There are potential unintended consequences of many of the health insurance proposals being touted. I have personally experienced the difficulty of finding a primary care physician (PCP) willing to accept me as a patient because of my Medicare insurance. I’d be concerned if that were the only option offered.
In my last article, “When Your Primary Care Physician Breaks Up With You,” I lamented that after 23 years, my doctor decided to go full concierge, requiring me to pay $2,000 up front in exchange for greater access and shorter wait times. Finding a local physician willing to accept new Medicare patients was not an easy task when I tried a few years ago. So I wondered whether my doctor was violating the AMA’s Code of Ethics requiring physicians to “assist those patients who leave the practice in finding new physicians” who are local, and ensuring that patients “continue to receive the same quality of care.” What, exactly, does local mean? And more important, what constitutes the same quality of care?
In the metropolitan area where I live (Northern Virginia), local is measured not in distance, but rather in travel time. Five or ten miles might take 10-15 minutes to drive in the middle of the day, a reasonable definition of “local.” At other times, especially in the morning or afternoon, the same drive might take 40 minutes given the traffic conditions in this area. Would 40 minutes away be considered “local?” Certainly if there were an emergency, that much travel time would be unacceptable. In my opinion, an average travel time of 20 minutes would be acceptable, though certainly not desirable.
The bigger question I have is how to know whether a new doctor provides the same quality of care. One possible filter is whether there is a single doctor or a group practice with multiple providers. If a single doctor, where’s the backup? How difficult would it be to have access? Coming from a fully electronic practice with a strong database and multiple physicians and nurse practitioners, plus lab and nursing staff, I’m not certain that a practice with one doctor and one nurse would provide equivalent quality, regardless of the doctor’s and nurse’s credentials. If it takes significantly longer to get an appointment, or even to get a prescription refill, is that equivalent quality? I don’t think so.
My soon-to-be former PCP provided a list of 16 “local” medical practices, five of which were not accepting new Medicare patients. Out of the remaining eleven, eight are solo practices. Two more are 14 and 17 miles away, with an average travel time of 30 to 45 minutes on a good day. That leaves just one group practice that meets my definition of local and seemingly of equal quality! That one, 7 miles away, is about a 15 minute drive with no traffic, and 30 – 40 minutes with any measurable traffic (even more during the commute hours).
Do you think having one real choice meets the AMA’s Code of Ethics requiring a “local” replacement.
As for quality care, beyond my requirement that the practice have more than one provider, there is also the question of the provider’s credentials. Without casting aspersions on any particular medical school, can any of us know that a medical degree from a Romanian, Indian, or Caribbean school means I’d get the same quality of care?
Continuing my investigation, I learned that not all of the PCPs in the practice accept Medicare, and that not all of those doctors who accept Medicare are accepting new patients. In this practice of more than 20 physicians, only one PCP accepts new Medicare patents.
This brings me to the key question of whether any of the current health insurance proposals will lead to unintended consequences such as this.
There is no doubt in my mind that my former PCP decided to go full concierge for more than just monetary reasons. He’s been a great doctor for many years, and I strongly believe he has had my interest at heart. But he confessed in the past that he felt he couldn’t spend as much time with me as he would like because of the need to see as many patients as possible to literally keep the lights on. Getting an appointment with him was difficult so I generally saw his nurse practitioner. I understand fully that running a medical practice is expensive, especially in close proximity to a hospital (his office is literally in an adjacent building).
I also understand that Medicare and private insurance payments are deeply discounted. They don’t come close to paying enough — you can just look at what Medicare approves compared to what the doctor charges.
So it’s not a surprise that by going concierge, my PCP is seeking a stable income source. I fear that more and more medical practices will be doing the same. If the doctors are only getting twenty, thirty, or even forty percent of what they charge, how many patients do they have to see to make up for that discount.
So one unintended consequence of Medicare-for-All or any kind of single payer system is reduced revenue for doctors and hospitals. While few will cry crocodile tears for them, we should be very careful to make sure doctors can keep their revenue at a sustainable level. Under a single payer plan, the goal is for patients to pay less. Therefore, to manage the total cost of the program, the reimbursement to doctors will be lower. How many doctors will be forced to go full concierge?
I wonder, also, how many doctors will decide that they won’t participate in any insurance program. what we now think of as out-of-network. Many specialists today already say they will treat you and will even assist you in filing your insurance forms. But you’ll have to pay the difference between what they charge and what insurance reimburses you. Will that be a growing trend?
And if concierge medicine and out-of-network charging is not possible, will many doctors-to-be choose to go into other fields. We already have a shortage of doctors in many areas. How many primary care physicians or general practitioners, today among the lowest paid doctors, will choose a specialty instead? Or another career, for that matter?
And what about the hospitals? Can they still be as high tech and adequately staffed with lower reimbursement? Will important medical research suffer?
Until these questions and others are addressed, I’m not ready to jump on the Medicare-for-All bandwagon.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.