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Making the best of a bad situation

February 28, 2010

As I’ve read med blogs, a recurring theme is that Medicare and Medicaid vastly underpay doctors compared to private insurance, to the point where doctors lose money for each such patient they see, both as a straight cash loss and because of the time and money spent dealing with M/M paperwork.  Normally I’d be a bit skeptical of such collective kvetching, if only because doctors have a lot to gain by making a fuss and getting rate increases through Congress.  But if you look at the history, physician reimbursements have actually fallen over the past 20 years, even as improving technology has increased the costs of providing such care.  All this means that, basically, Medicare reimbursement schedules are unsustainable, perhaps not surprising when prices are set by fiat, by a government under pressure to both increase benefits (when Democratic) and cut expenditures (when Republican.)

From a policy perspective, well and good.  We need to either rethink our expectations of the level of care provided by Medicare, or raise a ton of money to pay for our current level of expenditure.  Anything else ends in doctors eventually leaving Medicare en masse, unless they are somehow coerced.  (That would be a pretty disturbing scenario, by the way, all the more so because there is easy demagoguery potential: “greedy docs refusing to help poor seniors.”)

But the question remains, for the individual (would-be) doctor, how do you respond to something like this?  Do you say that the loss – both in cash and in the outright waste of paperwork – is not worth it, and build up your practice, perhaps donating the profits to charity?  Or do you refuse to punish seniors for a system that’s really not their fault and accept Medicare?

I am sympathetic to the argument, made here by a real physician, that we have a duty to serve all patients regardless of their ability to pay, as long as we can make a decent income.  But I think there’s more to this issue than “how much will you sacrifice for the greater good?”  After all, revenue is not just money in the bank, it is also money that you can use to improve your patient care.  By accepting Medicare, the doctor loses the ability to upgrade his equipment, hire more support staff, and thus either treat more patients or improve his treatment of each patient.  It is plausible that the decision to be generous and see Medicare patients could actually reduce the amount of good he can do.  Perhaps more importantly, the decision to treat Medicare prolongs the existence of a system that everyone agrees needs reform.  In contrast, physicians who embrace innovative practice models such as cash-only practices, medical homes, or the unfortunately-named concierge care are public demonstrations of systems that may be superior to the insurance/Medicare zeitgeist.  In pointing the way to a healthcare system without the inefficiencies of public or private insurance, such risky experimentation is also a public service.

And so, I lean towards the idea of doctors not accepting Medicare if it is a losing proposition for them.  Instead, they should reinvest in their practices, improve their quality of care, and find a system that allows them to provide effective and equitable care to as many patients as possible.  But it’s a tough call to make, and there’s no obvious right answer.


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