Why I Don't Accept Medicare

It is Medicare open enrollment season, the time of year when my office receives several calls a day from seniors looking for a primary care doctor. “Does Doctor Barrett take new Medicare patients?” is the common question. The sad answer is, “No.”

I stopped accepting traditional Medicare patients several years ago. Patients with Medicare who wish to join my practice can do so only by enrolling in a Medicare Advantage HMO plan (Such as SCAN or BlueShield 65+). Many patients cannot understand why I do not accept traditional Medicare. It takes only a few moments to explain my reasons.

1-      Medicare does not pay for some needed services.

If a 65 year-old patient is newly diagnosed with hypertension, many experts recommend an electrocardiogram (EKG) to see if the heart is enlarged. Medicare does not seem care what these experts say. They refuse to pay for the service. As Medicare does not allow me to bill the patient, I must either provide the service for free or not provide it at all. This does not happen with HMO patients. The payment model for Medicare HMO allows me to provide all needed care.

2-      Medicare has arbitrary and foolish limits on testing

For diabetes, the most important test is a hemoglobin A1c, which provides an estimate of the average blood sugar for the previous 3 months. This test is infinitely more valuable than a single blood sugar. When I make medication changes in a patient whose diabetes is way out of control I will sometimes order the A1c after a month or two. While the value has not yet reached a steady level, if the number is moving downward the result is encouraging to me and the patient. If it is not decreasing I know I need to make additional changes. Medicare does not share my belief in the value of the test. They will only pay for the test once every 90 days. Make a mistake and send the patient to the lab on day 89 and the lab will send the bill to the physician. HMO's allow me to order tests whenever I feel they are necessary.

3-      Medicare provides no support for quality care.

Medicare HMO’s provide real time data to help me manage patient care. When a Medicare HMO patient comes to the office the electronic record has integrated reminders telling me which screening tests the patient needs. Better still, with the HMO I receive reminders for patients who have not even come to my office yet, allowing me to reach out and encourage them to receive needed care. I have seen this save lives. For traditional Medicare, the patient and I are on our own. I know nothing about them until they come in, I receive no reminders of needed tests and if they don’t know what tests they have had I am forced to call previous doctors (if they can even remember who did the colonoscopy years ago), dig through their chart or log into the hospital system to find results. Frequently these efforts prove futile. Many doctors take the easier path and simply give up and repeat the tests.

4-      Medicare HMO’s invest in programs to improve patient care.

HMO plans pay medical groups flat monthly fees on a per patient basis, which means that when patients get sick, expenses go up and profits go down. As a result medical groups invest in programs to keep patients healthy. As an example my medical group, Greater Newport Physicians, has programs for diabetes management, in home health assessments and immediate post-hospital follow up, all of which help patients stay out of the hospital and none of which are available to patients on traditional Medicare.

5-      Medicare requirements for wellness visits are absurd yet mandatory.

Medicare pays for wellness visits once a year, but only considers the visit and charges valid if the doctor addresses every item on the Medicare checklist. Not all of the items are relevant. For example, doctors are required ask a health 65 year-old patient who plays tennis 6 days a week if he is able to dress himself, bathe himself and take care of his daily needs. Failure to ask these questions and document the answers in the chart puts doctors at risk for failing a Medicare audit and being charged with Medicare fraud. Even worse, an initial “Welcome to Medicare” visit for a healthy requires a routine EKG, even though the test has been proven to be useless and potentially harmful. (yes Medicare denies payment for a necessary EKG yet requires it when it is useless!)

6- Traditional Medicare reimbursement is dramatically lower than Medicare HMO, and pays for the wrong things

With traditional Medicare, the more a doctor does to a patient, or the sicker the patient gets, the greater the payment to a doctor. For doctors like me who try to keep patients healthy and do only what is needed the end result is a low level of reimbursement. I prefer to treat patients in a system that pays me for doing the right thing.

It is for these reasons and more that I made the difficult decision to only accept Medicare HMO patients. It is always painful to say “No” to a patient who wants to be a part of my practice but my hope is that patients will come to understand that I want the very best for them and do not want to settle for anything less.

In spite of all of these challenges there is some hope for Medicare. In my area, medical groups such as Greater Newport Physicians and Healthcare systems such as MemorialCare are partnering together to try to find ways to improve care and provide better service to traditional Medicare patients. It may be years before the quality and service approaches that provided to HMO Medicare patients, but it is reassuring to know that the work is underway.

-          Bart