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When Time Doesn't Equal Money


More doctors, including yours truly, are avoiding Medicare patients, not just because of pay cuts but because you need to be a master coder to get fully reimbursed. And a crucial factor that isn't often mentioned in the debate over doctor pay is that senior patients take far more time per visit -- time that is not money.

As the baby boomers, some 30 million strong, flood into Medicare over the next decade, they, and we, are going to be put to the test. Yes, they will have more medical coverage than many have had previous to Medicare eligibility. But they will find increasing difficulty in actually finding physicians who can and/or will take them on as patients. And don't forget the additional pressure of the 30-plus-million younger folks, previously uninsured, who will soon be covered because of the new law.

Many primary care physicians already have closed practices and these two surges will fill up many of those who still have space for patients. The particular issues for seniors seeking a physician include the fact that they generally require more face time with care givers, and the reimbursements from Medicare are inadequate to support a practice with even a heavy minority of geriatric patients. Already, many primary care doctors don’t accept Medicare payment.

Breaking a Broken Code

For an example of why doctors -- including this one -- are increasingly reluctant to get involved with Medicare, look no further than the kerfuffle in Congress to further reduce Medicare payments (in other words, to reduce the incentive for doctors to actually see these patients). On top of that, you have to be a master coder to get fully reimbursed under Medicare -- which most of us most certainly are not. A recent extreme example is that I attended a dying 100-year-old patient in a nursing facility and received, many weeks later, the munificent sum of $1.43. It cost more than that to cut the check! (To read more about how much revenue you could be losing to undercoding, click here.)

This goes back to the point I made earlier about seniors needing more time per visit -- you can't make up for the extra time by upcoding. Medicare rates, and the private insurers who ape their low rates using the federal government for cover, won't pay enough to sustain a primary care practice's overhead.

As physicians, we also know that: 1) The elderly are on an average of six medications, which also requires more time to monitor (some patients I've seen are on as many as 20); 2) seniors process information more slowly, aside from short-term memory issues; 3) many seniors are hearing or sight impaired, which also slows things down; and, finally, 4) many simply want to spend more time with their doctor because they’re lonely, or they recall an earlier era where -- in lieu of being actually able to do anything -- doctors would simply sit, hold their hands and be a good listener.

Remember Marcus Welby, M.D., the TV-show that aired in the 1970s? Even at that time, the character Dr. Welby was an illusion because a doctor could never have covered all his office expenses spending so much time with so few patients. Let's face it, a new business model simply has to be created for patients and doctors, as I have long argued in these annals. Geriatrics is just another stand-out example of why we need to adopt a new way to code for the special requirements of elderly patients.

Ways to Make Up the Cost

The other major growth area for seniors -- and therefore for the doctors who will care for them -- is in assisted-living and skilled-nursing facilities. Legal requirements in most states specify that there should be a Medical Director, with varying, often unspecified duties and responsibilities. Many states also have a bar to the corporate practice of medicine, like California, my fair state, so it becomes problematic how authority, responsibility and payment will flow. Local arrangements that I have seen range from the awkward, through the wink and a nod, to borderline ethical and legal. All signs of a dysfunctional system that is being gamed in the interest of caring for senior patients and being reimbursed for it.

In some locales, physicians have no incentive to go out to SNFs, losing higher office revenue and often under-reimbursed travel time. The occasional entrepreneurial doctor may use cost-effective physician extenders, such as physician’s assistants or family nurse practitioners, and obtain a string of medical directorships to make the effort worthwhile. There is economic opportunity there, though it tends to be a low-status activity, due to the low pay and many doctors just don’t want to do it.

Last year, only 300 specifically trained geriatricians entered the employment pool, at least one additional zero short of the need. Again, physicians respond to incentives in the system, and you have to be personally powerfully motivated to swim upstream against the disincentives to become a geriatrician -- or to see geriatric patients at all, whatever your specialty.

In the breach, common practice is that many primary care doctors see a few seniors, the number of which increases as practice population ages. Some will work part-time or volunteer for senior centers, and the like. In other words, we muddle through. (Specialists, being largely procedure oriented and therefore having a fee structure multiple times greater, have a different perspective, to put it politely.)

To sum up, this decade is going to see a tremendous surge in covered patients and especially Medicare baby boomers. America is not now set up to effectively manage the increase, so we will have to continue to push for structural change. Even now, many health-related special interests are frantically rewriting various provisions of the healthcare reform bill to push on to their favorite (read funded by them) legislator.

Some doctors, for their part, will see the growing opportunities in geriatric healthcare and find ways to take advantage of them. There is a huge developing need, so go for it.

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Victor J. Dzau, MD, gives expert advice
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