I am going to state something that is completely obvious to most primary care physicians:  I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business. In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance.  If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit.  This is totally obvious to me, and I suspect to most primary care physicians.  A huge part of our overhead comes from the fact that we are dealing with insurance.  A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge.  As  it stands, the percentage of my collections that goes to overhead is between 50 and 60% (depending on the month).  A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing, and documenting.  If I dropped insurance and charged a fixed amount, I could:

  1. Cut my billing staff nearly to zero (someone would still have to do bookkeeping).
  2. Increase my payment per visit, which would allow me to see less patients per day.
  3. Document for the sake of patient care, and not for the sake of getting paid.
  4. Add extra services like email access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid?  Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me.  There are several reasons why this is possible for insured patients:

  • Insured patients generally have the option of filing for their own insurance (there are some that still don't allow this, but that number is dwindling with the decrease of HMO's)
  • Insured patients could choose to just pay me cash if they choose

Can't Medicare/Medicaid patients do this?  No, for several reasons:

  • If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files.
  • If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered).  So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud.
  • If I drop M/M, I cannot sign up for it again for 3 years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still?  Why would I continue to make my life so difficult?  Two words: duty and calling.  I view my seeing M/M patients as a social responsibility (especially Medicare).  These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income.  So far.

Plus, I just like to take care of the elderly and the poor.  My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need.  If I dropped M/M I would reject the calling for personal gain, which is something I can't do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care.  The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system.  I am personally willing to continue on this course as long as (it doesn't get too much worse) but I have complete sympathy for PCP's who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP's.  PCP's keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital.  The system is just holding on with the PCP's we have; decreasing that number would be devastating and perhaps fatal to the system.  It's a very bad sign when the best business model for PCP's is to do something that, if done by all PCP's, would wreck the system.  Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors!  They have to earn less money!  They have to actually have a conscience!  What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle, and live by my conscience.  At this time, most PCP's accepting M/M are doing the same.  But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish.  Pushing down M/M payments for PCP's will make a bad situation worse.

That's bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

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