1. Reimbursement - At least in my field, it is nearly impossible to run a practice off of what it pays.  Most physicians who are on Medicare offset its bad reimbursement with private insurance or procedures that are outside of Medicare.
  2. Prevention is discouraged - A person cannot come in if they are well.  They have to develop a disease before being seen.  They tried to fix this with the "Welcome to Medicare Physical," but the rules were so laborious, it is nearly impossible to take advantage of this.
  3. Fraud Accusations - If you do anything that is not by the rules, you are defrauding the government.  This includes choosing to not charge any of your non-Medicare patients.  If I choose to make less money on my poor patients by not charging them I am committing fraud because I am not offering that same discount to my Medicare patients.  Docs routinely down-code notes to avoid coming under scrutiny for fraud.
  4. Part D - The pharmacy benefit has helped some people, but the concept of the "donut hole" has caused many of my patients to go off of medications they need.  The system is so complex with so many Part D plans that I never know if a medication is covered until the patient tries to fill it.
  5. Stupidity - Drug companies give discount cards or coupons to us to give to our patients.  Medicare patients cannot use these cards.  Obviously it is not in anyone's best interest for Medicare patients to pay less for medications.
  6. Balance Billing - We must always accept whatever Medicare says they will pay and not balance bill the patients.  I can't set my prices.  Furthermore, the other insurance companies pin their fee-schedules on Medicare's rates.  There will never be "transparent pricing" as long as this is the case.  We cannot charge what we choose to charge.
  7. The RUC - The RVS update committee sets the Medicare fee-schedule.  It is dominated by specialists, and so it protects the interests of specialists over primary care.  It is so tied to special interest groups that it is hard to believe it is used as an "unbiased" source of advice for the fee-schedule.  Actually, it is a travesty to the system.
  8. Dropping Out - If you drop off of Medicare as a provider, you cannot reapply for 2 years.  This stung us when we tried to hire a physician who had previously dropped off of the list.  He simply could not see our patients.  I am not sure I understand the rationale for this.  Are they just spiteful?
  9. Sustainable Growth Rate - On the surface, this looks OK.  If we can't afford Medicare, it automatically cuts the reimbursement.  The problem is that the cut will be equal across all areas.  This hits primary care extremely hard, making it even more difficult to afford to take Medicare.  Specialists can afford to have office visits reimbursed less because they make most of their money off of procedures.  Are they hurt too?  Yes, but they are not living on the edge like PCP's.
  10. PQRI - The new "pay for performance" system is a mess.  The system is based entirely on billing (by putting in special modifiers when you bill), and reimburses a very small amount.  Plus, you don't ever know how you are doing and whether you will qualify for the bonus.  I look forward to my $30 check...if I get anything.

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