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发帖数: 29846 | 1 Fewer American doctors are treating patients enrolled in the Medicare health
program for seniors, reflecting frustration with its payment rates and
pushback against mounting rules, according to health experts.
The number of doctors who opted out of Medicare last year, while a small
proportion of the nation's health professionals, nearly tripled from three
years earlier, according to the Centers for Medicare and Medicaid Services,
the government agency that administers the program. Other doctors are
limiting the number of Medicare patients they treat even if they don't
formally opt out of the system.
Even fewer doctors say they are accepting new Medicaid patients, and the
number who don't participate in private insurance contracts, while smaller,
is growing—just as millions of Americans are poised to gain access to such
coverage under the new health law next year. All told, health experts say
the number of doctors going "off-grid" isn't enough to undermine the
Affordable Care Act, but they say some Americans may have difficulty finding
doctors who will take their new benefits or face long waits for
appointments with those who do.
CMS said 9,539 physicians who had accepted Medicare opted out of the program
in 2012, up from 3,700 in 2009. That compares with 685,000 doctors who were
enrolled as participating physicians in Medicare last year, according to
CMS, which has never released annual opt-out figures before.
Meanwhile, the proportion of family doctors who accepted new Medicare
patients last year, 81%, was down from 83% in 2010, according to a survey by
the American Academy of Family Physicians of 800 members. The same study
found that 4% of family physicians are now in cash-only or concierge
practices, where patients pay a monthly or yearly fee for special access to
doctors, up from 3% in 2010.
A study in the journal Health Affairs this month found that 33% of primary-
care physicians didn't accept new Medicaid patients in 2010-2011.
The pullback in Medicare acceptance is being felt in certain quarters. Joe
Baker, president of the Medicare Rights Center, said his patient-advocacy
group has had an increase in calls from seniors who can't find doctors
willing to treat them—mainly from affluent urban and suburban areas where
many patients can pay out of pocket if their doctor doesn't accept Medicare.
"In most places, doctors can't pick and choose because Medicare is the
biggest game in town, or the only game in town," he said.
Some experts attribute the rise in defections to Medicare payment rates that
haven't kept pace with inflation and the threat of more cuts to come. Under
a budgetary formula enacted by Congress in 1997, physicians could see
Medicare reimbursements slashed by 25% in 2014 unless Congress intervenes to
delay the cuts, which it has done several times.
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"Medicare has really been pushing its luck with physicians," said economist
Paul Ginsburg, president of the nonpartisan Center for Studying Health
System Change. "By allowing the SGR and its temporary fixes to persist,
Medicare is risking a backlash by senior citizens who say, 'Hey, this
program isn't giving me the access to doctors I need.' ."
Some doctors say Medicare's reimbursement rates—as low as $58 for a 15-
minute office visit—force them to see 30 or more patients a day to make
ends meet. "Family physicians have been fed up for a long time and it's
getting worse," said Jeffrey Cain, president of the American Academy of
Family Physicians. By disengaging with Medicare and other third-party payers
, he says doctors can practice based on what patients need, not what
insurers will pay.
Other doctors are dropping out of Medicare to avoid deeper government
involvement in medicine, much of which is occurring in Medicare. For example
, Medicare is now paying incentives to doctors who switch to electronic
medical records and who send data on quality measures to the federal
government. Doctors who are part of the Medicare program who don't do so
will face penalties starting in 2015.
While the leaders of some large doctor groups have endorsed such initiatives
, Dr. Ginsburg says, "there are a lot of physicians, particularly older
physicians, who say, 'I don't want to do this. Let me run out the rest of my
career practicing like I've always done.' "
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Some doctors are particularly concerned about patient privacy. Earlier this
year, gynecologist Mary Jane Minkin, a professor at the Yale School of
Medicine, opted out of Medicare and the Yale Medical Group when she saw that
the electronic records system displayed patients' gynecological records to
other providers they consulted. "There's no reason the dermatologist has to
know about my patients' libido issues," Dr. Minkin said.
All but 10 of the 70 Medicare patients in her practice have continued to see
her, Dr. Minkin said, even though they must pay out of pocket to do so.
Doctors have three options for dealing with Medicare. Those who participate
bill Medicare directly and must agree to accept its reimbursement rates for
all covered services. So-called nonparticipating doctors still file Medicare
reimbursement claims but can charge as much as 10% over Medicare's rates
for some services, and they must bill patients for the difference. Those who
opt out can charge patients whatever they want, but they must forgo filing
Medicare claims for two years, and their Medicare-eligible patients must pay
out of pocket to see them.
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That prospect rankles many elderly people—in part because they must
continue paying their Medicare premiums or risk losing their Social Security
benefits. Republican-sponsored legislation in the House and Senate would
let seniors use their Medicare benefits to pay doctors privately, but
opponents believe that would undermine the entire system, and the bills aren
't given much chance of passage.
Doctors who don't take Medicare say they don't necessarily raise rates
significantly. Some say not having to submit claims and file mandated
reports allows them to keep their overhead low. They can also adjust their
fees to fit patients' needs.
"We give discounts to teachers and preachers, and anybody who comes in
wearing spurs gets $5 off," said Juliette Madrigal-Dersch, a pediatrician
and internist in Marble Falls, Texas. She says she also treats patients who
develop cancer free of charge. "I couldn't do that if I took Medicare. It's
considered an illegal enticement." Dr. Madrigal-Dersch is president of the
Association of American Physicians and Surgeons, a conservative group that
advocates private-pay medicine. "It's gone from being a fringy, rebellious
thing to a business model," she added.
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When the Mayo Clinic's small family practice office in Glendale, Ariz.,
stopped taking Medicare in 2009, only about 500 of its 3,500 Medicare
patients stayed on. Since then, an additional 250 elderly patients have
joined the practice, paying between $200 to $575 a visit. Physicians say
dropping out isn't easy, and some medical specialties are more dependent on
Medicare than others.
Smiley Thakur, a kidney specialist in Seattle, stopped taking Medicare,
Medicaid and commercial insurance in 2008 and had to resume two years later,
mainly because he stopped getting referrals from other doctors. "Patients
weren't interested in how good I was—they only wanted someone who took
their insurance," Dr. Thakur said. "It's hard to compete with free." |
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