Should You Opt Out of Medicare?

[Voevoda]

Maybe a similar thread was already created, but I tried searching for it and couldn't find it. Sorry if it is a repost.

Came across this article today: Should You Opt Out of Medicare?

It might not be relevant now to many of us who are on our way toward becoming physicians, but in a very near future we might just be the doctors in the exact predicament.

I know it is a long article (5 pages); here are the poorman's cliffs, but I encourage you to read the paper instead:

• Medicare reimbursements/paperwork/hassles are ludicrous.
• Some physicians are opting out of Medicare.
• Those who opt out spend more time with patients and have more profitable practices.
• If the current trend of Medicare continues more physicians will opt-out.

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[FutureCTDoc]

The answer is yes, with a caveat. If you're in a traditionally cash and carry specialty i.e. Psych, derm or plastics, the answer is a resounding yes. Some other specialties like IM/FM might be able to depending on the area of practice. Medicare is a huge pain.

 

[Musclemass]

The answer is yes, with a caveat. If you're in a traditionally cash and carry specialty i.e. Psych, derm or plastics, the answer is a resounding yes.

What's a cash and carry specialty?

Physicians have a public health obligation, part of which is covered by the expectation that they will accept some Medicare patients. Choosing to limit the number in a practice seems reasonable but rejecting all, I have a problem with. Does your grandma have a doc to go to when she has a medical problem? How would you feel if she didn't? If her doc opts out, who should provide her care?

Medicare is a very political matter. Docs don't have a lot of friends in Congress. Opting out puts no pressure on Congress to raise reimbursements, it's ineffective (and selfishly childish). If too many opt out, it will simply be mandated.

 

[group_theory]

What's a cash and carry specialty?

Physicians have a public health obligation, part of which is covered by the expectation that they will accept some Medicare patients. Choosing to limit the number in a practice seems reasonable but rejecting all, I have a problem with. Does your grandma have a doc to go to when she has a medical problem? How would you feel if she didn't? If her doc opts out, who should provide her care?

Medicare is a very political matter. Docs don't have a lot of friends in Congress. Opting out puts no pressure on Congress to raise reimbursements, it's ineffective (and selfishly childish). If too many opt out, it will simply be mandated.

There's a public health obligation? Really? Where? Show me. And if you mention hippocratic oath, show me where.


Medicare comes with lots of regulations and associated unfunded mandates attached. It is also subject to a lot of paperwork, and if you fill out the paperwork incorrectly, you committed medicare fraud (fines, penalties, paybacks, etc), just because you didn't fill it out properly.

Also, when you hear about medicare cuts of 20%, it's not 20% of your paycheck. It's 20% of your reimbursement. Your overhead and expenses remains the same or higher. So your net income loss is more than 20%.

Medicaid is even worse, often the reimbursement doesn't cover overhead expenses (so you're losing money by seeing a medicaid patient instead of an insured patient). And with state budgets these days, medicaid reimbursements will get cut even more.

In terms of opting out - Senior Citizens/AARP are very powerful forces. The AARP applies a lot of pressure on Congress to patch the medicare system every year (to prevent the cuts).

 

[Lokhtar]

Considering medicare spends like $500k training you, I'd personally feel weird about refusing medicare patients. But that's me. People are free to do what they want.

I am not planning on going into private practice anyway, so I won't have to make that decision.

 

[Mizoodles]

how does medicare spend 500k training you?

 

[Lokhtar]

Residency is paid for by Medicare.

 

[FutureCTDoc]

What's a cash and carry specialty?

Physicians have a public health obligation, part of which is covered by the expectation that they will accept some Medicare patients. Choosing to limit the number in a practice seems reasonable but rejecting all, I have a problem with. Does your grandma have a doc to go to when she has a medical problem? How would you feel if she didn't? If her doc opts out, who should provide her care?

Medicare is a very political matter. Docs don't have a lot of friends in Congress. Opting out puts no pressure on Congress to raise reimbursements, it's ineffective (and selfishly childish). If too many opt out, it will simply be mandated.

I don't see it as an obligation to take a certain insurance carrier. I can say I don't take Blue Cross/Blue Shield, is that a moral issue? My grandmother does have a physician to go to, if she didn't she would go to a physician who was cash and carry and if not that my father has an MD after his name.

If congress tries and force it 1) this is a power delegated to the states 2) I could "accept medicare" with the next open medicare appointment in 2099 or with a retainer up front and go concierge.

 

[Slack3r]

What's a cash and carry specialty?

Physicians have a public health obligation, part of which is covered by the expectation that they will accept some Medicare patients. Choosing to limit the number in a practice seems reasonable but rejecting all, I have a problem with. Does your grandma have a doc to go to when she has a medical problem? How would you feel if she didn't? If her doc opts out, who should provide her care?

Medicare is a very political matter. Docs don't have a lot of friends in Congress. Opting out puts no pressure on Congress to raise reimbursements, it's ineffective (and selfishly childish). If too many opt out, it will simply be mandated.

Lol. Settle down, hippie.

 

[IvyHopeful20]

If congress tries and force it 1) this is a power delegated to the states

No, they can certainly make restrictions on your ability to practice medicine. Regardless, if you accept federal government funds for training, they can certainly (legally) put that type of restrictions.

They likely won't, but it would certainly be legal.

 

[FutureCTDoc]

No, they can certainly make restrictions on your ability to practice medicine. Regardless, if you accept federal government funds for training, they can certainly (legally) put that type of restrictions.

They likely won't, but it would certainly be legal.

Actually it wouldn't be. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." This power is not delegated to the feds, when they try and make an end run via either calling it taxation or commerce clause, odds are SCOTUS will say no. Medicine has traditionally been regulated by the states and I doubt that saying you must take medicare would be constitutional.

 

[gettheleadout]

Actually it wouldn't be. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." This power is not delegated to the feds, when they try and make an end run via either calling it taxation or commerce clause, odds are SCOTUS will say no. Medicine has traditionally been regulated by the states and I doubt that saying you must take medicare would be constitutional.

Personally I think the idea of "accepting Medicare" and warning in advance that you're booked for the next 30 years sounds good. If you really have to get out of it, that is.

 

[Musclemass]

There's a public health obligation? Really? Where? Show me. And if you mention hippocratic oath, show me where.


Medicare comes with lots of regulations and associated unfunded mandates attached. It is also subject to a lot of paperwork, and if you fill out the paperwork incorrectly, you committed medicare fraud (fines, penalties, paybacks, etc), just because you didn't fill it out properly.

Also, when you hear about medicare cuts of 20%, it's not 20% of your paycheck. It's 20% of your reimbursement. Your overhead and expenses remains the same or higher. So your net income loss is more than 20%.

Medicaid is even worse, often the reimbursement doesn't cover overhead expenses (so you're losing money by seeing a medicaid patient instead of an insured patient). And with state budgets these days, medicaid reimbursements will get cut even more.

In terms of opting out - Senior Citizens/AARP are very powerful forces. The AARP applies a lot of pressure on Congress to patch the medicare system every year (to prevent the cuts).

I understand quite well how it works. Neither the AMA nor AARP have been effective, because as I mentioned, I don't think docs have too many friends in the federal or state legislatures. The system could get worse before it gets better, but thankfully there are many fine docs to provide care for people who you think are not deserving of your time.

 

[Musclemass]

My grandmother does have a physician to go to, if she didn't she would go to a physician who was cash and carry and if not that my father has an MD after his name.

Go to an inner city or low income area. I don't care which, you pick one. Drive or walk around until you see a female senior citizen. Ok, that's your grandma, what's your suggestion if she becomes ill?

For those who feel there is any societal or moral obligation to make medical care more available, there is at least partial coverage available now for older people. The system is broken in many different ways but I think something is better than nothing.

It makes no sense to me to think universal coverage is desirable, but you opt out of the partial system that exists now. And if you don't think broader coverage should be available (just as a concept, without regard to what the details are), then that saddens me.

 

[gravitywave]

Actually it wouldn't be. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." This power is not delegated to the feds, when they try and make an end run via either calling it taxation or commerce clause, odds are SCOTUS will say no. Medicine has traditionally been regulated by the states and I doubt that saying you must take medicare would be constitutional.

ummm, no. there aren't many laws that SCOTUS has taken down based on the Tenth Amendment, and none in the manner you are describing.

 

[IvyHopeful20]

Actually it wouldn't be. "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." This power is not delegated to the feds, when they try and make an end run via either calling it taxation or commerce clause, odds are SCOTUS will say no. Medicine has traditionally been regulated by the states and I doubt that saying you must take medicare would be constitutional.

Um, it has never been interpreted that way. The law could easily say that if you have been trained using medicare funds, you must take medicare in order to be licenced (maybe for DEA licence).

So either train yourself outside of medicare, or take medicare.


Obviously, I don't think this will happen, but it wouldn't be illegal.

 

[gettheleadout]

I understand quite well how it works. Neither the AMA nor AARP have been effective, because as I mentioned, I don't think docs have too many friends in the federal or state legislatures. The system could get worse before it gets better, but thankfully there are many fine docs to provide care for people who you think are not deserving of your time.

Its not an issue of whether a patient who pays through certain means is deserving or not, it's an issue of "I can't keep my practice open if I take Medicare because I lose money on every patient."

 

[Ursa]

Residency is paid for by Medicare.

So by 500K you mean like maybe 200K? Tell me what residency position pays a total of 500K and I'll tell you where I'm doing my residency.

And FWIW, I would totally opt out of Medicaid if given the opportunity. Maybe Medicare too, we'll see how that situation looks after a few years.

 

[Parts Unknown]

So by 500K you mean like maybe 200K? Tell me what residency position pays a total of 500K and I'll tell you where I'm doing my residency.

When you factor in non-salary benefits (health insurance, malpractice insurance, life insurance, disability insurance, etc.), the per-year funding for a resident can approach 100K. If you do IM and then subspecialize, that's six years, during which you can very much soak up 500K in aggregate CMS dollars.

 

[Ursa]

When you factor in non-salary benefits (health insurance, malpractice insurance, life insurance, disability insurance, etc.), the per-year funding for a resident can approach 100K. If you do IM and then subspecialize, that's six years, during which you can very much soak up 500K in aggregate CMS dollars.

Meh, benefits. Ones aint money.

 

[Parts Unknown]

Meh, benefits. Ones aint money.

Now that I am in private practice and paying for my own life insurance and disability insurance out of pocket, and my health/dental insurance is far less subsidized than it was in training, I can assure you that benefits is money.

 

[Ursa]

Now that I am in private practice and paying for my own life insurance and disability insurance out of pocket, and my health/dental insurance is far less subsidized than it was in training, I can assure you that benefits is money.

I said ones aint money, not benefits. It was sort of an inside reference. Sorry if you didn't understand.

TauKap > AAA

 

[RogueUnicorn]

There's a public health obligation? Really? Where? Show me.

government backed loans?

 

[IvyHopeful20]

So by 500K you mean like maybe 200K? Tell me what residency position pays a total of 500K and I'll tell you where I'm doing my residency.

Well just because it's not your salary doesn't mean medicare doesn't pay. It simply pays to the hospital - you get a percentage of that, but it still costs medicare that much $$.

 

[powersr8810]

Healthcare costs currently account for 16% of America's GDP and this number is only going up. Medicare pays for a SIGNIFICANT chunk of this care (try 14% of the federal budget in 2009, thats $511 Billion!!!) There is a lot of Medicare money out there for any Doc. By not accepting Medicare patients you are passing on easy money, especially b/c Medicare is Fee For Service (ie. you get paid for every procedure/test/whatever else you bill for as a physician). Not to sound crass but there are a lot of old people out there that go to the Dr. a lot so it is quite easy to make up for the lower reimbursement rates through volume. If any hospital in the US decided to decline Medicare, they would not be able to afford to stay open anymore --> leading to worse healthcare and sicker patients. So do the math, it is likely a better business decision to accept Medicare patients, unless of course you are in plastics doing boob jobs (which is elective and Medicare wouldn't pay for anyways).

 

[Xerxes1729]

Moral arguments aside, the pool of elderly patients who can pay for their health care out-of-pocket is fairly limited. A few physicians can opt out of Medicare now and still have enough patients, but if everyone were to do it, there wouldn't be enough self-pay patients to go around.

 

[Charles_Carmichael]

Healthcare costs currently account for 16% of America's GDP and this number is only going up. Medicare pays for a SIGNIFICANT chunk of this care (try 14% of the federal budget in 2009, thats $511 Billion!!!) There is a lot of Medicare money out there for any Doc. By not accepting Medicare patients you are passing on easy money, especially b/c Medicare is Fee For Service (ie. you get paid for every procedure/test/whatever else you bill for as a physician). Not to sound crass but there are a lot of old people out there that go to the Dr. a lot so it is quite easy to make up for the lower reimbursement rates through volume. If any hospital in the US decided to decline Medicare, they would not be able to afford to stay open anymore --> leading to worse healthcare and sicker patients. So do the math, it is likely a better business decision to accept Medicare patients, unless of course you are in plastics doing boob jobs (which is elective and Medicare wouldn't pay for anyways).

You can only increase your patient volume so much. From what I've gathered from talking to physicians, the math suggests that it's not a good idea to add on Medicare/Medicaid patients. I'm weakly-versed in this area though, so I could be wrong/misinterpreting what was told to me.

 

[powersr8810]

The point I was making is that a doc can still make a lot of money off of Medicare patients. Imagine an orthopedic surgeon that specializes in knees and hips (I shadowed on exactly like this). A very large proportion of his patients were Medicare and he still had 2 airplanes and many very nice toys. In primary care, this is unlikely so I suppose it really depends on the Dr.

 

[Charles_Carmichael]

The point I was making is that a doc can still make a lot of money off of Medicare patients. Imagine an orthopedic surgeon that specializes in knees and hips (I shadowed on exactly like this). A very large proportion of his patients were Medicare and he still had 2 airplanes and many very nice toys. In primary care, this is unlikely so I suppose it really depends on the Dr.

The physician you shadowed is an outlier, not an example of the norm. Not many people, physician or not, own even one plane, let alone two.

Besides, from what I understand, the reimbursement for orthopedic surgeries is much higher than an office visit to a PCP. That needs to be taken into account as well.

 

[DrYoda]

By not accepting Medicare patients you are passing on easy money

No, you're passing up a lower paying client.

especially b/c Medicare is Fee For Service (ie. you get paid for every procedure/test/whatever else you bill for as a physician)

It doesn't matter. Lower payment is lower payment. (and it's not like medicare is the only payer that pays fee-for-service.)

So do the math, it is likely a better business decision to accept Medicare patients,

It's actually a better business decision to shun medicare/aid and take the higher payment for the same work.

 

[Dr Oops]

government backed loans?

key word loan. which u pay interest on.

 

[gravitywave]

By not accepting Medicare patients you are passing on easy money, especially b/c Medicare is Fee For Service (ie. you get paid for every procedure/test/whatever else you bill for as a physician).

plenty of insurance programs are fee-for-service. i'm pretty sure the docs who stop accepting government insurance know that. It's not so much that they are trying not to treat the patient with the lower paying insurance as they are trying to treat more of the higher paying ones. when there are only so many hours in the day, it's easy to end up losing money on every Medicare patient you see. and nearly everyone loses money on Medicaid patients, that's straight-up charity.

key word loan. which u pay interest on.

lol, no. key word is "government-backed." have you had a look at what you'd pay for a private loan?

 

[Parts Unknown]

Maybe a similar thread was already created, but I tried searching for it and couldn't find it. Sorry if it is a repost.

Came across this article today: Should You Opt Out of Medicare?

It might not be relevant now to many of us who are on our way toward becoming physicians, but in a very near future we might just be the doctors in the exact predicament.

That depends on a number of variables. This article was geared towards physicians who work in outpatient clinics, and therefore have some say in their patient base. If you work for a hospital as either a direct employee or a contract worker you may not have this choice. Opting out of Medicare if you work in an ICU probably isn't a viable career path.

Also, contrary to what some would have you believe, it is possible to make money from Medicare patients. You just have to be performing services with favorable fees. People doing cardiac caths made a killing, so to speak, which explains why so many patients got them as opposed to aggressive medical management (which is at leaste as effective). In my field, flow cytometry brought in mad cash for a period, up to a third of the entire revenue stream of an academic department. The profit margins for home health were 17%, although those days are ending.

The last paragraph of this article sums it up nicely for me:

As a healthcare ethicist, Waymack has his own words of advice to those just entering the medical field: “Think about the social good side of medicine as a profession. Medicine isn’t a job like selling automobiles or real estate—it’s a profession. Part of the baggage of that profession is not only certain privileges but also certain obligations. In my mind, the long-term solution rather than opting out is to persuade, argue, or lobby for a more rational Medicare reimbursement system.”

 

[RogueUnicorn]

key word loan. which u pay interest on.

a loan you might not have gotten otherwise and a rate lower than you might have gotten otherwise..

 

[powersr8810]

The physician you shadowed is an outlier, not an example of the norm. Not many people, physician or not, own even one plane, let alone two.

Besides, from what I understand, the reimbursement for orthopedic surgeries is much higher than an office visit to a PCP. That needs to be taken into account as well.

Good point. And ya PCP's get paid far less than any surgeon but thats a whole other issue.

 

[NickNaylor]

government backed loans?

Maybe I'm selfish, but I don't feel bad about simply paying back ny government loans and going on my merry way.

 

[RogueUnicorn]

Maybe I'm selfish, but I don't feel bad about simply paying back ny government loans and going on my merry way.

there's nothing wrong with that at all. but the reason med students are able to get these loans to start with is because the government recognizes doctors as a public necessity.

 

[Dr Oops]

a loan you might not have gotten otherwise and a rate lower than you might have gotten otherwise..

Wrong. private loans have lower interest rates right now as long as your credit isnt ****. In fact about 2-3 years ago government loan interest rates were higher.

Banks and lenders would love to give med students loans, the drop out rate is low and there is high probability that you will be able to make the payments after school.

The good thing about government loans is IBR and discharge after 10 years if you work a nonprofit.

But doesnt matter who the lender is they always have the better side of the deal.

 

[familyaerospace]

If I work at a hospital, I don't think I would care about whether or not the patient had Medicare/Medicaid.

If I go into private practice since I would have to run a business, I would chose to limit Medicare/Medicaid patients once my practice started to fill up. Eventually, it would be a "no new Medicare/Medicaid" issue. That isn't to say I wouldn't treat poor people if my practice ended up at 100% non-government, I would end up volunteering a few hours a month at a free clinic. If I were to go into some type of "concierge medicine" business I would most likely spend even more time with the poor or do more volunteer work. Maybe something like Dr. Lawson from Royal Pains who was once called "Doctor to the rich, Robin Hood to the poor." I like that idea.

My best friend is on Medicaid and she knows all too well all the problems that she has finding doctors are because of doctors opting out due to poor reimbursement rates. She doesn't blame the doctors one bit which I think is pretty big of her. Of course the more she hangs around me, the more sympathy she feels for doctors!

My grandmother is also disgusted with Medicare's treatment of doctors and she doesn't blame them either. Of course, I think half the reason she still works at the age of 78 even though she is disabled and really shouldn't be working is because her company offers her medical insurance so she doesn't have to rely as highly on the Medicare system.