Second-prize winner in our 2001 writing contest

I was wrong. Medicare is great!

A former critic has an epiphany. Now he's a believer in government medicine.

By L.W. Ghormley, MD
General Surgeon/Blackwell, OK

edicare was born in 1965 when I'd already been practicing for 12 years. Like many physicians at the time, I was outraged at the intrusion of government into a private enterprise. I fought the carrier at every opportunity, and even wrote a Medicare-bashing article for Medical Economics about the inherent bias against doctors in the appeals process. I bitterly resented the government paying rural surgeons less than city surgeons for the identical operation. For 30 years, I never took a single assignment. My antigovernment bona fides were well established.

Looking back, I realize that I viewed the Medicare program with an almost obsessive hostility. I thought patients should fend for themselves—with some charity from physicians—instead of asking the government to pay for their health care. I've since undergone an evolution in my thinking.

The march of time changes everything

Not taking assignment had its drawbacks. I attempted to train Medicare patients to bring their government checks to the business manager, dutifully sign them over, and pay the balance. If they couldn't pay, we wrote it off. The problem was that some folks saw the government checks as manna from Medicare. They cashed them and spent the proceeds. Did you ever contemplate suing an 85-year-old and trying to attach her Social Security check? We either kissed and made up after I wrote off the account (on the promise of better behavior until death did us part), or we separated professionally.

As long as I enjoyed a large mix of non-Medicare patients, I could absorb the losses and indulge my political viewpoint. My business manager did most of the confronting; I seldom had to dirty my hands. Ordering the troops into battle is a lot cleaner than bayoneting the enemy yourself.

If you practice long enough, though, things change. As the town population shrank, rural rot set in and the large mix of non-Medicare patients withered away. The older folks couldn't afford to move. Ultimately, I was seeing almost no one under 65. More than 90 percent of my practice was Medicare.

Other things happened, too. Oklahoma instituted a capitation payment system for impoverished patients. After taking care of welfare patients for 40 years, I refused on principle to have anything to do with the program.

So I was left with a Medicare clientele, a handful of insured non-Medicare patients, and a cluster of patients with no insurance. Self-pay means no pay. I'll get my reward in heaven. I take care of them as a community service.

The government was also the main source of revenue for our community hospital, which got paid less than the city hospitals for the same DRG. There was no choice but to accept this. No government money, no hospital. It's as simple as that. Economics 101.

Learning to be a good Medicare soldier

In 1995, after much soul-searching, I knuckled under and went on 100 percent Medicare assignment. I now belong lock, stock, and barrel to the company store.

We bill Medicare electronically, and receive all payments directly instead of through patients. Medicare imposes a 10 percent discount for this service, but the surcharge is offset by the fact that Medicare files the claims for private supplementary insurance. This simplifies my billing procedures. Medicare pays expeditiously. I always know exactly how much I'm going to receive for any service. And I usually get an annual fee increase.

With Medicare, I have few coding headaches. I don't upcode because I'm not greedy, but I don't downcode either because I'm not stupid. I personally code all surgical procedures. Office services are precoded and merely have to be checked off on the bill. The rare dispute is easily settled in the carrier's fair-hearing process.

Once, I was ensnared in the carrier's computer search for "medically unnecessary" charges. They scooped up 60 of my charts and gave me 30 days to explain. I appeared before Aetna in Oklahoma City. The "investigators" turned out to be ordinary people trying to obey often-confusing regulations. Apparently I was the only general surgeon in Oklahoma with X-ray equipment and a lab in the office, so I stuck out like a sore thumb.

They wanted a $1,500 refund. I asked how to keep this problem from recurring. They said if I changed my specialty classification from general surgeon to general practitioner, I'd be in a more comparable group; that is, with doctors who have labs and X-ray equipment in their offices. The computer would never again single me out. My ego wasn't involved. I signed the papers. Aetna now carries me as a GP and the scrutiny has stopped.

As for the $1,500, I just paid it. The government had to show something for the "investigation." I remain convinced that I would have won if I had decided to fight, but that would have taken more time and effort than it was worth. Some people who knew me in my "sound and fury" days may be shocked to hear me say this, but overall, Medicare has been fair.

Government money keeps rolling in

Let me digress for an observation about the Oklahoma Medicaid program. Two years ago, I changed my mind and signed up. I get paid so much a head each month whether I see the patients or not. And government money buys the same things as private money.

The patients don't take up much of my time. Any halfway competent physician could handle their medical complaints. And the fallout has been beneficial. Two big-time Medicaid doctors in my community started making referrals to me. These cases help fill in holes in my schedule and have never been burdensome. Do I like working for half price? Well, it's certainly more lucrative than treating self-pay patients.

Medicare, on the face of it, looks a lot better than the HMOs. The government program doesn't have restricted panels of physicians. Fair-hearing disputes are more easily settled. And HMOs certainly don't pay better than Medicare. Full surgical fee? What's that? I haven't seen one in years.

Revenue streams are drying up in rural communities. My father, also a doctor, told me: "You're not going to be paid for everything you do and you're not going to get rich in the practice of medicine, but you'll always make a good living."

Prophecy! I have always made a good living. Despite my earlier misgivings, Medicare and Medicaid have been very helpful in making that living. Remember, an army marches on its belly. Whoever feeds me commands my loyalty.

My thinking has come full circle. If not for Medicare, I'd be out of business and so would my hospital. Medicare needs to be extended. Everyone should receive medical care, no matter what their social status. I can easily pay for my own care but I'm tickled pink when Medicare steps in and pays my bill.

I figure that President George W. Bush has this term to solve the problem of the uninsured. Self-pay is a dripping sore on the social fabric. I've been a Republican for my entire adult life, but Al Gore struck a responsive chord in my heart during the last campaign. I may even bolt the Grand Old Party and vote for the next Big Al.

God bless Medicare, warts and all.

Provider No. C94968.

 

L. Ghormley. I was wrong. Medicare is great!. Medical Economics 2002;9:71.