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On January 1, 2013 the SGR was due to be repealed by Congress and health care providers were due to receive an 18%- 45% reduction in fees for services.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 Will Never Be Able to Reduce the Cost of Care in the Last Three Months of Life

MedicareWe are frequently reminded by the General Accounting Office and CMS that a great proportion of Medicare health costs are incurred in the last three months of a patient’s life. Health care policy experts have tried to reduce these costs by encouraging end of life planning.  Living Wills, health care directives and the availability of hospice and palliative services will not put a dent in these costs because of human nature. I will provide some examples in the next few blogs.  Patient “L.J.” is my first example.

 I have a sweet 97 year old patient L.J., who lives in an upscale skilled nursing facility. He has a living will and a yellow “Do Not Resuscitate” sticker on his room door.  Three years ago he went into a severe depression after losing his second wife, to dementia.  His diabetes and chronic kidney disease have exacerbated because in addition to the natural progression of his diseases, he chooses not to take care of himself or follow instructions. His depression has been refractory to treatment despite the best efforts of two caring and experienced geriatric psychiatrists and their staffs.  He suffers from myelodysplasia and requires periodic blood transfusions to keep his blood count at a level that will keep him comfortable.

In recent months he has refused to be transported to an infusion center for his transfusions.  Despite his blood count dropping he remains comfortable, in no pain and able to participate successfully in those facility activities that he chooses to.   His nurse has become exceptionally attached to him.  As the patient’s health declines, despite being in no discomfort, the nurse is tortured by his decline. She calls and emails the out-of-state children and makes suggestions for additional care that the patient does not need or want.

Three months ago she suggested a palliative care consult.  I asked her “why” and questioned what services the palliative care team will provide that the patient is not already receiving or that he needs?  The children had demanded the palliative care consult so one was called. 

The local hospice program has a new palliative care program. They bill Medicare Part B for their services.  The palliative team arrived and wrote a consult that basically said there was nothing for them to do. They saw no need for their services. 

Three months later the same nurse contacted the family and said the patient needs Hospice care. I asked “why”?  She told me her mother had died of cancer and Hospice had been very helpful. I have no objections to working with Hospice and have over the years been a voluntary hospice medical director as well as referring many patients for end of life care. There is nothing for them to do at this point.  When the nurse contacted the out of state children they chose to “not leave any options on the table” and asked for Hospice to evaluate the patient. They did and billed Medicare Part B. They had nothing new to offer other than sending in a social worker and chaplain periodically to meet with the patient. Each time they visit the patient they bill Medicare Part B.

It is unclear if hospice is treating the floor nurse or the out of town children but they are certainly not adding anything to the patient’s care.   The taxpayers’ foot the bill as the system fails from expenses it cannot meet.