Doctors opt out of Medicare because the administratively determined fee schedule often is reimbursing them at a rate less than it costs for them to provide care. I know of no other group of business people or more specifically government contractors as in the case of Medicare or Medicaid who are expected to lose money in order to provide their services. I know of no other group of business people who would actually agree to take a loss in order to provide a valuable service on a regular basis, all the while being harrassed by ever expanding regulatory requirements that often do liitle to improve quality of care, but do provide jobs for bureaucrats. But apparently this is what the federal government and many citizens expect of their physicians. At this level, it is a form of economic indentured servitude. So doctors quit.

We have a lot of problems related to the financing of healthcare in this country and the Medicare program is one of the worst examples of the misalignment of incentives in paying for healthcare. Increasingly Medicare functions as a proxy for private insurers who use it as the benchmark for their reimbursement as well. If the government were to limit its involvement in healthcare to providing coverage to those who are medically indigent, and allow consumers and physicians to have greater autonomy, a lot of these problems would be improved. Until that happens, which may be a long time from now if ever, the system we have will continue to deteriorate.

Another problem that I feel should be adressed is rediculous medical malpractice suits, perhaps a cap on how much an ambulance chaser can make. These shysters aren’t about helping the wronged but helping themselves to lots of cash.
In that same vein, patients should be held responsible for taking a proactive approach, excersising, weight loss, smoking cessation & following MD orders ought to be taken into consideration too.

I have a cousin that possibly has the flu and vomiting very bad. He is refusing to go to the doctor because he has no insurance, but he is stay obsolete from the public and has used Lysol and sprayed all over. Does he need any medicine? he is taking thermaflu but he vomits it out.
Heath
Columbus, GA

Dr. Siegel,

Your point about using insurance for prevention and emergencies, with high deductibles and supplementing with HSAs is excellent. I’ve written a white paper on this topic for our patients, but find that many do not want to make the break with their copays, even if it would save them thousands of dollars per year. I think people in general do not research their options, or understand their options, when they do attempt to look into it. Fear is also a huge factor, from the conversations I’ve had, of losing their “sterling coverage”. Unfortunately, that sterling coverage is wasting money for everyone, except health insurance companies! They’re laughing all the way to the bank.
I’m glad you are making your voice heard.

Elfrieda

Dr. Siegel makes a salient point. Physicians are not necessarily slaves to the system. I opted out of private insurance long ago. I take Medicare, straight Medicaid, and Tricare for moral reasons (old folk, poor folk, and military deserve care) but not to make money. I run a cash walk-in clinic that offers comprehensive primary care services, and have a low cost boutique care option for those willing to sign on for a year. The private portion of the practice (about 67%) subsidizes the public portion of the practice, and none of it supports the private health insurers. However, were Medicare, Medicaid, and Tricare reimbursements to go substantially lower, or were these public insured patients to compose a larger percentage of my practice, then I would have to reconsider accepting these patients and go to a completely cash system. Incentives are low enough, and bureaucratic hurdles high enough right now, to convince many Physicians that continuing to take insurance of any sort is simply not good business. No one can currently force Doctors to work for free (except in residency programs – but that is a different issue). The concern then becomes will this government, like the Spanish socialists after Franco, tie Physician Licensing into complying with the dictates of some future Federal Health Care system. For all our sakes, I hope not.

Dr. Seigel,
Thank you !!

After a fifty year career of providing medical care, I am now, exclusively, a consumer of care. Interestingly, the picture from either side looks similar. Medicare, for all its faults, is an efficient operation. If the provider supplies the correct information, he/she will receive the “appropriate reimbursement.” The problem, as elsewhere noted, is that the cost of providing care in the typical setting exceeds the amount reimbursed. Furthermore, reimbursement is still highly procedure oriented. The value of cognitive service is not adequately recognized. The Medicare model, therefore, will work if more broadly applied and reimbursement adjusted to reflect the actual cost of providing services. It remains to be seen, moreover, whether the average American will accept “best practices” and demand unscientific and unreasonable treatment. We have been spoiled by a “boutiquey,” self directed approach to diagnois and treatment. Inappropriate demands for MRIs, PET scans, ultrasounds and antibiotics for URIs and hundreds of other examples must be denied. The discussions required are, themselves, costly and unreimbursed under the present rules. Few deny the need for fundamental changes to the current system. The devil is in the details.

Unfortunately it seems most non-providers just don’t get it. The administrative requirements put on primary care providers is counter-productive and detracts from the quality of care provided. After all healthcare providers go to school to be in the practice of medicine not the business of medicine. Alas with only 2% of the 2009 med school class going into primary care, the government may feel it has to take steps in order to have providers for it’s national healthcare plans.