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Old 05-04-2011, 09:19 PM   #1
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Concierge Doctor

Before today, my only experience with concierge medicine was watching a couple of episodes of Royal Pains - Wikipedia, the free encyclopedia. My opinion was "doctors for rich people", and not for me.

Recent events have me reconsidering my opinion.

Our primary care physician has gone from a halfway decent guy who would take the time to talk to you and discuss treatments in depth to being all about the money. I think he may have taken a financial hit a couple of years ago when his former group practice closed overnight due to unspecified fiscal irregularities. The new group he joined with has horrible office staff with policies and procedures that make me feel like just another funding "cow" to be milked and moved along. My doc has changed his demeanor to match - I'm lucky if I get five minutes with the man - he acts like there is someone behind him with a whip.

With recent changes in my medical insurance I think now is a good time to make a move (i.e., fire my PCP). In the course of that search locally I found a couple of guys who are concierge physicians in practice together. The concept intrigues me solely on a personal level - I'm not looking to start yet another debate on health care as an economic or political issue.

My goal is to find a primary care provider who will spend the time to help us work on preventative medicine so we can enhance quality of life as we get older. I'm tired of getting the get 'em in and get 'em out routine that seems to be the norm today. The concierge docs seem like one way to do this, I assume there are others but how do I find them? Or, what should I expect for my extra money that's going to the concierge docs?
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Old 05-04-2011, 09:33 PM   #2
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I just had a physical. My internal medicine doc sounds like the person you want. He spends about an hour with me during the physical. It's mostly talking about preventative stuff. He moved off of insurance plans a while ago and now has a concierge plan. I take no meds, so need no blood tests every few months. I had not been to him in 18 months.

Nevertheless, it's cheaper just to pay him per visit (once every 18 months) than it is to get on his concierge plan. My health insurance allows for out-of-network doctors, but with a $2000 deductible. So we just load up the FSA to cover that deductible. If we don't use that money by year-end, then we spend it on disposable contact lenses for the teenagers or eyeglasses for us.

However, I have been to other doctors in that 18 months. Since the internal med guy is all about arteries, when you break a bone he cannot help you. If you get a kidney stone, he cannot help you. If you have something wrong with your heart, he sends you to a cardiologist. So while he is a good listener and a good health coach, he is mostly into preventative medicine (think statins, exercise, and don't smoke). He will prescribe antibiotics if you need them. But the reality is, he is sending you to someone else.

My spouse goes to him as well and would not ever change physicians.

How to find them? Just ask your friends and colleagues. If one of these doctors exists near you, someone knows about them. They do not have to have concierge plans. They just need to be happy talking to patients.
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Old 05-04-2011, 10:15 PM   #3
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Originally Posted by Leonidas View Post
My goal is to find a primary care provider who will spend the time to help us work on preventative medicine so we can enhance quality of life as we get older.
Me too. Probably many here have that goal. My closest contact with concierge medicine is, also, Royal Pains. I am sort of between PCPs -- I came to distrust my previous PCP (in family practice) and am now using my medical oncologist for this. I'm not sure he knows he's my PCP, but he does include what I ask in my blood tests, or other diagnostics, and seems very willing to discuss any health issues with me or make referrals to specialists. He's a smart guy. But he is only reactive -- I have to bring things up, or they don't come up. I'm really not sure whether I should be looking for a better arrangement.
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Old 05-04-2011, 10:31 PM   #4
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Sorry, Leonidas, I don't have a lead for you. But keep us informed of what you find. Here's an analogous situation someone in our family has: they are relatively young and have no serious (e.g. life-threatening) conditions, but are taking dozens of prescription medicines daily for a host of chronic ailments, all prescribed by a different specialist. The pills, conditions being treated, and specialized appointments just keep adding up, but no one is coordinating this stuff. I'd bet that a lot of these meds are interacting in negative ways, but there's no hope that a PCP will have the time in a short visit to tease apart the rat's nest and build a plan to reduce the meds and get the person healthy (through exercise, diet, medication, etc). What is needed is a health coach with the power to prescribe medications, the know-how to work with the specialists, the time to devote to the problem, and a steady focus on a plan of action that is longer than 10 minutes.

Good luck with your situation, I wish I had a suggestion.

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Old 05-04-2011, 11:41 PM   #5
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The concierge docs seem like one way to do this, I assume there are others but how do I find them? Or, what should I expect for my extra money that's going to the concierge docs?
Do you have any docs among your friends? Maybe a PM to Rich_in_Tampa?
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Old 05-05-2011, 12:45 AM   #6
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My goal is to find a primary care provider who will spend the time to help us work on preventative medicine so we can enhance quality of life as we get older. I'm tired of getting the get 'em in and get 'em out routine that seems to be the norm today. The concierge docs seem like one way to do this, I assume there are others but how do I find them? Or, what should I expect for my extra money that's going to the concierge docs?
Have you considered a nurse practitioner?
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Old 05-05-2011, 07:44 AM   #7
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My doc (internal medicine) started a sort of halfway-concierge practice (he calls it "priority access") a couple of years ago. His main goal was simply to limit the number of patients he has to see, as he was feeling overstressed by the workload.

It works this way: He still sees anyone, but limits his availability. For those of us who want to be in the program, we pay a $350 fee at the start of the year. In return, we are guaranteed same-day appointments when we need them, and he spends as much time with us as we need during visits. He also takes care of any paperwork (letters to employers, etc.) and will handle phone inquiries. He also has a habit of calling to check up on progress after any significant interaction.

He's a great guy, and a superb diagnostician, and we really like him, so we're very happy with this arrangement.
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Old 05-05-2011, 08:24 AM   #8
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(Note: The above post has been reviewed and is 100% free of political content)
Sure, except for the obvious hidden message that will be apparent to all who look for it:

Quote:
Sorry, Leonidas, I don't have a lead for you. But keep us informed of what you find. Here's an analogous situation someone in our family has: they are relatively young and have no serious (e.g. life-threatening) conditions, but are taking dozens of prescription medicines daily for a host of chronic ailments, all prescribed by a different specialist. The pills, conditions being treated, and specialized appointments just keep adding up, but no one is coordinating this stuff. I'd bet that a lot of these meds are interacting in negative ways, but there's no hope that a PCP will have the time in a short visit to tease apart the rat's nest and build a plan to reduce the meds and get the person healthy (through exercise, diet, medication, etc). What is needed is a health coach with the power to prescribe medications, the know-how to work with the specialists, the time to devote to the problem, and a steady focus on a plan of action that is longer than 10 minutes.

Good luck with your situation, I wish I had a suggestion.
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Old 05-05-2011, 09:18 AM   #9
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Concierge medicine is a business model. It has no bearing on quality of care or outcomes in my experience.

I was approached with such an opportunity about 12 years ago, looked at the numbers, the uncertain viability, the priorities of my potential future colleagues etc. and decided it was not for me.

If you know and like the doctor and are willing to pay a premium for a more orderly practice check it out.

I suggests calling the nurses at a local emergency room and asking who their favorite internists are. Certain names will probably pop up over and over. That's your doctor.
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Old 05-05-2011, 06:01 PM   #10
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I think finding a good PCP is the best place to start. Get a physical once a year. I agree with asking any health professionals you know for recommendations. I would also be informed about generally accepted time lines for testing, like colonoscopy after age 50 (earlier if there is a family history), mammogram annually, body check by dermatologist annually for skin CA, etc.
We all know about diet and exercise. My health plan encourages me periodically to call my "personal health advocate" to discuss my health goals (I ignore this suggestion), even though I am given a name and number in Pittsburgh for this health advocate.
Last year my bad cholesterol was a little high so my PCP gave me the name of a cardiologist who is nationally known in the area of anti-aging medicine. I drove into Pittsburgh and listened to what he had to say (he is big on resveratrol and a largely vegetarian diet with the exception of oily baked fish). They ran some non-invasive tests and had me wear a halter monitor for 24 hours (all normal). I was supposed to follow the prescribed diet and come back and see him in two months. I have canceled the appointment twice, have not had the blood work and might have to duck out on on the appointment scheduled for June due to being a malingerer in the diet department (he will want to see the results of that blood work and I love cheese). I am not sure I want to be the healthiest person in the Alzheimer's unit, but then again I might just be one of those dumb people who has to suffer a cardiac "incident" to take things as seriously as I should. Stroke and heart attack runs in my paternal line, always in the seventies and they (the males) go fast.
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Old 05-05-2011, 06:13 PM   #11
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... might have to duck out on on the appointment scheduled for June due to being a malingerer in the diet department (he will want to see the results of that blood work and I love cheese).
Cheese is my downfall, too. However, I haven't quite sunk to the level of canceling a doctor's appointment through cholesterol embarrassment.
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Old 05-05-2011, 08:07 PM   #12
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I had a good doctor for about 20+ years until he retired. I went to this practice that was recommended and after using 2 other doctors, I got an appointment with one of the senior doctors who I was really impressed with.
He took care of the problem at hand and at the end of the appointment told me that he and one of the other doctors would be branching off into a concierge medical practice. He is now part of the MDVIP network which I did join for a fee of 375 quarterly. The practice is capped at about 600-700 patients. I get annual physical which involves full blood work, ekg, chest xray and about 20 minuite interview going over the lab results taken a week earlier. He then does a complete physical. I can call his cell phone at any time that i need him. I get same day appointments with little waiting. His secretary will make appointments for me with any specialist I might need on my way out the door.
I think that it is worth the money. He as acted as a coach to help me loose weight and line up some other doctors that I should be seeing for minor problems.
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Old 05-06-2011, 07:47 PM   #13
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There are good internists out there who do take time with their patients. Mine has been in practice for almost 20 years, and still spends 45-60 minutes with me during my annual physical. She listens. She cares. And she's a great doc.

You just have to ask around. You can also check out healthgrades.com and find out what other patients are reporting.
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Old 05-06-2011, 09:12 PM   #14
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One of the hardest things about moving is finding new dentists and doctors. I had the same doctor for 30+ years in the megacity. When I retired we moved to the ranch. We tried a few doctors in the local area and wound up with a family practice in Shreveport. The nurse practioners are just as good as my former long-term doctor.
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Old 05-09-2011, 10:44 AM   #15
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You guys are great, as usual. Special thanks to all who sent PM’s with your favorite PCPs name and contact info. I’ll thank each of the latter individually as I get to them.

Many of you seem to have the same concerns, frustrations and desires that I have.

For me, it’s not that I necessarily want all the benefits that a concierge doctor provides, but I want something better than the experience I’m getting. It’s too much like a fast-food joint with me walking out with a burger prescription in hand and the suspicion that I got a one-size-fits-all outcome – and a slew of questions that are just starting to arise. A follow-up visit to answer those questions is expensive and time wasting. A telephone call to ask for clarification is actually three telephone calls over two days before you maybe talk to the doctor, or maybe a nurse, or maybe somebody named Gloria who is patronizing and clearly just passing on a response that she doesn’t understand and can’t explain. Email a question? We don’t do that here.
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Do you have any docs among your friends? Maybe a PM to Rich_in_Tampa?
He will be along soon.
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Concierge medicine is a business model. It has no bearing on quality of care or outcomes in my experience.
Speak of the devil doctor...

No disagreement here. However, while I concur that just because you paint the word “concierge” next to “Dr. Bob Dog” on the front door of one’s office does not make it what I would think is actually a concierge practice. At least not in the sense of what I’m looking for.

However, on the opposite side of all this is that other than the clinic inside my local grocery store, few docs are hanging out shingles proclaiming themselves, “Medico Rapido!”

Which leaves the giant faceless crowd of all the others.
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I suggests calling the nurses at a local emergency room and asking who their favorite internists are. Certain names will probably pop up over and over. That's your doctor.
That sounds like a great idea, but, my past experiences tell me the odds are against me on that working out. That past experience being onetime boss of the “Doctor Squad”, which was the guys that went around investigating pharmacists and physicians and their drug dispensing proclivities. Like most other professionals (and regular folks), there was no bad-mouthing of peers until you handed them the federal grand jury subpoena. Only then would Dr. Bob Dog admit that maybe his colleague wasn’t actually a “fine physician” and - truth be told – Bob wouldn’t want her near his kid’s hamster much less an actual human being (an actual quote). My suspicions my call to the ER as Mr. Leonidas would be a different experience than Dr. Tampa’s similar request. Not that I think I would get bad information as much as I suspect I would get nothing with a cold call like that.

Edit to ad: I've overcome my callous cop attitude and am going to give it a try.
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However, I have been to other doctors in that 18 months. Since the internal med guy is all about arteries, when you break a bone he cannot help you. If you get a kidney stone, he cannot help you. If you have something wrong with your heart, he sends you to a cardiologist. So while he is a good listener and a good health coach, he is mostly into preventative medicine (think statins, exercise, and don't smoke). He will prescribe antibiotics if you need them. But the reality is, he is sending you to someone else.
I had not considered the internist vs some other kind of doc as the PCP question. Thanks for discussing it.
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How to find them? Just ask your friends and colleagues. If one of these doctors exists near you, someone knows about them. They do not have to have concierge plans. They just need to be happy talking to patients.
That’s one of the directions we’re working on. My dentist is a former neighbor and he runs his practice similar to what I would like to see from a physician, and I will ask him or recommendations at my appointment next week. The DW is going to toss out the question tomorrow night at the neighborhood ladies’ dinner.
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I'm not sure he knows he's my PCP, but he does include what I ask in my blood tests, or other diagnostics, and seems very willing to discuss any health issues with me or make referrals to specialists. He's a smart guy. But he is only reactive -- I have to bring things up, or they don't come up. I'm really not sure whether I should be looking for a better arrangement.
Having the responsibility of bringing stuff up is okay with me, but the reaction I’ve been getting from my soon-to-be former PCP is terrible. “Oh, and I wanted to ask you about X”, almost always gets a nod and a response that’s not very responsive. Like I said, the dude moves so fast that the last couple of times I have found myself standing by the elevator short some cash, holding a scrip, and realizing, “Hey, he never answered my question.”
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What is needed is a health coach with the power to prescribe medications, the know-how to work with the specialists, the time to devote to the problem, and a steady focus on a plan of action that is longer than 10 minutes.
Agree. The group that I have received multiple recommendations about makes this as one of their premier attributes. The old insurance required referrals to specialists, and my PCP forgot all about it once the referral was made. With no referrals needed on my new plan I really want someone who is going to keep track of what I may have going on with outside treatments.
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Have you considered a nurse practitioner?
Not at all. I’ve googled the term and see it’s a wide field. How would I work such a professional into the picture in conjunction with a PCP?
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Originally Posted by braumeister View Post
My doc (internal medicine) started a sort of halfway-concierge practice (he calls it "priority access") a couple of years ago. His main goal was simply to limit the number of patients he has to see, as he was feeling overstressed by the workload.

It works this way: He still sees anyone, but limits his availability. For those of us who want to be in the program, we pay a $350 fee at the start of the year. In return, we are guaranteed same-day appointments when we need them, and he spends as much time with us as we need during visits. He also takes care of any paperwork (letters to employers, etc.) and will handle phone inquiries. He also has a habit of calling to check up on progress after any significant interaction.

He's a great guy, and a superb diagnostician, and we really like him, so we're very happy with this arrangement.
While all the ease of access benefits are nice, I’m really looking for that last set of characteristics (great guy, superb diagnostician – and I assume takes his time to listen and explain).

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I would also be informed about generally accepted time lines for testing, like colonoscopy after age 50 (earlier if there is a family history), mammogram annually, body check by dermatologist annually for skin CA, etc.
Excellent point. I have not been as assertive about this with my current PCP as I should have been. However, as I mentioned above, the few times I have tried to bring some of these things up it has been pushed aside. One of my biggest complaints about the guy is that he is focused on getting me out of his office. Usually I get a two-five minute talk about whatever I made the appointment for and then he jets out of the room. There I sit thinking, “maybe he’ll answer that question when he comes back in.” The next thing I know the nurse is handing me a scrip and pushing me toward the check-out line.
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We all know about diet and exercise. My health plan encourages me periodically to call my "personal health advocate" to discuss my health goals (I ignore this suggestion), even though I am given a name and number in Pittsburgh for this health advocate.
My new plan has something similar, and I’m not sure I will use it either. Something more consistent and more personal is what I would prefer, and I think what they’re offering is going to be someone reading from a script displayed on their screen.

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Originally Posted by FreeAtLast View Post
You just have to ask around. You can also check out healthgrades.com and find out what other patients are reporting.
Looking at healthgrades, AngiesList – healthcare, and some other resources. I’m not being over inspired by any of them as comprehensive resources.
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One of the hardest things about moving is finding new dentists and doctors. I had the same doctor for 30+ years in the megacity. When I retired we moved to the ranch. We tried a few doctors in the local area and wound up with a family practice in Shreveport. The nurse practioners are just as good as my former long-term doctor.
So, does the nurse work in your physician’s office, or is he/she an outside resource?

You guys are all being a fantastic resource. I’m working on refining my goals/desires on this and will report back if anyone is interested.

Interesting related tidbit: Cigna wants my blood pressure, cholesterol, glucose, weight and height, by July as part of an online assessment.
Quote:
The assessment analyzes your answers and produces a personal-health report with details about your most important health issues. The report will include suggestions for health screenings and information about wellness and other health programs that may help you improve your health. Based upon your responses, you will also receive an invitation to participate in an online coaching program. You can print a summary of the report to take to your next doctor’s visit. Use it to ask your doctor questions and to learn more about your health.

The results are confidential – they won’t be shared with the city of (MegaCityUSA). CIGNA will, however, use them to identify programs that could potentially benefit you. The personal health team can then help you improve those numbers.
I wonder how useful that will be.

Does anyone else think it noteworthy that the insurance carrier wants to give me advice on my BP, blood sugar, weight, etc? Is it because they know that PCPs aren't doing such a good job of discussing this simple stuff with their patients?
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Old 05-09-2011, 11:15 AM   #16
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We have been researching the concierge medical approach this year also. There is a huge disparity in price, which did not surprise me at all, but does make me wonder how to work my way through it.
My used-to-be-ok insurance is denying my husbands annual physical as the doc did not call it a wellness exam and they are asking that we pay $936 for blood tests.
Suffice it to say, I will be spending hours fighting this one on principle as well as economy.
I think this issue is going to become a "hot" topic.
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Old 05-09-2011, 11:27 AM   #17
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You also need to think long term. Someday you will be 65 and on Medicare whether or not you want to be. Concierge doctors can't accept Medicare because Medicare limits what they can charge to the Medicare fee schedule. Around here, most Docs will not accept Medicare unless you were with them for some time before you turned 65. In some cases, they will accept someone in a Medicare Advantage Plan. Medicare is a big loser for Primary Care Docs. Part of the way Concierge plans work, is that they don't require the other patients to subsidize the Medicare patients because there aren't any.
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Old 05-09-2011, 11:43 AM   #18
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You also need to think long term. Someday you will be 65 and on Medicare whether or not you want to be. Concierge doctors can't accept Medicare because Medicare limits what they can charge to the Medicare fee schedule.
You're not suggesting that Leo seek out (or stay with) a crappy doc now who will take Medicare in 10 or 15 years, are you? What "long term" choices do you think Leo should be considering?

I'm happy with a clinic of GP doctors and residents, but I rarely see the same doc twice and so don't have to deal with difficult personalities very often.
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Old 05-10-2011, 09:45 AM   #19
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Gosh, I have no idea how old Leo is. For someone ten to 15 years from Medicare, obviously transitioning to Medicare won't be an issue. Once you get to 60 or so you have to think about what you are going to do.

For someone with a lot of resources who is over 65, since Medicare pays primary care drs. so little anyway, a concierge doc who doesn't bill Medicare might be a good way to get primary care. You could then self-refer to specialists who do bill Medicare. And Medicare hospital payments are much more adequate for providers.

People who retire early but are not wealthy (i.e. don't have a couple of million in assets) this transition question will be much more important. The pressure to reduce the cost of Medicare isn't going to go away. This may mean that access to primary care docs for those on Medicare will grow more difficult, especially in areas where the % of those over 65 in the population is high.

The recent idea of one party to end Medicare and give a $14k voucher instead is an excellent example of why those who are taking very early retirement need to think about whether or not they will have enough assets to pay for future medical care. $14k was what Medicare paid on the average for each person in 2004. We have had a lot of double digit increases in the cost of medical care since then.
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Old 05-10-2011, 09:52 AM   #20
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Just one more thing....today you have insurance and go to your primary care doctor. The doc bills $200, and your insurance pays $100 and everyone is happy. On Medicare the doc might get $20-40 depending on the coding. You can see the problem.
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