physician in the office and hospital.
Physicians yearn for relief. Medicare reimbursement in Washington is 42nd (lowest) out of 50 states. Some physicians support a universal health plan, believing getting paid something for their service is better than nothing. This bypasses the essence of the problem: Physicians lack the ability to determine the value of their own services. That is the root cause of physicians not being able to keep up with expenses and distinguishes our profession from all others.
Doctors follow the health of the Medicare system with concern. Medicare was set up initially as a safety net, but has now become the standard level of payment for service. Physicians typically have 30 percent to 70 percent of their patients using Medicare as their primary insurance. The Medicare Part A (hospital) fund will go bankrupt by 2018. Part B reimbursements will decline coupled with rising costs of providing service. The Medicare Trustees Report of 2005 projected a cumulative 28 percent decrease in reimbursement from 2006 to 2014. The projected cost of providing medical care, however, would increase by 22 percent. Thus physicians find themselves in the unusual position of having to shield themselves from overexposure to Medicare patients.
Certainly Congress did step in to avert the planned cuts of January 2007, January 2008, July 1, 2008, and July 15, 2008. The last cut (10.4 percent), however, was delayed only when the American Medical Association lobbied Congress with physician surveys indicating 60 percent of physicians would stop taking new Medicare patients if it went through. There is now an estimated 20.5 percent cut projected in 2010. It is hard to imagine any business planning growth when such large reimbursement uncertainties occur on a yearly basis.
Physicians know they are beat in the reimbursement solution to this problem. Their costs go up and contractually they can’t charge (balance bill) the patient to cover the shortfall. Physicians are also prohibited from accepting additional payment offered by patients. Physicians have two options. The first is to see more patients: Do 14 hours of work in 10 hours, and be paid for eight. The other is to stop taking new Medicare patients or withdraw services entirely. The Medicare card thus becomes a liability to patients who hold it.
Physicians turning away patients is only part of the physician access problem. Competitive demand among seniors will grow. As of 2004, there were already 775,000 Medicare beneficiaries in Washington. According to a 2005 state Department of Health report on primary health care access, about 400,000 will join between 2010 and 2020. More patients but fewer doctors.
The solution is to focus on the doctor-patient relationship, as it was before 1966. When the physician’s contribution was considered a service, not a right. As a service, the patient and doctor mutually could agree on a value. Compassion, availability, experience, skill, and price would determine the value of a physician. Patients who didn’t perceive value could simply go to another. Physicians and patients would be also be freed from “choosing” each other solely on the basis that they were on the same insurance panel.
It is our calling to serve the needy. Contracts, however, dictate a physician isn’t allowed to discount his fees unless he’s prepared to offer the same discount to all his patients. Such an arrangement denies the physician the ability to provide charity on a case-by-case basis. If freed from those limitations, doctors would be free to provide charity. For example, I accept donations to a local food bank from some patients, in lieu of payment.
When you purchase health insurance, you are actually prepaying for health care. The difference between the premiums you pay and the costs you generate is profit for the insurance company. This is not how insurance was meant to be used. One should purchase insurance to cover for an unexpected, undesirable event that has catastrophic consequences. If one insured his car the same way as his health, gas and oil changes would be included. Those who bought it would use as much gas as possible as it was already prepaid. Premiums the following year would rise predictably. Car insurance would become unaffordable. We need to rethink what we want from insurance companies. Patients need to seek out policies that mitigate catastrophic risk and use the savings to pay for care they direct themselves, without a gatekeeper. Health savings accounts may be such an option.
Aren’t patients who’ve paid into Medicare for decades in the form of payroll taxes entitled to receive a benefit? It falls on the lone physician who stands between the patient and his entitled service to deliver the bad news. There is no “fund” to pay for expenses. The elderly are receiving care paid for by the taxation of younger workers. This is a pyramid scheme that would be illegal if run by private citizens. There will be a day of reckoning. Physicians can no longer pretend that the current Medicare and private pay insurance care systems are adequate to deliver quality care.
Patients too are realizing the failed promise of Medicare. Price fixing of physician services will lead to shortages and queues. One only has to remember the long lines for $1 gallon imposed in 1979. Staggering costs will ensure rationing will continue. This takes the form of patients requiring preauthorization (gate keeping) for procedures and medications, or outright denials. Medicare premiums will continue to rise.
Physicians have learned the political will exists only to delay the problem for another party to solve. This is like debating which antibiotic to use on a cancer when the solution is a scalpel, and the will to use it. Insurers must stop interceding in the doctor-patient relationship. Insurers add nothing beneficial to this interaction. In medical terms, they are a parasite. The insurer should serve the patient, who pays their premiums, directly. If a competitive marketplace for insurance across state lines is created, patients who don’t perceive value, may switch to another insurer.
The Medicare program is a broken business model. Physician shortages are occurring as a result of price-fixing. Patients are losing access to their physicians. Therefore, holding insurance or Medicare cards doesn’t equate with access. By opting out of all government and insurance contracts, physicians can interact with patients directly. Competition, transparency and the lack of government/insurance company interference will permit doctors to remain accessible to their patients. Knowledge and planning provide for more options. Hoping for another Congress bailout in 2010 is not an option. Doctors know that. You need to as well.
Source: www.seattlepi.com
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