Medicare Catch 22

[SteveL]

I'm now less than three years from Medicare. Because our state is 47th in the US in the level of Medicare reimbursements for doctors, most of them in our county will not accept new Medicare patients.

Some of my friends have gotten around this by going into a Medicare Advantage plan. However, these plans cost the govt. a lot more than regular Medicare, and it seems likely that their subsidies will be reduced or eliminated by the new administration and then the plans will go away.

Under Medicare rules, if a Dr. accepts $1 from Medicare he/she cannot charge more than what Medicare allows, so Medicare Supplements don't help, and you can't pay the Dr. more out of your pocket. Most Docs have existing patients that they continue to care for, and use part of the fees from other patients to offset losses on Medicare.

All insurance plans have Medicare built-in and they don't offer a plan that doesn't require this.

Unless we move out of the state, I see a future where we are forced to pay for Medicare, and unable to get a Doctor.

I don't blame the Docs. I have seen some Medicare statements where the Dr. was allowed $15 for an $80 office visit.

This is a weird situation. If you go into the hospital, or see a specialist Medicare reimbursement is closer to real cost. It is just the primary care Docs. who are getting stiffed.

Anyone have any ideas?

 

[W2R]

Sounds awful.

Just to make sure I know what you are talking about, I guess you mean Medicare, part B, right... the part you can choose to pay for or not if you want to?

I am not that age yet but if my understanding is correct, Medicare Part A (the free part) just covers hospitalization.

 

[haha]

Anyone have any ideas?

Won't your current Doctor continue with you after Medicare?

 

[mickeyd]

Hey Steve,

most of them in our county will not accept new Medicare patients.

How about contacting a Dr in your area that DOES accept MC and see if they are accepting new patients?

 

[Moemg]

I'm now less than three years from Medicare. Because our state is 47th in the US in the level of Medicare reimbursements for doctors, most of them in our county will not accept new Medicare patients.

?

Just wondering what state do you live in ?

 

[RonBoyd]

I, too, am confused. Are you speaking of Medicaid or Medicare? Did you get your data from the official source -- Medicare.gov - The Official U.S. Government Site for People with Medicare?

In any event, I am unfamiliar with the "problems" you mention.

 

[harley]

This is a growing problem, as I understand it. My 72 yo mother's doctor quit practicing, and she tried 17 (count them) other doctors in her relatively rural area. Not one of them would accept new Medicare (not Medicaid) patients, for the reasons outlined by the OP. And if you don't have a primary care physician, you can't get access to the specialists. She finally went back to a doctor she had used 20 years ago, and who she can't stand, and who is nearly an hour away. By the way, she's in VA, about an hour and a half west of DC.

This is a major problem, and one of the most immediate needs that have to be addressed when Mr. Obama and his group of elves get going on the big change. I wish him good luck. I don't envy him the task.

 

[SteveL]

A little more info.....I retired at 55 (yeah) and my former employer has been providing a small subsidy for health ins and allowing us to buy what they provide to employees. Over the past seven years this has resulted in having to change plans four times. We are in WA. We have had to change plans again for 2009. After we return home from our annual search for warmer weather, we will be looking for primary care docs. We will be asking about being able to continue after medicare. I know that many doctors won't do it. Who can blame them?
Yes, you can choose not to join Part B. You then have no coverage for Dr.s or outpaitent care, and you can't buy it elsewhere.
Even if a Dr. we choose this year will continue, we might have to change ins plans again before we are 65.
And, every year, Congress has to pass a bill to keep Dr. payments from going down even more!

 

[W2R]

A little more info.....I retired at 55 (yeah) and my former employer has been providing a small subsidy for health ins and allowing us to buy what they provide to employees. Over the past seven years this has resulted in having to change plans four times. We are in WA. We have had to change plans again for 2009. After we return home from our annual search for warmer weather, we will be looking for primary care docs. We will be asking about being able to continue after medicare. I know that many doctors won't do it. Who can blame them?
Yes, you can choose not to join Part B. You then have no coverage for Dr.s or outpaitent care, and you can't buy it elsewhere.
Even if a Dr. we choose this year will continue, we might have to change ins plans again before we are 65.
And, every year, Congress has to pass a bill to keep Dr. payments from going down even more!

Your former employer's plan won't cover doctor or outpatient care, because you elected not to pay for Part B? I'm confused.

 

[SteveL]

Your former employer's plan won't cover doctor or outpatient care, because you elected not to pay for Part B? I'm confused.

At 62, I still have regular ins, now with Blue Cross. No problems. However, in less that three years, I will be out of BC and into Medicare, with its associated problems.

 

[OAG]

DW and I have been on Medicare for over 3 years and have not had a problem finding a Doctor to take us or have we had any problems getting referrals (eye care and dermatology). We used to live in FL and now live in central Ohio. Personally, I think (and hope) that all of the "horror" stories I have read and seen about Medicare are a tad overblown. Several years back I had many more problems taking care of my Mother under BC/BS than DW and I have experienced.

 

[Hobo]

I am retired, and have Part B Medicare which pays for hospitalization. Part A is not free, and not even cheap. I canceled part A. I just put $10,000 into a savings account and pay the money I would have paid for Part A into the same account.

If I need a doctor, I take the money from the savings account to pay for it. However, first I talk to the doctor in advance about the cost of the visit. At first the doctor wouldn't talk to me - only the nurse.

I really complained loudly..."I am paying for this and I have the right to know how much it is going to cost." The nurse looked in her note book which had the different rates they pay to all the different insurance carriers for an office visit. She looked at the "uninsured" rate and it was very expensive. I could see they paid other insurance carries a lot less - so I said, "I want that cheap price."

All of this was causing a commotion and everyone waiting for hours in the waiting room were staring at us. By this time I was yelling how unfair this was. "Why should the insurance carriers get a better rate than me? I will pay cash - no paperwork."

The doctor gave the nurse a smirk and nodded his head, and I got the cheap rate. Us Americans are too darn complacent to let the health care system get away with murder.

"No I don't want that lump you cut out tested for cancer." "No, I don't need to pay for a doctor's visit, all I need is a prescription renewal - give me a nurse practitioner."

These are true stories and they work... Do you know why? Because doctors and nurses are just as complacent as us patients. They can't believe I would argue like this in front of all the other people waiting for the doctor - so they just give in to keep me quiet. What are they going to say - "go away?" Never.

Oh yea, my personal medical savings account now has grown to $15,500!

 

[RonBoyd]

I am retired, and have Part B Medicare which pays for hospitalization. Part A is not free, and not even cheap. I canceled part A. I just put $10,000 into a savings account and pay the money I would have paid for Part A into the same account.

If I need a doctor, I take the money from the savings account to pay for it. However, first I talk to the doctor in advance about the cost of the visit. At first the doctor wouldn't talk to me - only the nurse.

I really complained loudly..."I am paying for this and I have the right to know how much it is going to cost." The nurse looked in her note book which had the different rates they pay to all the different insurance carriers for an office visit. She looked at the "uninsured" rate and it was very expensive. I could see they paid other insurance carries a lot less - so I said, "I want that cheap price."

All of this was causing a commotion and everyone waiting for hours in the waiting room were staring at us. By this time I was yelling how unfair this was. "Why should the insurance carriers get a better rate than me? I will pay cash - no paperwork."

The doctor gave the nurse a smirk and nodded his head, and I got the cheap rate. Us Americans are too darn complacent to let the health care system get away with murder.

"No I don't want that lump you cut out tested for cancer." "No, I don't need to pay for a doctor's visit, all I need is a prescription renewal - give me a nurse practitioner."

These are true stories and they work... Do you know why? Because doctors and nurses are just as complacent as us patients. They can't believe I would argue like this in front of all the other people waiting for the doctor - so they just give in to keep me quiet. What are they going to say - "go away?" Never.

Oh yea, my personal medical savings account now has grown to $15,500!

As I said earlier the truth can be found here:

[FONT=Verdana, Helvetica]Medicare Premiums for 2009:[/FONT]
[FONT=Verdana, Helvetica]Part A: (Hospital Insurance) Premium[/FONT]

• [FONT=Verdana, Helvetica]Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.[/FONT]
• [FONT=Verdana, Helvetica]The Part A premium is $244.00 per month for people having 30-39 quarters of Medicare-covered employment.[/FONT]
• [FONT=Verdana, Helvetica]The Part A premium is $443.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.[/FONT]

The key here is "most people."

I am unsure as to what you are saying about your negotiating prowess... that you expect the same "volume discount" that a large pool of patients get? And this seems like a singular instance. What was the result of subsequent confrontations?

"What are they going to say - 'go away?'" I would.

 

[Rich_by_the_Bay]

I really complained loudly..."I am paying for this and I have the right to know how much it is going to cost." The nurse looked in her note book which had the different rates they pay to all the different insurance carriers for an office visit. She looked at the "uninsured" rate and it was very expensive. I could see they paid other insurance carries a lot less - so I said, "I want that cheap price."

All of this was causing a commotion and everyone waiting for hours in the waiting room were staring at us. By this time I was yelling how unfair this was. "Why should the insurance carriers get a better rate than me? I will pay cash - no paperwork."

The doctor gave the nurse a smirk and nodded his head, and I got the cheap rate. Us Americans are too darn complacent to let the health care system get away with murder.

"No I don't want that lump you cut out tested for cancer." "No, I don't need to pay for a doctor's visit, all I need is a prescription renewal - give me a nurse practitioner."

These are true stories and they work... Do you know why? Because doctors and nurses are just as complacent as us patients. They can't believe I would argue like this in front of all the other people waiting for the doctor - so they just give in to keep me quiet. What are they going to say - "go away?" Never.

You may have your supporters here regarding taking an assertive role toward discussing fees and other finances of health care with your doctors. I'd entertain that discussion with any patient whether we ended up agreeing or not, though blatant hostiilty probably wouldn't gain much traction in my office.

But you sure lost me when you decide you know best whether to send a biopsy to the lab, or just wanting a prescription renewed indefinitely without ever being seen by the doctor (probably malpractice in some situations, since you are not monitoring the potential risks of the medication). Wonder how long it would take someone to sue the doctor for missing that cancer diagnosis, omitted because a combative patient yelled and made a scene in my office, or develop a serious side-effect because an early drug reaction was missed for lack of office follow-up.

Most patients I see (and many are very well-informed and sophisticated) find less combative ways to protect their own interests without antagonizing their health care providers or jeopardizing their own health care.

 

[Nords]

Most patients I see (and many are very well-informed and sophisticated) find less combative ways to protect their own interests without antagonizing their health care providers or jeopardizing their own health care.

Most doctors & dentists I've seen are thrilled to take cash patients, and at a very healthy discount because there's only about a tenth of the paperwork and a thousandth of the payment delays.

I don't see how a confrontational relationship would work in the patient's favor among people who wield catheters, scapels, and power drills...

Personally I favor sending all biopsies to the lab. If my mother-in-law hadn't agreed to have that spot on her ear tested then she wouldn't have known it was cancerous... and my parents-in-law would probably still be living here!

 

[Hobo]

RonBoyd - My mistake. I was talking about canceling the coverage to see a doctor... which is Part B, and had been costing me almost $100 per month. I still have Part A, which covers hospital expenses and is free (for me).

Rich_in_Tampa -

"But you sure lost me when you decide you know best whether to send a biopsy to the lab, or just wanting a prescription renewed indefinitely without ever being seen by the doctor (probably malpractice in some situations, since you are not monitoring the potential risks of the medication). Wonder how long it would take someone to sue the doctor for missing that cancer diagnosis, omitted because a combative patient yelled and made a scene in my office, or develop a serious side-effect because an early drug reaction was missed for lack of office follow-up."
​

This is the "I know best" attitude that most doctors have regarding their patients - and it makes me furious. It's my money, it's my body... I decide what is good for me, NOT YOU. I don't want to know if I have cancer and I don't want to pay for a biopsy.

Your treatment for cancer would be more time (and money) in a hospital, with a lot of pain. My treatment for cancer is suicide, so I don't need a biopsy. That's my choice - not yours, and not your malpractice insurance carrier.

As far as renewing a prescription, it sure doesn't require a doctor to "monitor the potential risks of a medication". A trained nurse can do the same thing. That is one reason medical care is so expensive - doctors are doing the menial work that could be done by people with less training.

"Most patients I see (and many are very well-informed and sophisticated) find less combative ways to protect their own interests without antagonizing their health care providers or jeopardizing their own health care."
​

I would certainly like to know what "less combative ways" they use to protect their interests. Why do I have this feeling that the only way is to agree with your judgment of what treatment is necessary? Have you ever agreed with a patient that one option in the treatment in cancer is to wait and let nature takes its course? Would you agree to not send the tissue from a removed lump to a laboratory for a biopsy - if that is what I wanted?

Nords -

"Most doctors & dentists I've seen are thrilled to take cash patients, and at a very healthy discount because there's only about a tenth of the paperwork and a thousandth of the payment delays."
​

Thrilled to take cash - yes. A discount to the same rate they charge insurance companies? I have never seen it readily offered.

 

[burch64]

When I lost my Dental Insurance I asked the Dentist about a discount for people who have no insurance and would be paying cash for their procedures.

He stated he would give a 10% discount for cash customers and gave me a sheet with his charges for different procedures.

Jim

 

[W2R]

Your treatment for cancer would be more time (and money) in a hospital, with a lot of pain. My treatment for cancer is suicide, so I don't need a biopsy. That's my choice - not yours, and not your malpractice insurance carrier.

Unless you are suicidally depressed (in which case, I hope you seek help), in my opinion that choice is unwise and verging on the ridiculous. I think that all of us know people who have had cancer diagnosed and treated early, and afterwards have enjoyed decades of happy, satisfying, productive life without any recurrence . Suicide due to an early cancer diagnosis is no less tragic than any other suicide.

 

[Hobo]

Unless you are suicidally depressed (in which case, I hope you seek help), in my opinion that choice is unwise and verging on the ridiculous. I think that all of us know people who have had cancer diagnosed and treated early, and afterwards have enjoyed decades of happy, satisfying, productive life without any recurrence . Suicide due to an early cancer diagnosis is no less tragic than any other suicide.

Thanks for your concern, but believe me I am not suicidal. I have a wonderful life now in retirement. I live in a wonderful situation, surrounded by people and family I love. As long as I am healthy, I hope to expect to live a long and happy life.

I have a different view of how I wish my life to end when that time arrives. Perhaps my views are influenced by the way both my parents died - a very long and extremely painful period of illness intentionally prolonged by "standard medical practices". I will not allow myself to be put in a situation where I no longer have the choice to either live and suffer, or die. I will never surrender my life into the hands of some other person.

You can see from Rich in Tampa's post that he, as a doctor, is trained to keep me alive and will never vary from his Hippocratic oath. Plus, he is forced by our legal system to use "generally accepted medical practices" on me, regardless of my wishes. He cannot allow me to die, and as you can see from his post, he is virtually obligated to take control of my body, my lump, my life and my decisions to prevent me from dying.

I will never accept that philosophy. If he cuts out a lump from my body, I should have the right to 1) take it home and throw it out, 2) take it to a laboratory or 3) store it in formaldehyde in case I want it tested later.

I am not ignorant to the fact that some cancers can be treated if caught early. I understand that and am quite capable of researching the implications of my illness. I don't have a death wish, but I also don't have a wish to die after a long and painful illness.

I have a God given right to life and death, and by extension, I also have a right to choose how I treat an illness. I hope you can understand my statement had nothing to do with any sort of "wish to die". This is about my inalienable right to choose what happens to my body; a right I will never surrender to a doctor (or anyone else).

 

[Rustic23]

Gotta side with Rich on this one. I know how to do a lot of things. Surgery is not one of them. Neither is cancer prevention or diagnosis. When I take my car to a mechanic, I generally take his advice because I trust my mechanic. I had my house built and I hired a contractor to do the work. While we talked about the things I wanted in the house, he was responsible for building it and getting me the quality I required. I guess what I am trying to say is 'When you got to a specialist you should plan on taking his advice. If you go in not trusting his advice, don't go to him!"

 

[Hobo]

When I lost my Dental Insurance I asked the Dentist about a discount for people who have no insurance and would be paying cash for their procedures.

He stated he would give a 10% discount for cash customers and gave me a sheet with his charges for different procedures.

Jim

Not to be argumentative, but I did some research on this by asking several dentists how of a discount they give to insurance companies. In most cases it 20-25%. Of course, the presumption is this will bring in more business.

Second, ask if you can visit the dentist without getting your teeth cleaned. A strong argument can be made that using proper dental cleaning with modern equipment that also stimulates the gums negates the need for dental cleaning at the dentist. I found it very difficult to find a dentist office that allows you to forego the routine cleaning - priced at $100.

 

[Rich_by_the_Bay]

You can see from Rich in Tampa's post that he, as a doctor, is trained to keep me alive and will never vary from his Hippocratic oath. Plus, he is forced by our legal system to use "generally accepted medical practices" on me, regardless of my wishes. He cannot allow me to die, and as you can see from his post, he is virtually obligated to take control of my body, my lump, my life and my decisions to prevent me from dying..

Not quite my perception of the situation, Hobo. I and many colleagues like to support shared decision-making. This means to me that we might discuss each of the issues of concern to you, including the possibilities that I might have information that you don't have even after your research, and that I might have experience which you would find valuable in coming to your own decision. I would document that you chose to decline my advice and usually this would reduce my medicolegal risk. We do or omit stuff "against medical advice" all the time, upon the patient's direction.

It's true that there are exceptions to the above. For example, I would not do something which might harm my patient with no risk of benefit no matter what the patient asked for, it's my ethical obligation. And I might decide that a given patient was making an irrational choice due to some mental or physical condition that brings the soundness of their judgment into question.

I would probably not respond positively to a patient who comes in making vigorous demands that I do one thing or another -- that's not shared decision making, it's one-side decision making. It would be a whole different story if you thoughtfully told me what you wanted and why, I had a chance to respond and coach you, and ultimately we agreed on what was wise, or agreed to disagree. I would not jeopardize my medical license or malpractice protection to do so, but I routinely modify Plan A in order to meet special requests from patients. Both parties need to be comfortable with that decision, at least in my practice. I allow people to die of their disease routinely in my practice (in a referral cancer center), and in fact help keep them comfortable in the process.

Hope that clarifies what I meant.

 

[Hobo]

Gotta side with Rich on this one. I know how to do a lot of things. Surgery is not one of them. Neither is cancer prevention or diagnosis. When I take my car to a mechanic, I generally take his advice because I trust my mechanic. I had my house built and I hired a contractor to do the work. While we talked about the things I wanted in the house, he was responsible for building it and getting me the quality I required. I guess what I am trying to say is 'When you got to a specialist you should plan on taking his advice. If you go in not trusting his advice, don't go to him!"

This is a good point, but it simply doesn't apply to a doctor. He is obligated by a code of law that says he must follow the "legal standard of care". He may have seen 1000 non-cancerous lumps like he just cut out but he is required to have it tested for cancer.

Let me quote a journal article entitled:
Medical malpractice and the legal standard of care SpringerLink - Journal Article

"In this essay, I examine the relationship between lawsuits for medical malpractice and the legal standard of care. I suggest that there is an insidious, dynamic relationship between physicians' reactions to the recent increase in malpractice litigation and an artificial elevation of the legal standard of care.

The legal standard for proper medical care is based upon the community standard of care rather than the reasonable person standard. [When] that overtreatment or "defensive" medicine becomes widespread as a reaction to malpractice litigation, the legal standard becomes elevated as well.

Thus, it will increasingly be the case that unless a physician practices defensive medicine, and hence practices unreasonably, he/she risks being found liable for medical malpractice."

​

As a Registered Civil Engineer I was forced to follow by the same legal principles: "community standard of care". This is NOT like a contractor or a car mechanic who will give you his honest opinion. You cannot go elsewhere for a different opinion.

This is a professional who must live by the rules established by the law and lawyers - and it is driving up our health care costs.

Consider what happens when a bio-tech company comes out with a new, expensive piece of equipment to test for cancer. The bio-tech company salesman sells the unit to a laboratory and some rich man demands the best possible care. Soon that new piece of equipment becomes the new standard of care - and all doctors (and laboratories) must use it.

The old way of just looking at the lump under a microscope is no longer good enough. And now your laboratory bill just doubled.

The worst thing is human intelligence or the desire of the patient does not enter into the equation. You pay the doctor to be smart, but the law forces him to be a robot.

The American people need to get smart about health care. We need tort reform, or what I would call "NO FAULT MEDICAL CARE". That is, I can go into a doctor's office and sign an agreement to indemnify the doctor and hold him harmless. That means I cannot sue, but it also means my cost is cut in half. If my doctor makes a mistake - well, life ain't fair.

 

[Hobo]

Not quite my perception of the situation, Hobo. I and many colleagues like to support shared decision-making. This means to me that we might discuss each of the issues of concern to you, including the possibilities that I might have information that you don't have even after your research, and that I might have experience which you would find valuable in coming to your own decision. I would document that you chose to decline my advice and usually this would reduce my medicolegal risk. We do or omit stuff "against medical advice" all the time, upon the patient's direction.

It's true that there are exceptions to the above. For example, I would not do something which might harm my patient with no risk of benefit no matter what the patient asked for, it's my ethical obligation. And I might decide that a given patient was making an irrational choice due to some mental or physical condition that brings the soundness of their judgment into question.

I would probably not respond positively to a patient who comes in making vigorous demands that I do one thing or another -- that's not shared decision making, it's one-side decision making. It would be a whole different story if you thoughtfully told me what you wanted and why, I had a chance to respond and coach you, and ultimately we agreed on what was wise, or agreed to disagree. I would not jeopardize my medical license or malpractice protection to do so, but I routinely modify Plan A in order to meet special requests from patients. Both parties need to be comfortable with that decision, at least in my practice. I allow people to die of their disease routinely in my practice (in a referral cancer center), and in fact help keep them comfortable in the process.

Hope that clarifies what I meant.

That does clarify a lot. I hope we can agree that these kind of issues must be part of the upcoming debate on health care. I am sure that you would be much more comfortable with reasonable tort reform, as would I.

I have a great respect for most doctors - and their opinions. However, I have run into situations where the sword of Damocles, ie, malpractice law suits, hangs over the head of a doctor and has stood in the way of (what I consider) my God-given rights.

I also hope we can also agree that the trajectory of technology must be leveled off at some point. The way we are heading it will soon be possible to keep the human body alive indefinitely. An ethical sea change is clearly necessary. The Hippocratic oath needs to be modernized to reflect a world which is starting to feel the effects of over-population.

 

[Rich_by_the_Bay]

My academic focus in my career has been decision analysis. I am painfully aware of the dangers of misinterpreting probabilities, and the need to incorporate patient values into medical decision making. Not all of my colleagues are so oriented, and not all of my patients are interested in it.

You might be surprised to know that perhaps 80% of my patients, when faced with that kind of decision, just say some form of, "I'll do whatever you recommend." Even then, I run through my patter in all its glory.

Sounds like you've been burned in the past. Just wanted to strike a cautionary note - this medicine gig can get pretty complex, pretty fast, with pretty serious results. For the easy stuff it probably doesn't matter whether you even see a doctor, but for the more serious issues we old folks will be facing sooner or later it's a good idea to have a shepherd in place.