Texas doctors opting out of Medicare at alarming rate

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Moonglow

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(Disclaimer: I have an active Texas medical license)


By TODD ACKERMAN
HOUSTON CHRONICLE

May 17, 2010, 11:02PM

Texas doctors are opting out of Medicare at alarming rates, frustrated by reimbursement cuts they say make participation in government-funded care of seniors unaffordable.

Two years after a survey found nearly half of Texas doctors weren't taking some new Medicare patients, new data shows 100 to 200 a year are now ending all involvement with the program. Before 2007, the number of doctors opting out averaged less than a handful a year.

"This new data shows the Medicare system is beginning to implode," said Dr. Susan Bailey, president of the Texas Medical Association. "If Congress doesn't fix Medicare soon, there'll be more and more doctors dropping out and Congress' promise to provide medical care to seniors will be broken."
More than 300 doctors have dropped the program in the last two years, including 50 in the first three months of 2010, according to data compiled by the Houston Chronicle. Texas Medical Association officials, who conducted the 2008 survey, said the numbers far exceeded their assumptions.

The largest number of doctors opting out comes from primary care, a field already short of practitioners nationally and especially in Texas. Psychiatrists also make up a large share of the pie, causing one Texas leader to say, "God forbid that a senior has dementia."

The opt-outs follow years of declining Medicare reimbursement that culminated in a looming 21 percent cut in 2010. Congress has voted three times to postpone the cut, which was originally to take effect Jan. 1. It is now set to take effect June 1.

Not cost-effective

The uncertainty proved too much for Dr. Guy Culpepper, a Dallas-area family practice doctor who says he wrestled with his decision for years before opting out in March. It was, he said, the only way "he could stop getting bullied and take control of his practice."

"You do Medicare for God and country because you lose money on it," said Culpepper, a graduate of the University of Texas Medical School at Houston. "The only way to provide cost-effective care is outside the Medicare system, a system without constant paperwork and headaches and inadequate reimbursement."

Ending Medicare participation is just one consequence of the system's funding problems. In a new Texas Medical Association survey, opting out was one of the least common options doctors have taken or are planning as a result of declining Medicare funding — behind increasing fees, reducing staff wages and benefits, reducing charity care and not accepting new Medicare patients.

In 2008, 42 percent of Texas doctors participating in the survey said they were no longer accepting all new Medicare patients. Among primary-care doctors, the percentage was 62 percent.

The impact on doctors has not been lost on their patients. Kathy Sweeney, a Houston retiree, twice has been turned away by specialists because they weren't accepting new Medicare patients. She worries her doctors might have to drop her if Medicare cuts go through and they can't afford to continue in the program.

"I've talked to them about the possibility," said Sweeney, who sent her legislators a letter calling on them to fix Medicare. "They're hanging in there as long as there's not a severe cut, but just thinking I couldn't continue doctor-patient relationships I built up over years is disturbing. Seniors should be able to see the doctors they want."

The problem dates back to 1997, when Congress passed a balanced budget law that included a Medicare payment formula aimed at reining in spending. The formula, which assumed low growth rates, called for payment cuts if spending exceeded goals, a scenario that occurred year after year as health care costs grew. The scheduled cuts, expected to be modest, turned out to be large.

Congress would overturn the cuts, but their short-term fixes didn't keep up with inflation. The Texas Medical Association says the cumulative effect since 2001 already amounts to an inflation-adjusted cut of 20.9 percent. In 2001, doctors receiving a $1,000 Medicare payment made roughly $410, after taking out operating expenses. In 2010, they'll net $290. If the scheduled 21.2 percent cut goes through, they'd net $72, effectively an 83 percent cut since 2001.

The issue caused the Texas Medical Association to break ranks with the American Medical Association and oppose health care reform efforts throughout 2009. Then TMA President Dr. William Fleming said "reform is doomed to failure" without Medicare reform and called Congress' failure to devise a rational payment plan "an insult to seniors, people with disabilities and military families."

No surprise to senator

U.S. Sen. John Cornyn, R-Texas, said he isn't surprised by the new opt-out numbers, allowing that Congress' inability to reform Medicare is leaving "seniors without access and breaking the promise we made to them."

"The problem has been how to eliminate the cuts without running up the deficit," said Cornyn, responding to blame U.S. Rep. Gene Green, D-Houston, placed on the Senate for not passing a House bill that would have provided a longer-term Medicare fix. "There hasn't been the political will, but we really have no choice but to fix it."

Cornyn acknowledged the task is daunting. The Congressional Budget Office recently estimated that eliminating scheduled Medicare payment cuts through 2020 would cost $276 billion.

The growth in Texas Medicare opt-outs began in earnest in 2007, when 70 doctors notified Trailblazer Health Enterprises, the state's Medicare carrier, they would no longer participate, up from seven in 2006. The numbers jumped to 151 in 2008, fell back to 135 in 2009 and are on pace for 200 in 2010. From 1998 to 2002, by contrast, no more than three a year opted out.

Now, according to a Texas Medical Association new poll, more than four in 10 doctors are considering the move.

"I've been in practice 24 years, and a lot of my patients got old right along with me," Culpepper said. "It's stressful to tell them you're leaving Medicare and they're responsible for payments if they want to stay with you. You feel like you're abandoning them."

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http://www.chron.com/disp/story.mpl/metropolitan/7009807.html

Comment: An average of three hundred physicians opting out over two years in a state the size of Texas may not seem alarming, but it is a dramatic percentage increase in the rate of physicians opting out; and how many thousands of patients did those 300 docs cover? And obviously there are a growing percentage of new Texas physicians who will not be taking Medicare/Medicaid/Tricare patients.

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(Disclaimer: I have an active Texas medical license)




Comment: An average of three hundred physicians opting out over two years in a state the size of Texas may not seem alarming, but it is a dramatic percentage increase in the rate of physicians opting out; and how many thousands of patients did those 300 docs cover? And obviously there are a growing percentage of new Texas physicians who will not be taking Medicare/Medicaid/Tricare patients.

A few comments:

a. On one hand, this is upsetting because for the most part ... Medicare patients are very worthy, need a lot of medical attention, etc.

b. On the other hand ... I do think it's good when docs stand up for their financial well being, and don't act like government employees

c. This should come as a surprise to absolutely no one, and it's only going to continue to get worse. I honestly think that even if they fix the SGR formula, docs are still going to stop seeing Medicare patients in higher and higher numbers.
 
I seriously can't think of any other result between physicians and the federal government. One party is going to have to force the other's hand on this one.

There's no chance that this can keep on occurring without the government taking action. There's also little to no chance that Medicare funding will be increased, TARP or not.

If this continues, the only question is how long it'll take before the government does do something, and how drastic of an action it will be.
 
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No problem. DNP willl take over since more than 10 states allow DNP as independent providers . There is no need for doctors to see medicare pts.
 
Predicted government response?

State liscensure will be contingent upon mandatory acceptance of medicare/medicaid patients.

However, rather than impeding on state's rights and creating a federal law meddling with each state's licensing protocols they will frame the law in the context of medicare tax-based funding already in place to finance residencies.

States that do not adopt this federal law will not be eligible for DHHS direct medical education payments.

Legislator's standpoint:
Your state doesn't mandate its physicians to see medicare patients? Fine, but my constituents will no longer pick up the tab to train your noncompliant, greedy doctors.
 
Predicted government response?

State liscensure will be contingent upon mandatory acceptance of medicare/medicaid patients.


Bingo. This is already happening in Massachusetts
 
Predicted government response?

State liscensure will be contingent upon mandatory acceptance of medicare/medicaid patients.

However, rather than impeding on state's rights and creating a federal law meddling with each state's licensing protocols they will frame the law in the context of medicare tax-based funding already in place to finance residencies.

States that do not adopt this federal law will not be eligible for DHHS direct medical education payments.

Legislator's standpoint:
Your state doesn't mandate its physicians to see medicare patients? Fine, but my constituents will no longer pick up the tab to train your noncompliant, greedy doctors.

Yup. This is probably a good prediction.

It doesn't even have to be the federal government forcing doctors' hands on this one. As we see in Massachusetts, masses of seniors without medical care doesn't sit well with state legislators either. Even though there will be different thresholds of tolerance, eventually, if enough Medicare patients are turned down, every state will adopt some form of Massachusetts' Medicare-for-license bill.
 
I'm starting medical school this summer, and as such, I have no skin in the game at this point. Since I'm still relatively ignorant to the hardships that are associated with taking medicaid or medicare, please forgive my question/suggestion if it still seems difficult to accept. Assuming several states began to force physicians to accept medicare/medicaid, how would you all feel if the forced compliance was only to a specific number of patients per physician. Anything over that hypothetical amount being non-compulsory.

Further, I'm curious as to what else the federal or state governments could be doing to make it easier to take medicare or medicaid without increasing the amount of reimbursement. Are there any potentially cost saving measures that could be instituted, such as tort-reform?

As most of you are far closer to the situation than those legislating, you're in a unique position to offer insight that cannot be garnered elsewhere. I figure, we might as well make this productive. No idea is too stupid.
 
Wow, a doctor working for a private clinic earning just 72 dollars for a patient consult that is likely going to suck 1 entire hour? These idiot people in government think doctors can just give away their work for free or something.

I'm sure if they forced doctors to accept medicare patients, they'd only choose the people that don't have a lot of underlying conditions and are relatively healthy for their age.

I know how it feels to be literally giving away your work as a doctor half starving to death while many ungrateful patients all too spoiled by the government fed idea they can get everything for free without bringing something back. However, essentially I'm a government employee on a forced contract I'm kind of forced to do to graduate so I have no rights whatsoever until next January when the abuses of the system will end (I do however enjoy the actual job, I do hate the pay and the fact I can be literally forced to work overtime with no notice with no pay because it's legal to do so).

However, now even force doctors that have finished their medical education to be told who they can or cannot see, kind of totalitarian isn't it?
Medicine isn't a free market, was never one, and never will be. It had a good run as a fairly lucrative profession, though.
 
This is where I predict NP's will play their most harmful role. We'll never be able to take a stand against anything so long as there's an autonomous NP there, happy to replace us.
 
This is where I predict NP's will play their most harmful role. We'll never be able to take a stand against anything so long as there's an autonomous NP there, happy to replace us.

That's where I think they're in for a shock. Those NPs aren't going to be willing to work for anywhere near as cheap as they make it sound like.
 
That's where I think they're in for a shock. Those NPs aren't going to be willing to work for anywhere near as cheap as they make it sound like.

They just have to steal enough market share before they start voicing their desire for higher reimbursement rates. Either way, dumping Medicare patients isn't a wise decision by physicians - it's shortsighted and will ultimately bite us in the ass one way or another.
 
They just have to steal enough market share before they start voicing their desire for higher reimbursement rates. Either way, dumping Medicare patients isn't a wise decision by physicians - it's shortsighted and will ultimately bite us in the ass one way or another.

So then what are we to do? We are much less politically powerful than our adversaries. We can't continue to see patients at a loss.

On a slightly different tangent based on your point that this stance will hurt us eventually do we as the current crop of practicing physicians have some kind of duty to medicine as a profession in the future? Is there some kind of imperative that we no take a stand that could decrease reimbursement to the next generation of doctors?
 
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So then what are we to do? We are much less politically powerful than our adversaries. We can't continue to see patients at a loss.

On a slightly different tangent based on your point that this stance will hurt us eventually do we as the current crop of practicing physicians have some kind of duty to medicine as a profession in the future? Is there some kind of imperative that we no take a stand that could decrease reimbursement to the next generation of doctors?

I don't know what can be done. Honestly, I think it's already too late. Not dumping Medicare patients won't stop what's coming, but it might delay it. Maybe if physicians were more cohesive as a whole, this whole thing could have been adverted or at least delayed back in the day. But, seeing how the AMA (whose positions aren't even unanimously supported across medicine) is the only representative physicians have in politics, I'd say that the future of this profession will be tugged left and right by the whims of other political groups.

And as far as a duty to take a stand for the reimbursement for future physicians, the same thing applies. There's simply not much that can be done at this point. Being a doctor will still be a "highly" paid profession, at the end of the day. It'll simply be a more level playing field across specialties.
 
If enough medicare pts get dropped one of two things will happen. Either the government will increase reimbursement, making these patients more desirable. Or they will force MD's to take medicare pts as a condition of licensure. There are already rumblings about this happening in some states.

NP's taking up the slack just isn't going to happen. Medicare pts vote, and telling them they only have the option to see a healthcare provider with less education isn't a choice any politician is going to make.
 
You know, in spite of all this, nearly every med student I know is a bleeding heart liberal. I suspect that being brainwashed and susceptible to media sob stories is one of the new progressive admission criteria.

Face it - everyone is against us, and we're not even cohesively fighting for ourselves. Was it Churchill who said "A Liberal is a person too open-minded to take his own side in an argument."? There's nothing that makes me think more precisely of medical students and physicians, too empathetic to defend themselves against a mass of politicians and midlevels out to aggressively shackle them.

And please, no typical "John Stewart" or "Reasonable intellectual" defenses, a strategy consisting of nothing more than making fun of the very people pointing out impending dangers and losses of freedom. Simply acting as if an idea is ridiculous (or funny) in order to defer dealing with the truth of it is not something we should be falling for. No, doctors no longer "make plenty of money anyway." Stop accepting this guilty line as an excuse to be deliberately schemed and taken advantage of.

If we're to look out for our own benefits, we need to support the people who are supporting us. Ironically, we tend to be too progressive and tweedy to do this. Write a letter to your governor with your opinion on how "healthcare reform" will just put more weight on a broken system. Better yet, support somebody like Rand Paul, who actually gives a **** about us. As a medical professional, you'll be surprised how much weight your words will carry in this context.
 
If enough medicare pts get dropped one of two things will happen. Either the government will increase reimbursement, making these patients more desirable. Or they will force MD's to take medicare pts as a condition of licensure. There are already rumblings about this happening in some states.
.

Well, the first scenario won't happen, so that basically leaves the second. The idea that the government will increase Medicare funding just to appease physicians is the stuff of fairy tales.
 
You know, in spite of all this, nearly every med student I know is a bleeding heart liberal.

Nothing new. It was like that 13 years ago when I started med school. 2 years ago, there was a med student that - literally - described herself as a communist.

They filter out - to the left or the right - as residents (although some still linger until they're attendings - however, the liberals that are attendings, to my experience (FWIW - YMMV, kthxby), are of a different tenor than those of the med student variety).
 
Not to hijack this thread too much but I've always had a theory as to why most med students are so leftist. Med students tend to be very science oriented and they immerse themselves in math and the sciences from early adolescence. They tend not to pay too much attention to politics until they are forced to do their general requirement classes in college. The vast majority of colleges in the US are very liberal and they are indoctrinated in that environment where "progressivism" is rewarded both academically and culturally. Thus is born a liberal med student.
 
Not to hijack this thread too much but I've always had a theory as to why most med students are so leftist. Med students tend to be very science oriented and they immerse themselves in math and the sciences from early adolescence. They tend not to pay too much attention to politics until they are forced to do their general requirement classes in college. The vast majority of colleges in the US are very liberal and they are indoctrinated in that environment where "progressivism" is rewarded both academically and culturally. Thus is born a liberal med student.

Couldn't agree more. I also think it's because students, who receive mass amount of grants, loans, financial aid, and money from parents, are really isolated from "real world" money issues. The fact that most med students go from 4 years of this in undergrad (while undergoing everything you mentioned) straight to another 4 years of this in med school only makes it worse.
 
Not to hijack this thread too much but I've always had a theory as to why most med students are so leftist. Med students tend to be very science oriented and they immerse themselves in math and the sciences from early adolescence. They tend not to pay too much attention to politics until they are forced to do their general requirement classes in college. The vast majority of colleges in the US are very liberal and they are indoctrinated in that environment where "progressivism" is rewarded both academically and culturally. Thus is born a liberal med student.

That and young people in general tend to be more liberal. I used to argue with my dad (a hardcore conservative) about how I would happily work for free as a doctor to help people. Then I woke the F*** up. Nearly everyone of my friends identifies as far left, but can't even really explain why. You know the saying; "if you're conservative as a youth, you're heartless; if you're liberal as an adult, you're brainless".
 
I'm sure a lot of med students move rightward once they start making money and realize how much it sucks working 4-5 months of the year for the government. All of the sudden those massive social projects don't seem as just and necessary.
 
You know, in spite of all this, nearly every med student I know is a bleeding heart liberal. I suspect that being brainwashed and susceptible to media sob stories is one of the new progressive admission criteria.

Face it - everyone is against us, and we're not even cohesively fighting for ourselves. Was it Churchill who said "A Liberal is a person too open-minded to take his own side in an argument."? There's nothing that makes me think more precisely of medical students and physicians, too empathetic to defend themselves against a mass of politicians and midlevels out to aggressively shackle them.

And please, no typical "John Stewart" or "Reasonable intellectual" defenses, a strategy consisting of nothing more than making fun of the very people pointing out impending dangers and losses of freedom. Simply acting as if an idea is ridiculous (or funny) in order to defer dealing with the truth of it is not something we should be falling for. No, doctors no longer "make plenty of money anyway." Stop accepting this guilty line as an excuse to be deliberately schemed and taken advantage of.

If we're to look out for our own benefits, we need to support the people who are supporting us. Ironically, we tend to be too progressive and tweedy to do this. Write a letter to your governor with your opinion on how "healthcare reform" will just put more weight on a broken system. Better yet, support somebody like Rand Paul, who actually gives a **** about us. As a medical professional, you'll be surprised how much weight your words will carry in this context.

Totally agree.


I found this synopsis of the political phases of medical students to hit the nail on the head...

THE FOUR UNIVERSAL TRUTHS OF MEDICAL SCHOOL CLASSES
1) Most of your classmates will be liberal-socialist types hell-bent on saving the world through social justice, single payer petitions, and Marxist redistribution of wealth. This is one big reason why they got accepted to medical school in the first place.
2) Many of them will magically become great lovers of capitalism around residency application time, happily applying to high-paying specialties which actually compensate them for their time and effort, even if in some cases it means treating acne or implanting fake boobs rather than saving starving babies.
3) By the end of residency the majority of your former classmates will be fiscal conservatives who will loathe the government for the tax rape they are about to endure from them.
4) The few remaining liberal-socialist types will go into academic medicine and perpetuate the cycle within the academic environment.
 
Totally agree.


I found this synopsis of the political phases of medical students to hit the nail on the head...

THE FOUR UNIVERSAL TRUTHS OF MEDICAL SCHOOL CLASSES
1) Most of your classmates will be liberal-socialist types hell-bent on saving the world through social justice, single payer petitions, and Marxist redistribution of wealth. This is one big reason why they got accepted to medical school in the first place.
2) Many of them will magically become great lovers of capitalism around residency application time, happily applying to high-paying specialties which actually compensate them for their time and effort, even if in some cases it means treating acne or implanting fake boobs rather than saving starving babies.
3) By the end of residency the majority of your former classmates will be fiscal conservatives who will loathe the government for the tax rape they are about to endure from them.
4) The few remaining liberal-socialist types will go into academic medicine and perpetuate the cycle within the academic environment.

:thumbup: :laugh:

About to start med school in a few months.... I'm at step 3 on your list. The transformation from a "liberal-socialist" type to a moderate-conservative occured for me as soon as I saw the cost of attendace for my school.... this must mean I'm a heartless, money grubbing capitalist now :cool:
 
I don't know...

I was pretty conservative, and grew more so in college...

I got less conservative after I got out into the "real world" before medical school. Although my "real world" experience was in one of the poorest places in the US, and also working a pretty crappy job(s) while applying to med school.

Now, I am more open minded, I think. Not saying I am now some huge fan of the government (that would be pretty ironic, actually, my real world experience left me with far less trust of it...), but I just have a perspective for people who are growing up in places and cultures that I did not grow up around.
 
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