Wednesday, July 7, 2010

Has Medicare access reached a tipping point?

For years, physicians have argued that the specter of annual cuts in Medicare will cause many of them to leave the program, or at the very least, to limit how many new Medicare patients they will accept in their practices. Yet, for the most part, measures of seniors' access show that the vast majority enjoy good access to care.

For instance, in May of this year, the Medicare Payment Advisory Commission (MedPAC), which advises Congress on payment policies, published the results of focus groups of physicians and beneficiaries. It reported that neither beneficiaries nor physicians believe that there are widespread access problems for beneficiaries.

Views of beneficiaries:

"We heard few concerns about access to physicians in any of the three locations selected for this study ... Most beneficiaries felt they could get appointments in a reasonable amount of time as appropriate to the medical situation. For the most part, access issues do not appear to have changed for these beneficiaries over the past several years. Most beneficiaries have no trouble finding doctors, but there were a few more reports of issues with access to specialists than for primary care."

Views of physicians:

"Most physicians were accepting new Medicare patients, but a few were not. All physicians were required to have at least 10 percent Medicare patients in their practice to be invited to one of our focus groups, but a few reported that they had stopped taking new Medicare patients. A few others have given serious consideration to stopping ... Physicians see Medicare as a reliable payer, and appreciate the lack of preapproval requirements."

The focus group findings mirrored surveys of beneficiaries, also commissioned by MedPAC. "In 2006 - the most recent year for which we [MedPAC] have data from the Medicare Current Beneficiary Survey - more than 90 percent of beneficiaries reported good access to care, regardless of the question asked." Moreover, Medicare beneficiaries' reported access was better than for privately-insured persons. The same survey, though, did show that there may be a growing (but relatively modest) problem with beneficiary access to primary care:

"Of the 6 percent of Medicare beneficiaries who were looking for a new primary care physician in 2008, 28 percent reported problems finding one. Although this amounts to less than 2 percent of the total Medicare population reporting problems, the Commission is concerned about the continuing trend of greater access problems for primary care.

Maggie Mahar, blogging in Health Beat, also casts doubt more on the notion that a large number of doctors are boycotting Medicare. Citing the MedPAC surveys and other data, she notes that there is palpable "anxiety" among physicians, "The take-away message is that while the 21% cuts doctors are now facing are an administrative nightmare, they will be fleeting. And reports of a mass exodus by doctors from Medicare are overblown."

She may be right that there isn’t a "mass" exodus from Medicare - yet.

But something tells me that this time, things may be different. The latest cut and the chaos it creates may have reached a tipping point. An ACP member from Georgia told me that it wasn't until yesterday that her practice received the first check from Medicare (with the 21% cut included) since the first of the month, and that as a result, her practice is living off credit and having trouble making ends meet. She predicted that she, and many others, will soon have no choice but to close their primary care practices if Medicare can’t be counted on to pay its bills.

But it more than money, I think, that is behind more and more physicians giving thought to what in the past was unthinkable: finding a way to make a living that doesn't involve Medicare. It is a matter of the government breaking the bond of trust between doctors and the program. Trust that they government will pay them fairly, and on time, for their services, in exchange for physicians honoring their commitment to provide seniors with the best care possible. And as any cuckolded spouse can tell you, once a bond of trust is broken, it is almost impossible to restore.

Today's question: Do you think the latest SGR debacle will create an access "tipping point" for patients?


Steve Lucas said...

The problem with surveys is they tend to be rearward looking, and while useful for planning in a fairly stagnant environment, they will not take into account major shifts in pricing or technology.

Doctors and patients need to look forward to determine what practice model will best serve both our needs. One issue often forgotten in the whole health care debate is; medicine is a craft. While it is possible to put together a standard time for any function, the reality is some things take longer and some things can be done faster than book We have all had those days when nothing goes right.

EMR’s and yearly health plans are great in theory, but if used as measurement tools for a practice may become impediments to good medicine. Time spent with an EMR is time away from the patient. Yearly health plans are great for the stable patient, but go out the window in dealing with the often fast paced changes in a person’s health. We are sorry Mr. Smith but your heart attack is not on this year’s health plan, we will work it in next year.

Once again I would ask; Doctors where do you want to be in regards to your practice and how will you get there in the next year?

Steve Lucas

Jay Larson MD said...

The MedPAC focus group survey published this past May is not statistically significant. The study only involved 99 patients and 64 MD’s (32 specialists/32primary care) from Baltimore, Chicago, or Seattle. How can so few represent the experiences of hundreds of thousands of physicians and tens of millions Medicare recipients? Plus, there was no evaluation of rural areas in the study.

If the same survey took place in Helena, MT, the results would be much different. At the end of this year, Helena will be at 4 general internists, down from a dozen in 1990 when the population was half as much.

Other sources of information reflect a different trend than the MedPAC study. In the USA Today 6-21-10 there was an article that cited that:

“• The American Academy of Family Physicians says 13% of respondents didn't participate in Medicare last year, up from 8% in 2008 and 6% in 2004.

• The American Osteopathic Association says 15% of its members don't participate in Medicare and 19% don't accept new Medicare patients. If the cut is not reversed, it says, the numbers will double.

• The American Medical Association says 17% of more than 9,000 doctors surveyed restrict the number of Medicare patients in their practice. Among primary care physicians, the rate is 31%.

States are starting to see a flight from Medicare:
•In Illinois, 18% of doctors restrict the number of Medicare patients in their practice, according to a medical society survey.

•In North Carolina, 117 doctors have opted out of Medicare since January, the state's medical society says.

•In New York, about 1,100 doctors have left Medicare. Even the medical society president isn't taking new Medicare patients.”

The question of access should not be “do most Medicare patients have access”, but rather “do those who need access the most (multiple chronic medical conditions) have access”. 20% of the population with chronic medical illness consume 80% of health care dollars. This is the group that needs access to primary care. The current trend is for most new physicians to pursue procedure based specialties. By attrition, this will result in less primary care availability.

With the recent 21% SGR cut debacle, I looked into what it takes to opt out of Medicare. It is rather an easy process. Medicare recipients could still see a provider who opted out of Medicare, it is just that they are financially responsible for the charges (which is set by the provider and not Medicare). Since cognitive office visits are relatively inexpensive compared to procedures, many Medicare patients could pay for these office visits. This would, though, leaves Medicare recipients with limited financial resources scrambling to find another physician.

For those who feel that there will not be any Medicare access to primary care issues in the future, just remember, a car runs just as well when the fuel gauge is near E(mpty) as it does when it is near F(ull). It just doesn’t go very far.

Harrison said...

Too many doctors and too few patients with resources.
Doctors in large numbers cannot choose to move away from Medicare unless they also in large numbers choose to move out of the practice of medicine.
It doesn't make sense to threaten legislators as we have been doing.
I believe that if you are threatening something you probably should already have done it.
Threats weaken your argument.


Rich Neubauer MD said...

Dr. Larson's entry is excellent and well put.

The measures that CMS has used to index access have been flawed to the point of being meaningless for many years. Clearly, CMS policies have driven the overall decline of primary care in this country for years. Sadly, national policies on payment and a lack of meaningful workforce policy have combined to yield a current situation where primary care is on the skids.

In Anchorage, Alaska where I work, the situation is much like Helena Montana. There are fewer and fewer internists who are working as primary care physicians and they are getting older and older. Family doctors here (with few exceptions) define their practices as "if you are medicare age, you are too complex for a family doctor". New young internists willing to work in an outpatient setting are nowhere to be found. Opting out of Medicare is increasing. Internists are not taking new Medicare patients. Those of us who care about this growing debacle are looking for other solutions, but it is difficult.

When a resource (such as excellent primary care for complex patients with multiple medical problems -- ie those best seen by a well trained, experienced general internist) dries up to a certain degree, it reaches a tipping point. Basically, it is no longer seen as something that is and should be there for everyone, it is looked at as a novelty that may be there for some but only the lucky (or those who can afford it....). I think this is Dr. Larson's point, and I concur. If CMS does not look at the current situation as a crisis, all they need to do is wait a bit longer and the crisis will be there for them and in their face. The tank is indeed near empty.

Unknown said...

Most medical practices are small businesses. To make payroll you must dip into your own assets or credit if the government or insurance companies do not pay their bills. Not taking Medicare patients is only one method of trying to make payroll. Small practices are closing in response to these fiscal realities. The burden of rules and regulations as well as the instability of cash flow make it nearly impossible to practice solo. With a group practice comes a business manager. The pressures to give up the fiscally irresponsible acts of charity we all commit, is a harsh unsatisfying reality that comes with a business manager. Charity is no longer private. My father went into medicine because he wanted to take care of everyone, no matter what their resources. It is a matter of personal shame that I make too little money to do this. Too much charity is too easily interpreted as "fraud and abuse". For the ACP to really understand the problems we face they need to understand the problems of practices that are on the verge of bankruptcy. Lofty ideas about "access" and the "right" to care cannot be addressed without realizing their are no rights without obligations. We cannot pay the bills and the escalating price of toys like ICD 10 without more money. Money is in short supply. What I want however is less rules and more freedom to simply see patients. Pay me, not the person that generates paperwork without actually touching and caring for patients.

PCP said...

It all depends on what you call access. If access to Mid level providers, CHCs and other massively expanding and Gov't subsidised "safety net clinics" or EMTALA captive ERs is considered access, then the future looks very bright indeed.
Current Gov't policies, roundly supported by organised medicine are making for a toxic environment for the average private practitioner. Yet there is no consideration for the necessary changes and worse yet less advocacy.
The list of issues that need fixing grows ever longer with increasing gov't intrusion into the health care delivery system. Ultimately we(the profession) will be blamed for its failings and the end result no matter what is professed at this time, will be an eventual nationalisation of a failed system with massive need and limited resources.
We as a nation appear unable or unwilling to tackle the main issues in this debate, such as the inevitable rationing of resources, curbs on welfare, revalidation of the Physician's leadership role in primary care teams etc.

So in my opinion, in the way defined by many including arguably the ACP. We will not have access issues.