Why You Can Not Find a Physician Who Accepts Medicare

CMSSGR (sustained growth rate) is a policy and law put in place by the U.S. Congress signed into law four Presidential administrations ago and kept in place year after year by our non-creative elected Federal officials. It was designed to keep the costs of health care growth down by reducing payments to providers if they exceeded the health spending budget for the previous fiscal year. The problem is that health care spending has climbed continuously and it has never stayed within the budgetary guidelines legislated by Congress.

After the first year of the law the General Accounting Office noted an 8% increase in health care spending above the budgeted amount. Congress was supposed to reduce health care payments to providers by 8% the next year, but the providers howled about an 8% reduction and the President and the Congress backed down. Instead of a reduction they gave providers a cost of living increase. The GAO showed that the increased spending was not due to physician pay increases or physician generated costs but due to increased usage and expense in areas outside provider control. Every subsequent year since the SGR became law, the Congress has backed down and granted a miniscule increase instead. The difference between what was budgeted and what was actually spent has accumulated from year to year and each subsequent Presidential administration and U.S. Congress has been reluctant to correct the SGR because the monetary difference would appear on their administration’s balance sheet and legacy. That continued until the Affordable Health Care Act (Obama Care) passed and signed into law before anyone who voted on it actually read it, made correcting the SGR part of the law.

On January 1, 2013 the SGR was due to be repealed by Congress and health care providers were due to receive an 18%- 45% reduction in fees for services. Congress kicked the can down the block until January 1, 2014 and again until December 31, 2014 when Obama Care made the reduction mandatory. The last Congress kicked the issue down the road until April 15, 2015. They were supposed to settle the issue before their spring recess but they adjourned for the spring recess with promises of passing new legislation upon their return on Monday April 13, 2015. That was yesterday when Conservative Republicans announced that after two weeks of consideration they had major problems with provisions of the legislation they had agreed to pass before their spring recess. Their delay will go beyond April 15th.

The Centers for Medicare Services or CMS decided simply to not process any bills or make any payments to health care providers until Congress makes up its mind. Since April 1st they have paid no one except themselves. If no legislation is agreed upon by midnight tonight, CMS will begin processing payments to providers retroactively to April 1, 2015 with a minimum 21% reduction in fees compared to the 2014 payment rates. Physicians are reacting just as expected. Many have decided to no longer see Medicare patients. Those that do see Medicare patients will require payment for services by cash or credit card at the time of service with payments up to 115% of the 2014 Medicare allowable rate for that service. Many will leave the Medicare system entirely.

Our office will continue to see Medicare patients at the current time under the existing payment systems and we will give this Congress an opportunity to fix the problem. When we refer you to specialty physicians we have no way of knowing who will be seeing Medicare patients and who will not. We suggest you ask that particular office before your planned visit so there are no surprises at the check in check out window.

Medicare Part D Open Enrollment For 2015

MedicareFrom October 15, 2014 through December 14, 2014 Medicare beneficiaries will have an opportunity to choose their 2015 prescription drug plan. These plans change annually. If you do nothing you will remain in your current plan in 2015 even though the price will change and the drugs covered will change.

On your computer go to http://www.medicare.gov . Choose prescription drug plans. You will be asked to put in your name, your Medicare ID number and your zip code. They will ask you to enter your favorite pharmacy and then all your medications by name, dosage and frequency of administration. You will then run the program and it will suggest the best plan for you. I suggest you choose the least expensive plan. There are elective add on features which pay your drug deductible and even cover the donut hole for a higher fee.

If you have any questions feel free to call us. If you cannot use a computer and need our help please let us know.

Small Medical Practices Result in Fewer Hospital Admissions

Quantity-v-QualityThe American College of Physicians and the Affordable Care Act or “Obamacare”, are blatantly trying to make small independent medical practices obsolete. Under a barrage of rules, regulations and requirements all punishable by fines and or a reduction of payment for Medicare payments, the government is herding small practices into selling their practices to large hospital or health care systems. The goal is to provide more complete care in a paperless, seamless system of coordinated care. The American College of Physicians has gone as far as to aggressively push medical practices to become a Patient Centered Medical Home. This is all being done at the expense of mom and pop practices that have long term relationships with their patients but lack the resources to build and maintain the infrastructure that government and insurers demand from health care providers today.

It must have come as quite a shock to the ACP and the Center for Medicare Services (CMS) when a study published in Health Affairs and reviewed in the 08/21/2014 MedPage Today discussed a survey which showed that smaller primary care practices with fewer than 10 physicians had fewer preventable hospital admissions among their Medicare beneficiaries than larger practices.

The data was obtained between 2007 and 2009 and its publication produced the expected response from CMS and the ACP. They theorized that Patient Centered Medical Homes were just getting started and speculated that if the data from today was reviewed it would tell a different story. The problem is that when one looks at data from small medical practices, such as the data presented by the MDVIP concierge group from their small practices nationwide, you see exactly the same trend. Not only do the small practices hospitalize less but they score higher on quality measures designed by the government and insurers themselves.

The authors of the current study noted that 83.2% of US office based physicians are practicing in small practices of 10 or less physicians. Small practices in which physicians know their patients long term and are accessible and available clearly outperformed the larger health system and government sponsored mega groups.

Think about that the next time you look for a doctor. Which health care setting do you want your insurance plan to cover?

Medicare Payment Figures Released

Center for Medicare ServicesThe Center for Medicare Services (CMS) parent organization of the Medicare program, released detailed raw data showing how much providers of Medicare services are paid. For many years, hospitals and physician organizations have battled to keep this information private from the media, the public and private health insurance companies. As a citizen I have no problem with transparency, but if in fact we are asked to show our payments from Medicare then I believe every other individual and business
should be required to have their federal payments revealed to the public and media as well.

The data revealed that a physician in West Palm Beach, who treats diseases of the eyes in the elderly, received 21 million dollars from Medicare during the time period reviewed, leading the country in individual payments. That physician claims that most of the payment was for a drug called Lucentis injected into the eyes of seniors with macular degeneration a potentially sight ending disease. The problem is that other experts claim that a less expensive drug, injected into the eye produces equal or better results for far less cost. If the less expensive drug produces equal or better results then why is Medicare still paying for Lucentis, except in cases where the patient is allergic to the cheaper alternative or where it has not worked? CMS has the ability to control its payments for ineffective products. It just chooses not to do so. The NY Times made a big splash headline of the fact that this physician made a sizeable political contribution to a political party and then asked elected officials to look into why he was being singled out for repeated Medicare audits? Yes Medicare has the right to review each chart and determine if the treatment was indicated, if it was provided, if it was documented and then billed per their extensive rules and regulations. CMS makes the rules. If the physician follows those rules then it is inappropriate to slander him and accuse him and ask the tabloids to do what CMS could not do because the physician was in fact playing by their rules!

At the same time that CMS released this data, organized crime continues to profit from Medicare fraud in south Florida, particularly in Dade and Broward Counties because it is less risky to commit Medicare fraud than it is to run drugs, prostitution, human trafficking and loan sharking. Maybe CMS should be trying to stop the flow of low hanging criminal fraud rather than releasing data on provider payment. As the storm clouds gather over the use of this data, ObamaCare seems to have reached its enrollment goals despite major startup problems. Despite this, Kathleen Sebellius, the CMS director resigned. Do you think it had something to do with the inappropriateness of the payment data release and the ultimate consequences?

Customer Satisfaction and the Quality of Your Health Care

CMSThe Center for Medicare Services (CMS) has issued edicts and guidelines to hospitals that their customer satisfaction survey ratings must improve or else they will be fined and penalized.  One of the areas where they want improvement is in the emergency room or department.  They now require ER’s to make a disposition and either treat you and send you on your way or admit you to stay within three hours (180 minutes). On the surface anyone who has spent time in an emergency room cannot possibly object to speedier more efficient service so why am I objecting to this new regulation?

For decades emergency rooms have practiced the art of triage. Triage means they treat the sickest but most salvageable patients first.  Those with simple non-life-threatening issues and those with severe issues but no hope of survival get placed at the back of the line in deference to sicker individuals with problems that require immediate attention if the patient is to survive. Emergency Rooms have become everyone’s after hours and weekend primary care office for many reasons. They are jammed with minor health problems and social issues that in an earlier less litigious era would have been treated at home by family and friends or seen by the family doctor in the office or in the past in their homes. Many of the reasons for these visits would have been treated with guidelines and instructions available in any Cub Scout or Brownie First Aid instructional manual but today clog the ERs.  Should an abrasion from a fall to the arm of a 12 year old receive the same immediate attention as a change in mental status and collapse of a previously healthy 45 year old father of three?

CMS has not differentiated between University Hospital Centers with fulltime on-site interns, residents and fellows and community hospitals where few if any of the treating physicians are on location full time.  In order to stay in compliance with these draconian rules, community hospitals are diverting doctors and nurses from caring for patients in the facility to the emergency department to “move patients along.”   Our community hospital initially imposed a “thirty minute rule” which said that when a community based physician received a phone call from the ER that a patient required admission they had 30 minutes to admit that patient.   Admitting a patient without seeing them, taking a history and doing an appropriate examination is not in the patient’s best interest. When the medical staff was asked to approve this rule as part of the Medical Staff bylaws, they overwhelmingly rejected it.

Everyone wants prompt, efficient, courteous attention and service especially when ill. CMS and this administration are trying to implement it by decree without true consideration of how their actions will impact patient care. One size does not fit all.  Without citizen outcry to their elected officials, poorly thought-out policy in the name of cost savings will impact you and your loved ones unless you speak up.