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CHICAGO -- Why doctors are leaving Medicare
By Maury M. Breecher, Ph.D., M.P.H.
Medicare recently dodged a potentially fatal bullet, but 2003 is still a make or break year for the 23-year-old program that provides most of the health care for this nation's senior citizens.
Doctors throughout the United States had threatened to severely limit their Medicare practices if the federal government followed through with previously mandated 4.4 percent physician fee cuts this year, on top of a 5.4 percent cut physicians were made to accept last year.
A recent study by the American Medical Association found nearly half (48 percent) of all U.S. physicians would have limited their Medicare practices if the 4.4 percent fee reduction had been implemented. Fearing a death blow to Medicare, Congress responded to the doctors' pain and canceled the scheduled fee reduction. Instead of the intended 4.4 percent cut, a 1.6 percent increase in Medicare physician payments becomes available.
"The Medicare physician payment provision in the budget bill helps shore up Medicare's foundation," said AMA President Yak D. Coble Jr., M.D. "We are pleased that both Congress and President Bush recognized that and will stop the Medicare cuts for 2003 and fix past mistakes. The bill comes just in the nick of time for Medicare patients and the physicians who care for them."
While Medicare may have dodged a potential crisis, many doctors are still refusing to accept new Medicare patients. Some are completely dropping out of the Medicare program because of other issues.
Two of the most troubling reasons are stepped-up threats of prosecution of doctors, and growing government red tape, according to the Association of American Physicians and Surgeons, or AAPS. In July 1999, AAPS released the results of a survey that revealed: "Medicare regulations and a recent increased government crack down on so-called 'fraudulent' billings are actually responsible for severely restricting patients' access to medical care."
"This study is concrete documentation of the atmosphere of fear in which doctors practice today," said Jane M. Orient, M.D., executive director of the AAPS. "Money is not the issue -- it's the government in the examining room. More doctors would rather treat uninsured patients, possibly for free, than risk being prosecuted as a 'Medicare cheat.'"
John A. Bennett, D.O., in a "Declaration of Independence" issued as an AAPS press release, articulately expressed reasons that medical doctors are dropping out of Medicare.
"The patient-physician relationship is the foundation of the practice of medicine, yet Medicare requirements are threatening that relationship," wrote Bennett, pointing to widespread Medicare interference with medical decision-making. "Clerks and administrators are empowered to rule visits and procedures as 'medically unnecessary.'
"Medicare has also not respected the principles of patient confidentiality," he continued. "Copies of patient's records are routinely requested by Medicare administrators. Medicare has criminalized the practice of medicine, setting huge fines for minor variation from arbitrary guidelines, even going so far as to offer large bounties to patients who will suggest that their physician might be a worthy target of investigation.
"Medicare rules and regulations are so numerous and complex, and they change so frequently, that it is not possible for a reasonably informed physician to know and even understand all the rules that must be followed," Bennett wrote. "These complex rules are enforced arbitrarily, as even the enforcers cannot understand them fully."
Richard Bartucci, D.O., of Williamstown, N.J., agrees. "By the early 1980s most patients over the age of 65 couldn't get any health insurance except those policies designed to supplement Medicare," he notes. "Inasmuch as all patients over the age of 65 are Medicare clients -- even those who are perfectly willing and able to pay for medical treatment out of their own pockets -- doctors were faced with the decision of whether to become a 'participating Medicare provider' or give up their patient's care.
"I am the kind of doctor who conceives of my profession as a duty to my patients," Bartucci says, "so I 'participated' ... with roughly the same willingness that I reach into my pocket and hand over my wallet when somebody points a gun at my belly and rumbles: 'Your money or your life.' When the federal government arbitrarily sets -- and cuts -- physician fees, I see no real difference between that government and a mob of Mafia goons."
Seattle, Wash. neurosurgeon Michael Schlitt, M.D., quit Medicare in 1991 because he felt the U.S. government was "basically proposing Marxism as a way to provide health care for seniors." He explained that Medicare had started limiting physicians fees "in earnest" using the Resource Based Relative Value Scale, or RBRVS. Built into the RBRVS was the idea that specialists should be paid relatively less than generalists.
"Implicit in this formula is the Marxist dictum, 'From each according to his ability to each according to his need,'" says Schlitt. "If I were considering rejoining today -- and I certainly am not -- I would be concerned about the enforcement aspect.
"As I understand what is happening at Medicare headquarters, their Office of Inspector General has been assigned a certain number of enforcement targets," Schlitt said. "Basically enforcement officers in that office have been told, 'Find 'x' number of bad doctors every year.' If a member of that office is a little short of his target in November, I wouldn't want to be a possible target."
Chicago pain specialist Mary Jane Curran, M.D., is another physician who has dropped off the Medicare rolls. "I could not be happier that I am out of Medicare," she told Health Care News. "I opted out in 1998. Life is less burdensome and more productive."
(Maury M. Breecher, Ph.D., M.P.H., is co-author of the forthcoming book "A Doctor's Prescription to Solve the Health Insurance Crisis, Improve the Health Care System, and Enhance Your Personal Health.")
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