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http://www.healthdecisions.org/News/default.aspx?doc_id=107009

Fewer Primary Care Doctors Take Medicare
Anchorage Daily News, Rosemary Shinohara
February 19, 2007



After Henry Taylor's doctor moved to Homer, Taylor, who is 77, needed two things: an Anchorage physician to prescribe drugs for diabetes and other ailments, and relief for his aching back.

He didn't realize his lungs were quietly killing him. He didn't find out until it was too late because he is on Medicare, and doctor after doctor refused to see him.

There's a crisis in health care for Alaska's older residents: Few primary care doctors take new patients on Medicare, the federal insurance program for people 65 and older.

The crisis is not new, but evidence indicates it is worsening.

Alaska is short of primary care doctors in general. And many of them say they can afford to treat only limited numbers of Medicare patients, if any, because the rates are too low -- often less than half what a doctor normally charges.

"When you get close to 23 to 25 percent of your visits from Medicare patients, you're going bankrupt," said Dr. Bruce Kiessling of Primary Care Associates, the largest primary care group in the state. "We do not take new Medicare, not at all."

Primary Care keeps existing patients who age into Medicare.

Once retired people turn 65, Medicare rules, even if a person has private insurance as well. Doctors must charge Medicare patients no more than Medicare allows. Medicare pays 80 percent of the allowed charge, after an annual deductible is met. The patient or private insurance picks up the rest.

About 55,000 Alaskans are enrolled in Medicare.

Some doctors opt out of Medicare altogether and patients are responsible for payments. Kiessling's office did that for a time.

"You can't blame the providers for not wanting to see us because the federal government is paying so little," said Janet Mischler, 67, a retired nurse. "A lot of people don't go (to the doctor) unless it's really bad."

Medicare represents a significant share of federal spending, and the government wants to hold costs as low as possible. The president's upcoming budget anticipates that payments to doctors will be cut at least 8 percent next year, The New York Times reported recently.

Anchorage residents on Medicare seem to have a harder time finding primary care doctors than in most of the country, although many say they don't have a problem getting in to see specialists like cardiologists or lung doctors.

Some Alaskans report they go Outside to get their general checkups because it's easier.

Doctors say there's such a big disparity between what Medicare allows for a service and what Alaska doctors charge non-Medicare patients partly because it costs more to practice medicine here.

Dr. Richard Neubauer, an internist who often speaks out on Medicare, said overhead is higher. There are no big outside forces, such as huge corporations or unions, that can impose their will on the medical establishment and drive down costs, Neubauer said.

The state's congressional delegation persuaded Congress that Alaska doctors needed special rates during 2004 and 2005. Alaska won a temporary boost of more than 50 percent in Medicare payments, according to a report at the time from the Alaska State Medical Association.

The delegation tried and failed to get that boost extended. The rates dropped in January 2006, and remain flat for 2007.

Those in the trenches of senior health care in Alaska say Medicare clients have more trouble than ever getting in to a general practitioner.

"It's gotten worse and worse and worse," said Rita Hatch of the Older Person's Action Group. She surveys Anchorage doctors' offices daily to see who's taking new Medicare patients and finds hardly any. "It's the most serious problem seniors are facing right now," Hatch said.

People seeking new doctors call Anchorage Neighborhood Health Center with two messages, said Dr. Tom Hunt, the center's medical director: My doctor dropped me, or, more commonly, I moved my mother into town. Or we just moved in, and this is the ninth doctor I called.

Anchorage Neighborhood Health is a nonprofit corporation that serves a lot of uninsured patients but is open to everyone. However, the center offers only limited advance appointments.

Hatch advises callers to use an advanced nurse practitioner instead of a doctor, because nurse practitioners are more accessible.

Anna Bell Stevens, 77, goes to a nurse practitioner. It works well, until she needs a doctor, she said. When she had pneumonia several years ago, she went to a small clinic near her house in Turnagain on a Saturday.

"When the lady saw I was past 65, she said, 'We're not taking Medicare patients.' I am dying, practically, and they wouldn't see me. There is something wrong with a system when you cannot walk into a doctor's office and pay for being seen. To me, it's just absolutely wrong."

Technically, a person can choose to pay out-of-pocket for services, and ask the doctor not to bill Medicare. But in practice, Medicare beneficiaries say, places that aren't taking new Medicare patients often won't see them, regardless.

Mary Ann Lindbeck, 82, secured a doctor for her husband, who has since died, by breaking down in her doctor's office.

"I was trying to get Ed in there. The office nurse was saying, 'We aren't taking any more, we can't.' And I burst into tears. (Her doctor) came by, looked at me, and said, 'What's the matter with you?' "

Henry Taylor, who lives in South Anchorage with daughter Pat Cochran and a Boston bull terrier that licks everything that moves, relies on his sense of humor in a grim situation.

"I call myself 'Medicareless Henry,'" he joked.

After the doctor Taylor had been seeing moved to Homer, Taylor drifted from one untenable arrangement to the next.

Though he lives off O'Malley Road, Taylor started seeing a doctor at the Acute Family Medicine Clinic in Eagle River because they would take him. Effective January 2006, that doctor wrote patients that the clinic would no longer bill or receive payments from Medicare -- they were opting out altogether.

Then Taylor went to an urgent care clinic but had to wait sometimes for hours before they could get to him. With his back problems, that was a struggle.

Sometimes a doctor's willingness to take new Medicare patients changes from day to day.

Taylor's daughter had contacts at AARP and elsewhere, and moved fast whenever she got word a doctor might be taking Medicare patients.

"I probably called two or three dozen," Cochran said.

Taylor got a tip that a 77-year-old semi-retired doctor might see him, and in November he finally got a comprehensive exam. That's when they discovered he had advanced lung cancer.

Outside Alaska, Medicare clients mostly report adequate access to doctors, says a 2006 study by the Government Accountability Office, a congressional watchdog agency. But the GAO survey found twice as many Alaskans reported major difficulty signing on with a doctor than the national average.

The government has an interest in keeping health costs down, so if the system is working well, Congress is unlikely to raise reimbursement rates.

Why is it such a problem here?

Dr. Neubauer said medical care is more expensive to deliver here than in other states.

A recent study done for the University of Alaska and the state Department of Health and Social Services documented a growing shortage of doctors here compared with the national average, and cited a need for even more than we have as the population ages. The large Baby Boom generation starts turning 65 in 2011, just four years from now, and is expected to strain the health care system further.

With enough primary care doctors, the Medicare population would be spread around and the system would be more workable, Neubauer said.

U.S. Sen. Lisa Murkowski, R-Alaska, secured a seat on the Senate Health, Education, Labor and Pensions Committee partly to work on improved Medicare coverage in Alaska, she said in an interview.

Murkowski said she'll push aggressively to get higher reimbursement rates, and thinks colleagues are coming to recognize that Alaska's situation is different. "Our facts are just that much more extreme."

Murkowski has scheduled a Senate Health Committee hearing in Anchorage Feb. 20 to allow doctors to explain how the Medicare rates affect their practices, and members of the public to share their experiences.

For Henry Taylor, any help with Medicare will come too late.

He is getting treatment, but there is no hope for a cure.

"They said from the beginning, 'We cannot save your life,'" said his daughter, Cochran. "It's in both lungs. It's inoperable. It's in his bones."

Which leaves Taylor and Cochran wondering whether his outlook could have been better, with more timely treatment.

HOW IT WORKS: Here's an example of what Medicare pays in Alaska, compared with what doctors and nurse practitioners charge other patients:

At Health Works Family Medical Clinic in Eagle River, an established patient on the most common visit would be charged $121, said office manager Renee Blakely. Medicare allows $59.70.

If someone comes in with a list of problems, and takes an hour, the charge would be $281, said Blakely. Medicare pays $122.07.

SPEAK OUT: U.S. Sen. Lisa Murkowski will hold a hearing on the shortage of primary care physicians in Alaska, particularly in rural areas. The hearing by the Senate's Health, Education, Labor and Pensions Committee begins at 9 a.m. Tuesday at Loussac Library.

MEDICARE AT A GLANCE: Medicare is health insurance for people 65 and older, and for people younger than that with certain disabilities.

--Medicare Part A covers hospital care, and everyone gets it free.

--Part B covers services of doctors and nurse-practioners. It is optional, and costs money -- $93.50 per month for those who make $80,000 or less. If you don't take Part B when you are first eligible, it can cost more.

--Part D is the new, optional, prescription drug coverage. Beneficiaries choose from among a variety of available plans that cost different amounts. There can also be a penalty for joining late.

HOW DOCTORS GET PAID:

1. Assignment: You assign Medicare to pay your doctor directly. If a doctor accepts assignment, the doctor agrees to collect only the amount Medicare approves.

2. No assignment: Your doctor may accept Medicare but not accept assignment. In that case, the doctor may charge more than the Medicare-approved amount. But still, doctors are generally limited to charging a maximum of 15 percent more.
 

Miami_med

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Of course this is a problem. The government is now underpaying for services. The government has no real way of determining a proper fee schedule. Of course, I've noticed that this will probably be blamed on the doctors.
 

Faebinder

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We spoke abouit that in the FM forums... alaska is a nutty state for many reasons as I stated in the FM forum.
 
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Unfortunately it will take one of two things to get this fixed (and it's not just alaska, it's all over the country):

1. Some powerful Washington politician will have a person close to them die while waiting to find a doctor. The media will pick it up and things will happen.

2. (and more likely) Doctors will have to resort to some sort of a work stoppage to get this thing fixed. It worked in Ontario several years ago, and it'll work here. If physicians stopped working we'd see this thing resolved in a matter of days.
 

dilated

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Unfortunately it will take one of two things to get this fixed (and it's not just alaska, it's all over the country):

You forgot 3) Alaska state legislature will pass a bill requiring all doctors to see X% of Medicare pts as a condition of licensure. It's a lot easier for them to dictate their will on one small segment of their population than it is the federal behemoth in DC.
 
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You forgot 3) Alaska state legislature will pass a bill requiring all doctors to see X% of Medicare pts as a condition of licensure. It's a lot easier for them to dictate their will on one small segment of their population than it is the federal behemoth in DC.

I wouldn't count on that. That would be a great way to get rid of the few doctors that Alaska has already. Talk about backfiring...
 

Faebinder

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You forgot 3) Alaska state legislature will pass a bill requiring all doctors to see X% of Medicare pts as a condition of licensure. It's a lot easier for them to dictate their will on one small segment of their population than it is the federal behemoth in DC.

Ya? Watch all the docs move out of Alaska at that point....
 
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