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Doctors Shunning Patients With Medicare - Global Action on Aging

Some Doctors Say They May Stop Seeing Medicare Patients After Cuts

"Will Your Doc Drop You When You Turn 65?" "Doctors Shunning Patients With Medicare." "Cuts in Medicare Reimbursement Rates Trickle Down to Patients."

The ominous headlines keep on coming, as news reports across the nation focus on claims that a significant number of doctors, for the first time in the history of Medicare, may be turning away new patients because the government pays too little to cover the cost of care.

Exactly how worried should Medicare beneficiaries be? Is there a widespread decline in access to health care, as some doctors' organizations claim? Or is this a temporary blip that can be corrected by timely congressional action to ease the impact of its own cost-cutting efforts?

"AARP pays close attention to any claims that beneficiaries' access to care may be compromised," says AARP policy director John Rother. "Our view is that some beneficiaries in some parts of the country are experiencing difficulties finding the doctors they want.

"But the headlines are misleading," he adds. "They exaggerate the extent of the problem, and by so doing scare people needlessly about the availability of doctors."

There is no disagreement on two points. On Jan. 1, Medicare payments to doctors, mandated by a congressional formula, were cut by an average of 5.4 percent—and doctors across the nation, facing rising costs for everything from equipment to malpractice insurance premiums, are angry. Many doctors claim the cut is the result of errors built into the payment formula that need to be fixed.

Tom Scully, administrator of the federal Centers for Medicare & Medicaid Services (CMS), says that access to doctors is not yet a serious problem nationwide but adds, "Let's be honest. When doctors are upset about doing business with Medicare, that's a problem in itself, and their concerns have to be addressed."

From 2000 to 2001, CMS found, the percentage of eligible doctors participating in Medicare declined only slightly, from 90.5 percent to 89.5 percent, a drop considered statistically insignificant.

But CMS has not tracked the willingness of doctors to treat new Medicare patients. A 2001 survey by the American Academy of Family Physicians (AAFP) found that 17 percent of doctors (compared with 15.4 percent in 1999) say they now refuse to accept new Medicare clients.

Even so, AAFP's own statistics show access to doctors by patients over 65 has risen overall during the past seven years. In 1994 more than 21 percent of AAFP members—compared with the current 17 percent—closed their doors to new Medicare patients.

Those who question claims that doctors are pulling out of Medicare cite a 1999 survey of physicians sponsored by the federal Medicare Payment Advisory Commission. The survey found that of doctors accepting new patients, more than 95 percent said they were continuing to accept new Medicare fee-for-service patients.

Another major survey of health care access, including consumers and doctors, is conducted yearly by the Center for Studying Health System Change (HSC), a private nonpartisan research organization.

Testifying before Congress in February, HSC President Paul Ginsburg reported a 4 percent drop during the past four years in the proportion of physicians accepting new Medicare patients—from 72 percent to 68 percent. Waiting times for appointments, for specific illnesses as well as for routine checkups, also increased.

Nevertheless, Medicare beneficiaries reported fewer access problems than privately insured patients ages 50 to 64. In 2001, 18 percent of privately insured 50- to 64-year-olds—compared with 11 percent of Medicare enrollees—said they delayed or did not receive needed care. Of all patients over 50, about 40 percent said they waited more than a week for an appointment even when they were ill.

"You can't talk about Medicare access except within the entire context of health insurance in this country," Ginsburg says. "Private insurance payments to doctors vary wildly across the nation. It makes perfect sense that we're seeing the biggest Medicare access problems in places where private payments to doctors are much higher than Medicare."

"Hot spots"—areas producing some of the most unsettling news reports— include Washington state (especially Seattle), Arkansas, the Boston region and Colorado.

In Colorado, for instance, a survey by the nonprofit Patient Advocacy Coalition indicated that fewer than 60 percent of the state's doctors are taking on new Medicare patients.

The Seattle Post-Intelligencer reported in April that several large medical practices have closed their doors to new Medicare and Medicaid patients. Emergency rooms have been called upon to take up the slack, with usage up statewide by 28 percent during the past two years.

Richard G. Roberts, M.D., board chair of the American Academy of Family Physicians and a physician in private practice in Bellville, Wis., agrees that the combination of changes in private health insurance and Medicare reimbursement formulas is responsible for the squeeze felt by many doctors today.

"Ten years ago, there were more patients with generous employer-financed health insurance," Roberts says. "And doctors could use that reimbursement to subsidize care for patients, on Medicare or not, for whom the reimbursement was less generous. Today there isn't the slack, so cuts in Medicare payments have an even bigger impact than they would have had in the past."

Should doctors get payment relief? With the disappearance of the federal budget surplus and huge new outlays in the wake of Sept. 11, Congress now finds itself in a financial bind. There isn't a lot of money to do all the things lawmakers would like to do.

Estimates for adjusting the Medicare payment formula are steep. The creation of a prescription drug benefit—strongly supported by AARP, most consumer advocacy organizations and doctors associations—would also add to costs.

"It's a balancing act," says Kirsten Sloan, AARP's acting director of health issues and federal affairs. "Miscalculations in Medicare reimbursement should be addressed but not at the expense of prescription drug coverage."

Congress may well delay action on both prescription drugs and revising doctor fee schedules until late summer—just before legislators running for re-election must go home and face their constituents.

"Right now, the glitches in the system are pretty much limited to certain areas of the country," says Ginsburg. "Fix them as soon as possible, and you prevent a general problem from developing."

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