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Less Access at Greater Cost

By Dr R Scott Poppen

I always try to be sympathetic when my physician colleagues ask for fair financial reimbursement for their services.  After all, our days are long, stressful, and the job entails years of training before those first bills can even be sent.  But when docs push for increased reimbursement under a false flag of improving patient access, and patients are placed in potentially coercive situations, I cry foul.


Meet H.R. 1700/S. 1042 – The Medicare Patient Empowerment Act.  It would allow us docs to contract with patients and balance bill them for amounts above and beyond the currently well defined Medicare reimbursement schedule.  That might be an amount that is close to, or even exceeds, standard fee-for-service schedules…long ago inflated to sometimes obscene levels to compensate for much lower contracted rates with private insurers …or just something much closer to those contracted rates.  Rolled out about a year ago, the proposed bill is now being pushed by the American Medical Association and some state medical societies.


How would this work? Let’s say I’m in a small primary care office.  I could decide that only new Medicare patients need to contract to pay me more (never mind the waiting room mêlée that will eventually occur when the patients start talking among themselves) or require all my established Medicare patients to contract.  Either way, two things happen.  Some patients, perceiving that I am man’s-best-doctor, will gladly, or based on fear that their health may be threatened, sign up.  Some will have money to burn; others really can’t afford it but will sacrifice financially in other areas including necessary health expenditures (i.e. dentists, prescription drugs).  But in my neck-of-the-woods, where many primary care docs are accepting new Medicare patients, most of my existing patients will say “love you doc…but” and burn a path in the carpet leading to the records transfer staff.


But what about a family doc practice in a place with high overhead costs…like downtown LA or Manhattan…or Sun Belt locales where offices can be knee deep with seniors every January.  Medicare reimbursement rates can be a burden in such places.  Getting into an office requiring contracting will be financially impossible for many seniors and drive them to already overloaded non-contracting offices.  And many seniors, already established in newly contracting offices, will be fearful to leave even though they really can’t afford to pay their Medicare Part B premium, medi-gap insurance premium, co-pay, deductible plus a bill balance.  So, a worsening of access problems for most seniors in areas already with problematic access.


And don’t even think of balance billing if you are a doc in a mega-multispecialty group of one or two hundred physicians or employed within a big health system.  Once thousands of patients in a community are affected, it will not be long before the media finds tearful, 89 year-old Mrs. Jones, complete with walker and portable O2, complaining that she can no longer see her beloved doc of oh-so-many years.  That group will rapidly reverse its contracting decision and its administrators will put in longer hours than their docs as they backpedal and apologize.


Surgical specialists?  Some of these docs will jump on this contracting idea in a heartbeat.  Established and respected ophthalmologists or orthopedist, long feeling that perceived meager Medicare rates undervalue their expertise and experience in removing cataracts or replacing joints, will gladly ask for more cash from patients and get it from many.  More offices will want to get in on the gravy-train producing more access problems for lower income seniors.


Does the AMA really think this legislation will increase access?  I think not.  More likely this is a bone being thrown to members and state societies disgruntled by its well reasoned support of the Affordable Care Act.  This legislation has nearly zero chance of getting through the currently constituted US Senate.  But it is an example of attempts at Medicare reform that we will see more of, particularly if Obamacare falls, that restricts access to the folks most in need or shifts costs to populations least able to pay. 

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