One should not be surprised upon learning of Medicare access issues and how the President’s government takeover of healthcare law is exacerbating them. 

A recent survey of doctors by the American Medical Association reveals nearly a third of primary care physicians restrict the number of Medicare patients in their practice mainly on account of low and unreliable government payment.  The American Academy of Family Physicians reports that 13% of its doctors simply don’t accept Medicare patients, up from 8% in 2008 and 6% in 2004. [1]

Even the president of the New York Medical Society no longer takes Medicare patients.[2]

But what actually happens when a physician decides not to see Medicare patients any longer and “opts-out” of the program?  It likely is not enjoyable for the patient and comes with some measure of risk for the physician.

Doctors who opt-out of Medicare can no longer bill Medicare for anything or anyone with very limited exceptions.  So opting-out is not a decision to take lightly especially for physicians who see a significant number of Medicare beneficiaries.  Moreover, again with very limited exceptions, a doctor who opts-out cannot resume as a Medicare provider for a period of two years.[3]

During this period, the Medicare Benefit Policy Manual explains “Medicare covers no services provided by that individual and no Medicare payment can be made to that physician or practitioner directly or on a capitated basis.  Additionally, no Medicare payments may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program.”[4]

The manual continues “Under the statute, the physician/practitioner cannot choose to opt out of Medicare for some Medicare beneficiaries but not others; or for some services but not others. The physician/practitioner who chooses to opt out of Medicare may provide covered care to Medicare beneficiaries only through private agreements.”

And what happens to beneficiaries whose doctors opt-out or otherwise do not accept Medicare? 

A Medicare beneficiary can try to obtain alternative primary coverage, pay out-of-pocket through private agreement, or find a new doctor who accepts Medicare.   As reported recently, finding a new doctor can  be an unpleasant experience:  For example, “Kay Haneline, 67, said she and her husband were both dumped by their clinic they had been going to when they hit 65.  They could have stayed and paid cash at their old clinic but then couldn’t have used their Medicare or secondary insurance.   ‘The whole experience was distasteful,’ she said.  ‘I called over 30 different doctors and none of them would take us.’” 

And what likely will happen when Medicare reimbursement falls even further under the President’s government takeover of healthcare law?  The CMS Actuary confirms Medicare rates for physician services will drop well below Medicaid’s rates as detailed in the graph below.[5]

And years of inadequate payment rates, below the cost of care at times, have contributed to widespread Medicaid access problems for both primary and specialist care.  Inadequate payment is the most common reason for providers not to accept Medicaid patients.[6]  Moreover, only 42% of primary care physicians in 2008 were accepting all or most new Medicaid patients compared to 61% for Medicare patients and 84% for those with private insurance.[7]  As well, Medicaid enrollees access care through the emergency room at twice the rate of the uninsured and those with private coverage:[8]   “With states squeezing payments to providers…patients are finding it increasingly difficult to locate doctors and dentists who will accept their coverage.  Inevitably, many defer care or wind up in hospital emergency rooms.”[9]

If, in fact, Medicare reimbursement goes the way of Medicaid or even lower as provided for in the President’s government takeover of healthcare law, it is safe to say “opting-out” will become an all too familiar phrase for too many Medicare beneficiaries. 

 Staff Contact: For questions or further information contact David Rosenfeld at 5-2045