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Gatekeeper:
Why I decided to opt out of Medicare as a provider

There’s a lake in Northern Arizona where I jog. I call it “my” lake. It used to be filled to the brim, a playground for ducks, geese, Monarch butterflies, rabbits and squirrels. Over the years when I’d jog in the cold mornings, my lake dried away from drought, measured by bathtub rings on the boulders which surrounded it. Today, rust-colored grass fills the space where clear water once lay. The rings on the boulders are un-countable. Soon, my lake will be gone.

When I drove home last night from the clinic, I decided to set ourselves free from the drought which is drying us. I decided to opt out of Medicare as a provider.

Here’s a brief account of what’s been happening.


Medicare patients come in to our little urgent care clinic in Northern Arizona, sick with multi-system disease. They hobble in from their cars or taxis, clinging to the arms of their loved ones (if they’re lucky) or all alone if they’re not, a plastic bag full of medication in their knobby hands. They’re told at the front desk to choose Option 1, 2 or 3. If they choose Option 1, they will have to pay for any additional services provided in our clinic before they leave.

People used to complain about our new policy. But when all the other primary care physicians in this rural area stopped taking any new Medicare beneficiaries, their offices filled to the brim like that lake used to be, charging their patients 6, 7, or 8 hundred dollars a year before they would see them, our patients stopped complaining. They had nowhere else to go.

The number of Medicare patients we see has increased noticeably. Their primary care doctors, now scarce, can’t see them for weeks. And the only other place left is the over-stuffed emergency room down the road.

So they come to us.

At the end of a billing cycle, our net reimbursement on most Medicare patients is about $130.00 for a new patient, $80.00 or less for an established. That’s not too much to ask, considering the difficulty in making some of those complex decisions on very sick patients who we’ve never seen before, inside the span of a short visit. But it takes 30 – 45 days for us to get that desperately needed money back into the business, after a mound of paperwork, time and cost, a 6% billing fee and the constant fear of Medicare hold-backs. Imbedded inside this is the fear of missing something clinically important in that short visit; an elderly patient whose family has abandoned him and who can’t remember why he came to see us in the first place, let alone the names of his complex list of medications.

Our billing company keeps telling me that Medicare is cutting back, again. They tell me Medicare won’t pay for this, and for that, and for this, or that. It becomes difficult to tell a trembling patient straight to their face that they have a fractured ankle, and then watch them hobble out of the clinic on a broken leg, knowing that we won’t be reimbursed for the cost of giving them an expensive boot and crutches. It becomes difficult watching a chest pain patient make the decision to drive himself to the emergency room against medical advice because he’s afraid of the cost of an ambulance, knowing he could never pay it.

It’s tough, knowing that at the end of a billing cycle of 30- 45 days; we may or may not be paid our $40 or $50 balance, depending on Medicare’s new rules. That $40 or $50 dollars is sorely needed to keep the lights on these days.

It becomes difficult to know that the provision of services by a nurse practitioner or physician assistant will come at 80% of what a physician would bill, and that $40 or $50 dollars gets drained down to $32 – $40 dollars.

We have a great cash pay option for people who don’t have insurance. For $75 dollars, anyone can come to see us anytime if they have a loyalty card, purchased at a nominal fee. They can receive any additional services of their own choice, each charged separately for very reasonable costs. For example, an x-ray of any body part is $50 dollars. An injection of an antibiotic that has the potential to save an extremely expensive visit to the emergency room and possible hospitalization is $40 dollars. Our net, after treatment of those same Medicare beneficiaries, would be around $130, collected immediately at the time of service.

There would be no additional fees to be paid to a billing company so they can play games with our government. There would be no additional fees in bad debt or collection agencies. There would be no worries about committing fraud, incident-to billing, or the miscellany of other punitive rules, policies and regulations which have become exponential as America’s healthcare crisis spins out of control.

There would just be a doctor and her patient, and no one else in between.

Like that lake where I jog in the mornings, I’m watching our Medicare program run dry. Nothing will be left of it soon but a bunch of crusty old bathtub rings, and no one else to care.

It’s the hardest thing as a doctor, a humanitarian, a human being to watch others hobble in for help that you could give, clutching their plastic bags and know that you can’t give them what they need. Providing what they need would lead to your own financial demise, and the lights in the building would go out.

It’s the hardest thing to know that very soon, all that will be left of that beautiful lake, will be a field of rust-colored grass, with no living creature around for miles. The rabbits, butterflies, ducks and squirrels will be gone.

Doctors should be angry. Patients should be angry. You should be angry, too. But, it’s in these small acts, one by one, as hard as they are, that together through our pain, we can change this world.

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Gatekeeper:
A physician’s open letter to Medicare patients

Dear patients,

This is a hard letter to write, but it is important that you know about a major change that is coming for both of us in 2017, just a short year away.

As you recall, last year I left a large hospital group practice and opened my own office, and I want to thank you for your faithfulness in following me to my new location.  With the newfound freedom of running my own practice, I love being your doctor more than ever.


As a family physician in Southwest Florida, the majority of my patients are insured by Medicare, and you, my Medicare patients, are very important to me.  Not just for my financial livelihood, but because of the relationships that we have formed together over the last 15 years in this community.


I have welcomed you to Medicare with screening tests, explaining the risks and benefits, and keeping you up to date with the constant changes in guidelines.  I cared for you through various medical crises, and helped you to control your chronic diseases.  I was there to treat your acute illnesses, and coordinate your care with your various medical specialists. I requested prior authorizations when your preferred drugs weren’t covered, and helped you get free medicines when you were in the donut hole.  I did your preoperative clearances, your disabled parking forms, and the pages of paperwork you needed when we decided it was time to consider transitioning into an assisted living facility.  We’ve talked about end-of-life issues, and I’ve helped you understand advance directives and DNR forms.  I’ve visited you in hospice, and even held your hand as you died.

This is the side that you know about, and the part that is most important to both of us.  But unfortunately, what I have described is only half of my reality.  The other half is the regulatory burden that I have to bear in order to provide your medical care.


For every office visit that we spend together, I spend at least as much time on what Medicare deems as necessary documentation, especially a new program called meaningful use.  While the goals of meaningful use in improving quality of health care are admirable, the regulatory burden is intense.  To comply with Medicare requirements, I’ve had to spend thousands of dollars and massive amounts of time instituting electronic health records, adapting my practice to conform to the computer technology that wasn’t created to help me, your physician.

During and after every visit, I type away at my keyboard, clicking boxes to demonstrate to Medicare that I did my job.  My notes, which used to be informative and succinct, now include pages of irrelevant information, disclaimers and computer-generated statements to “document” that I am playing by the rules.

But even though I detest some of these new processes, I know that if I want to care for you, my Medicare patients, I must do everything that I can to follow the rules, no matter how burdensome.  You see, the problem isn’t just that the doctor doesn’t get paid if she fails to follow the letter of the law.  If Medicare detects any questionable billing processes or inadequate documentation, honest or not, the physician faces heavy fines and even jail time.


And I get it.  Costs have to be contained, and true Medicare fraud, unfortunately, does exist.  There is no doubt that medical costs have been spiraling upwards for years, and as our Baby Boomer generation reaches Medicare age, naturally our health care spending  will have to increase in turn.

Although physician payments only make up about 10 percent of the cost of health care in the United States, the government has looked to increasing regulation on physicians as a way of reining in cost.  And next year the whole ballgame changes for physicians as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) goes into full effect, with a complete paradigm shift in Medicare payment from “fee-for-service” (I send a bill for your medical care, Medicare pays me), to “value-based payment” (I submit a bill, and I get paid if Medicare thinks that I’ve done a good enough job).

Basically, in 2017, all doctors that care for Medicare patients will have to make a choice.  The first option is to join an accountable care organization (ACO), which is a large group that acts kind of like an HMO to control costs and accept financial risk.  Having just left a large hospital system with daily productivity reports and a glut of middle managers, this option does not appeal to me.

The second option, for those who choose to stay in solo or small practices, is for the physician to enter into a Merit-Based Incentive Payment System (MIPS), in which payment will be determined by where the doctor ranks on a physician scorecard.  The kicker is that the pot of money remains constant – so even if every doctor makes an ‘A’ grade, half of them will be paid less money, just by nature of this “budget-neutral” payment system.

And of course, this system begs the question: what happens to the doctors who care for sicker or less compliant patients?  Will doctors have to cherry-pick, dismissing patients simply because they choose not to take a statin drug for cholesterol?  What doctor will want to be paid less to care for patients in higher risk areas, such as centers of lower socioeconomic status, where patients may be inherently sicker?

And is there a conflict of interest when doctors are paid more to do less?   There is the potential not only for patients to suffer if doctors cut back on tests and treatments, but also for the physician to face malpractice lawsuits – the new Medicare law offers inadequate  liability protection for doctors who are being required to keep medical expenses down simply to get paid for their work.

Up to this point, I have managed to play by the rules that Medicare has set.  Yes, I’ve had to spend hours of additional work on documentation, and hire additional staff to help me comply with the new rules.  And yes, I’ve taken a pay cut from Medicare this year because I chose not to invest another $15,000 in an electronic patient portal, as required by the second phase of Meaningful Use.  But so far I have been able to absorb the increased expenses and decrease in payment, and I have been able to continue to care for my Medicare patients.

In 2017, this may no longer be the case.

I wonder if I will be able to afford to care for Medicare patients as a solo physician, not knowing if or when I will be paid, while my expenses remain fixed or increase with inflation.  On the other hand, I do not want to return to a large group, losing the freedom to run my own practice in the way that I feel is best for me, my patients, and my staff.

I understand that whoever pays the bills makes the rules.  The only recourse a player has is to choose whether or not to play the game, especially when the deck is stacked against them.

Perhaps the rules will change again before 2017, but it will take a loud voice not only from physicians and health care providers, but from you, my Medicare patients.

Sincerely,
Rebekah Bernard, MD

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Gatekeeper:
More doctors offering direct-pay health care

Nation Now

Jen Rini, The (Wilmington, Del.) News Journal9 hours ago

JASON MINTO/THE NEWS JOURNAL

Dr. Christina Bovelsky, with Peachtree Famly Medicine in Middletown. Dr. Bovelsky offers patients a monthly fee for unlimited services.

WILMINGTON, Del. --- Cristy Beckman, who suffers from chronic pain in her spine and osteoarthritis, spent six hours in a doctor's crowded waiting room in severe pain.

That was enough, she decided. It was time to make a drastic change in how she was treated.

At about the same time, Dr. Christina Bovelsky opened Peachtree Family Medicine in downtown Middletown, Del., with a unique approach to medicine.

Instead of dealing with traditional insurance, co-pays and deductibles, her patients pay a one-year membership fee that includes an annual physical exam and between two and four office visits. Small procedures such as nebulizer treatments, strep tests and electrocardiograms are included.

Beckman, 46, became one of Bovelsky's first patients.

"There's an absolute peace of mind that someone is looking after your healthcare," Beckman said. "I don't think there's any way I could do something different."

Bovelsky's patients can pay monthly fees between $65 and $75. Yearly rates for adults vary between $780 and $900, depending on the number of visits a patient wants. Care for children under 18 ranges from $240 to $360. Additional office visits cost $80 each.

Nationally, more health care providers are embracing the direct-pay, or "concierge medicine," model.

A Physicians' Foundation 2014 survey found 7 percent of doctors run a direct-pay practice and another 13 percent plan to transition to some form of direct-pay model.

Most of Bovelsky's patients still have insurance for additional procedures and tests not covered by the doctor's fees, such as vaccines and lab work.

Health care providers say they are transitioning to direct-pay medicine because they are able to spend more time with fewer patients, which allows them to drill down to the cause of a medical issue instead of ordering extra tests. The doctors are also more readily available to patients after hours.


SUCHAT PEDERSON/THE NEWS JOURNAL

Dave Wilderman is a physical therapist with 29 years in the business who is more

Specialists are also embracing the model.

David Wilderman, a longtime physical therapist, decided to sell his physical therapy practice in Pennsylvania and open a new one in Delaware to help patients, like Beckman, who wanted a more personal approach.

"My belief is everyone should receive high-quality health care," he said. "The optimal goal is for my patients is to avoid medication and surgery."

Even with the extra attention, some fear direct pay and concierge medicine will drive up medical costs for individuals. Insurance representatives say consumers should make sure they completely understand a direct fee plan and the cost of treatments from a physician who is not working within a traditional insurance plan network.

Courtney Jay, a spokeswoman for America’s Health Insurance Plans, a national trade association representing the health insurance industry, said in an email that a doctor can charge more for a specific procedure than he or she is typically reimbursed for by an insurance company, which means the patient will pay more for that procedure.

"The out-of-pocket amount for the patient would vary depending on the patient's specific policy within their plan," she said.

Dr. Nick Biasotto, a family doctor and past president of the Medical Society of Delaware, said many doctors are exploring these new business models because they are seeing more patients daily as practices merge and facing higher medical costs with technological advancements.

And, as doctors age, they tend to want to scale back.


JASON MINTO/THE NEWS JOURNAL

Dr. Christina Bovelsky meets with Christy Beckman of Middletown at Peachtree Famly Medicine in Middletown. Dr. Bovelsky offers patients a monthly fee for unlimited services.

At 65, Biasotto, said he found he couldn't keep the pace. He is beginning to transition to a direct-pay practice after becoming frustrated with seeing 45 patients a day. In his 36 years as a doctor, he's seen 4,000 patients.

"It's time for me to slow down. I don’t want to join the hospital system and crank out patient after patient," he said.

Under the direct-pay system, he might see 500 patients in a year and he'll be able to make house calls. He's heard of about eight other doctors pursuing these models.

But he also had to let some employees go and help some patients who couldn't afford monthly fees transition to new providers.

"That was the hardest part of the whole process ... saying goodbye to patients I've cared for for years," Biasotto said.

A direct-fee model also helps doctors and patients eliminate paperwork such as prior authorizations and filing for reimbursements. Bovelsky said she uses that time saved to focus more on patients.

"The average time a doctor has with a patient is 7 minutes," Bovelsky said. "Here, it is at least 30 to 60 minutes. Sometimes it's 90. When you take the time to sit down, you are going to find the answer to what is going on with them.

"I love what I do and I wanted to spend my time with patients. The way medicine is set up currently ... it really is a revolving door."

Insurance standards often dictate what services specialists, like physical therapists, can provide and how long they can care for patients, Wilderman said. Often patients in physical therapy have between 12 to 24 sessions, but the amount of time spent with a therapist is under a half hour.

"It's not in the patient's best interest," Wilderman explained.

Under his model, patients only will need four to six visits, for about an hour each, though there are no set number of visits a person must have. An initial assessment appointment is $195 with any additional visit costing $165. Patients can try to get their services reimbursed as well, he said.

"This is helping people get better faster...People don't have to lose valuable time away from work and family," Wilderman said. "I don't have to go by the insurance company saying 'I'm not going to cover that.'

"When you tally everything up, it is cheaper in the long run to do what I'm doing as an out-of-network provider."
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