GOVERNMENTOpting out: Physicians exiting Medicare programFrustrated with Medicare, some physicians are leaving the program or refusing to take new enrollees.By Kathleen Phalen, amednews correspondent. June 25, 2001. Michael Schlitt, MD, might be a trendsetter, at least when it comes to Medicare. The Seattle neurosurgeon decided to drop out of the program 10 years ago. Fed up with what he viewed as government arrogance, a growing distrust of physicians and new payment equations, Dr. Schlitt decided it would be easier to treat Medicare patients for free. He once performed brain surgery for $1. "I have a beautiful three-foot-long and three-foot-tall boat a patient made and gave me for payment for surgery," he says. His decision has not hurt his practice or his patients, something he says doctors worry would happen if they leave Medicare. "To my knowledge, I have never denied care to anyone who needed it," he says. "I was more than compensated by the freedom to make the right decision for my patients and the relief of getting the government out of my operating room." Now it seems as if many other physicians are following in his footsteps. Mired in thousands of treatment codes and pages of regulations, physicians are feeling overwhelmed and overburdened, they say. Administrative headaches, along with complicated reimbursement formulas, lowered or denied payments for certain services, and the threat of fraud-and-abuse investigations, are leading some physicians to say, "No more." The government says its figures don't support the contention that doctors are rejecting Medicare. But studies and anecdotal evidence indicate that in many urban areas, including Denver, Atlanta, Austin, Texas, and Spokane, Wash., elderly patients are having difficulty finding physicians and are getting shuttled from doctor to doctor until they come across one willing to accept Medicare. Studies in Colorado show that 40% of family physicians will not accept new Medicare patients. "The problem is that many doctors have closed their practices to new Medicare patients," says Marilyn Rissmiller, program manager of the health care financing department at the Colorado Medical Society in Denver. In Denver, barely 15% of doctors take new Medicare patients. The Assn. of American Physicians and Surgeons says about 77% of physicians nationwide are accepting new Medicare patients. There are growing fears that many of the 39 million elderly now covered by Medicare will be left with few options. "In some places, if there is no primary care doctor, patients will end up in the emergency room for routine care," Rissmiller says. The road to regulationWhen Medicare was passed 36 years ago, there was initial, and sometimes vehement, opposition by doctors because they feared government intrusion. Still, most voluntarily agreed to the terms. But with each passing year, physicians say, the rules changed, the government's reins tightened, and by the 1990s doctors were feeling more than a little disgruntled, their earlier fears realized. "Everybody was willing to accept the concept of providing for the health care needs of the elderly," says Richard Corlin, MD, a gastroenterologist in Santa Monica, Calif., and AMA president-elect. "But we didn't realize that the rules would be so arcane, absurd and inconsistent that any technical violation is considered fraud."
39% of physicians in an AMA survey identified "certificates of medical necessity" as the greatest Medicare problem.
Two of physicians' biggest complaints are the paperwork burden and complex Medicare rules. Lawrence Huntoon, MD, a neurologist from Jamestown, N.Y., keeps an eight-foot-tall and 186-pound stack of correspondence with the Health Care Financing Administration in the back of his office. "I call him little Frank," says Dr. Huntoon, a reference to Mary Shelley's Frankenstein. "I spend as much time on bureaucracy as treating patients." There are more than 7,000 medical treatment codes, says Dr. Huntoon, who treats Medicare patients, but is nonparticipating. "There's a code for injury that occurs while riding an animal that collides with another animal, a code for injury from being pecked by a bird, and a code for injury due to a fall from a spacecraft, flagpole or commode." One of Dr. Huntoon's biggest beefs is with advanced beneficiary notices. He routinely performs two different ultrasound procedures on the same patient. When Dr. Huntoon billed for both procedures, ABNs went to 100 of his patients, warning that their doctor may have broken the law by billing for both procedures. "I went through nine months of appeals; I won every case," he says. "When I proved the services were necessary, and Medicare agreed I did nothing wrong, they refused to notify my patients. Many won't come back." Physicians also include payment among their Medicare concerns. For example, Colorado doctors get paid about 20% less than physicians in Los Angeles or New York for the same services. Many say they are losing money. But one of reasons nearly half of Colorado's family doctors are limiting the number of Medicare patients they will treat has to do with fear of fraud-and-abuse audits and huge fines or legal costs. They are not alone. Dr. Schlitt says he worries about the law and hidden rules. Because of changes in the law since he dropped out of Medicare, he is required to bill the program for some patients. He has spent about $30,000 on lawyers to make sure he's not doing something wrong. "I have always wanted to be in compliance with the law," he says about his Medicare encounters over the past decade. "But I always wanted to care for patients." The government respondsHCFA officials say their data do not support the widespread claims of doctor defections from Medicare, but they are beginning to take physicians' concerns into consideration. According to the agency, physician participation in Medicare is actually increasing. It reached 86.3% in 2000 -- a 4 percentage point increase over 1999. "Our statistics suggest that physicians are not leaving the program, but we need to look behind those statistics," says HCFA medical adviser Barbara Paul, MD, who directs the agency's Physician's Regulatory Issues Team. The Medicare Payment Advisory Commission also doesn't have hard evidence of doctors leaving the program. "We have heard anecdotal reports, but we have no analytic reason to think there's a problem," says Murray Ross, executive director of MedPAC, which advises Congress on Medicare issues. Dr. Paul says the general health care environment makes Medicare challenges more difficult for doctors. "As I listen, there are a number of factors," she says. "The health care environment is exceedingly complex, there are so many uninsured and there is more stress on all sources of payment." No worse than others?Some experts argue that Medicare's procedures aren't any worse than other payers. The program pays faster than most, and the administrative and clinical challenges are like other managed care demands these days, they say. "There is really not much different about the way Medicare has created these rules from other carriers," says Darren Carter, MD, a family physician and research scientist at the HIV Center of Clinical and Behavioral Studies at the New York State Psychiatric Institute. Dr. Carter, also the medical director of Info-X, a firm that helps hospitals and doctors wade through regulations and medical coding, says physicians don't need to learn all 7,000 codes, but rather find and learn the 50 or so that relate to their practice. According to Dr. Paul, some physicians' problems with Medicare stem from misperceptions. The agency's regional offices are working with physicians to clear up some of the confusion, she says. But Colorado physicians are skeptical. "The doctors think they will be prosecuted," says Rissmiller, who noted that Dr. Paul is scheduled to meet with them in July. "It's really hard to change the doctors' minds about this fraud thing. I'm not really sure how to defuse this." Dr. Paul admits the program has some problems, but says recent changes -- heightened education efforts for carriers and physicians, and ongoing PRIT initiatives -- eventually will pay off. PRIT's targets include: ABNs; certificates of medical necessity, which nearly 39% of physicians in an AMA survey identified as the greatest Medicare problem; coverage of follow-up visits for cancer patients, often denied as routine screenings; coverage of pre-operative evaluations, also often denied; and laboratory services. Dr. Paul says PRIT's efforts in the past few years are leading to changes. "I'm hopeful that even the work we've done in the past two years will begin to be felt at the bedside," she says. "By the end of the year, physicians should begin to see some very specific results." Another positive development, Dr. Paul says, is an increased number of practicing physicians advising HCFA. "The agency has more than doubled the number of doctors at HCFA," she says. "The combination of a clinician working with a policy person makes a big difference." Other HCFA undertakings include: the correct coding initiative, improved customer service provided by claims processing contractors, and expanded education and outreach to help doctors and providers learn how to file and document claims through educational courses and the Medicare Learning Network. Nonetheless, some physicians say it will take more than just internally motivated changes. "Things like fairness, integrity and good business should apply to HCFA," Dr. Corlin says. "And that just isn't happening." The AMA is giving top priority to Medicare regulatory reform legislation. The Medicare Education and Regulatory Fairness Act, introduced in March, seeks to improve the Medicare audit and appeals processes, as well as reduce regulatory burdens. "There needs to be a fundamental attitude adjustment at HCFA," Dr. Corlin says. "Things have got to change. There is a cumulative building of inappropriate implementation that has been done so badly, they are collapsing of their own weight." ADDITIONAL INFORMATION:Physician viewsA 1999 physician survey by the Medicare Payment Advisory Commission shows that most physicians took new Medicare patients but had serious concerns about the program. According to the survey:
Physician numbersAmid rising defections, the total percentage of physicians participating in Medicare has been increasing: 2000: 86.3%
Source: Health Care Financing Administration Pulling back in ColoradoA survey last year of more than 900 physicians from nine Colorado counties showed that many physicians, particularly primary care doctors, are limiting their Medicare participation.
Copyright 2001 American Medical Association. All rights reserved.
|
Featured stories     
« Prev
1
2
3
4
5
6
Next »
Current topicsMost-viewed
This weekUnspent war funds eyed to avoid years of Medicare doctor pay cuts Rite Aid clinics place new twist on "doc-in-a-box" Get our email alertsUse our one-step registration. Learn more Your information will not be shared. Privacy policyColumns and series
From the vaultQuotable"Our goal really is to provide the right care for patients at the right time. Not too much and not too little." Steven Weinberger, MD, co-author of a list developed by the American College of Physicians of 37 clinical situations in which screenings and medical tests provide little or no benefit |
|||||||||
SHARE
