As of January 1, 2013, I no longer participated in Medicare. I was surprised by the reaction of some of the Medicare recipient patients. Several wrote angry letters and made accusations of abandonment. Though I had prepared my patients since early 2012, few thought I would go through with it. In fact a fascinating thing happened. The established patients made appointments with increased frequency. By spring of 2012, I instructed my staff to not schedule any new Medicare recipient patients, as I did not want any new patients to feel I have seen them just to discontinue a relationship in a few months.
On that January day, I was no longer a participant. I could still see Medicare recipient Patients, but I must make them sign a document letting them understand I am no longer a participating Physician and the fee’s will be paid by the recipient of the care. I noticed three difference responses from my Medicare recipient Patients. Some gladly arranged compensation for my services. One unfortunate group was not able to afford seeing me, but took my recommendation to see other physicians who remained on the program. The third group was very indignant, and angry.
Few realized that I could still provide their surgical services . Most did not understand that Medicare will still cover the hospital, the anesthesia, and diagnostic testing. The only additional expense would be my surgical fee. I could still continue to be their Surgeon, as long as they valued My expertise.
Over time, I got over my guilt on why I left Medicare, as in my opinion, I had sound reasons:
1. The reimbursements were too low to allow me to provide quality personal care, the kind I arrange for my Family. Not to say physicians who stay on medicare are not providing competent care. But if you think about it, quality, and competent does not mean the same thing. I like to use the analogy of Fine Dining versus Fast Food. Burger establishments provides inexpensive food, fast, efficient, with set quality measures to ensure food safety and consistency. In my opinion, Fast Food is competent delivery of food at a reasonable price. As a consumer, you know what you get, and understand what it is. But, most will not equate a Fast Food Restaurant as a quality personal experience. Fine Dining is personalized. It is not hurried. The wait staff courteously explain the menu. The food is customized to the Diner. For some Diners, there is an established relationship with the Restaurant, and the Restaurant Owner cultivates the relationship, providing extra services to enhance the experience. While the dining is more expensive than fast food, the Diner gladly pays, as the Diner values the experience. For patients, most accept that seeing a Physician can be like a Fast Food experience, except it is not fast. But, I no longer wanted the Fast Food Style of medical practice. I was determined to become the equivalent of a Fine Dining experience, with timely and personal interactions with the Patients. Frankly, Spine Surgery should be discussed with care, compassion, and thought. It should not be rushed, or hurried. Most Patients also value that experience, and many are willing to cover the additional cost. Patients want to be treated as Individuals, and as a Cherished Customer.
2. I am not a Commodity. By definition a Commodity is “ a basic good used in commerce that is interchangeable with other commodities of the same type. ” How are Surgeon’s considered commodities you ask? Insurance companies think all Board Certified Surgeons are the same. Once you meet the criterion, you are considered interchangeable with any other board certified Surgeon. Medicare definitely thinks that about Physicians. Think about this fact; the Surgeon that graduated yesterday from his training is compensated exactly the same as the Surgeon with 20 years experience by the Medicare Fee Schedule.
I know in the minds of the Government, and the Insurance Company, they need to set up a system that can be used to administer to a large population. On an individual level, you know that certain Surgeons have more experience and better outcomes in certain situations. Certainly the Operating Room Nurses have opinions on whom they would want operating on their Family. In the eyes of the Government, or the Insurance Company, there would be no difference. By this rationale, everyone should get their hair cut by any Hair Stylist, after all, their skills are the same. Everyone knows that is not true.
3. I did not want to be restricted in the types of surgery offered. With such reduced compensation, there is a monetary incentive to perform more complicated and bigger surgical procedures. To give an example, the public thinks the average spine surgeon receives $21,000 for a laminectomy procedure by Medicare. The truth is the actual reimbursement by medicare is about $1000. While that is still alot of money, that fee includes pre-operative counseling on the procedure, and up to three months of followup care. By that level of reimbursement, most Surgeons cannot provide individualized attention for each patient, as the compensation hardly cover the costs. To continue to provide for those Medicare recipients, you must do an assembly line, volume business. You must also structure a practice to identify patients that require the better compensated, but more complex procedures (i.e. larger operations like lumbar fusions), and you must be able to rationalize offering the more complex surgeries. Also, your office administration tends to develop programs that are designed to offer additional treatments such as in office braces, in office physical therapy, in office MRI’s, CT’s, etc. I am not criticizing these offices. There are definite needs for the more complex surgeries in selected situations. Ancillary services can improve patient conditions. I am just saying remaining in the Medicare System incentivizes the offices to develop ancillary income streams, volume processing of patients, and larger, more complex spine surgery. I no longer wanted to practice in that system. I want to continue to offer the surgeries that had predictable outcomes while also providing personal office time and counseling. The Medicare reimbursement is too low to allow me to spend quality time, and provide the simpler surgery. I want to be able to provide the FOUNTAIN of YOUTH Spine Surgery that I blogged about before.
4. I want to remain in Private Practice. There is nothing wrong with being employed. Many of my Colleagues are employed by a Business Entity and are satisfied by the arrangement. But I find most employment situations difficult for Surgeons who want to provide a quality personalized approach to surgery. The Business may not understand the approach, and find it easier to look at the physician-patient relationship as a buy product of the business transaction. In business, the main goal is production, and efficiency. In the employment model, Patients and Physicians are evaluated as units of production, or units of costs. The Businesses can sugar coat it in many ways. The Mantra of ” it is because of the patient” is used to shape policy and behavior. But the goal is always the same. The Businesses are evaluated by the numbers generated. While some of the intangibles are touted, it still comes down to the Dollars. While it is true that the Private Practice Physician also has some of the same pressures, at least the Private Pratice Physician has ownership, and can also apply the principle of Professionalism and Medical Ethics while making those business decisions. The Physician still knows the Patient – Physician relationship is sacred. That is why seasoned Physicians do not enter into business agreements that compromise the quality of the Patient-Physician relationship. If the physician cannot get adequate compensation, then the physician must cut corners, in terms of time spent, and counseling rendered. If the Physician cannot negotiate adequate compensation, then the physician must rely on volume. With Medicare, there is no negotiation. The fees are set. WE are back to the Fast Food Style again.
If you are a Medicare Recipient, and are frustrated by your level of counseling, and access to medical care, you may have an alternative. That alternative is to see the Physician who will provide you the value you seek. You might consider seeing a Physician who consciously decide not to participate in Medicare. That Physician will likely cherish you as a patient, a person, a customer.
The Web Surfer has found this Blog on the internet. Does the Surfer know that you can look up Physicians and Surgeons, and find out what they actually collected from Medicare, and the procedures performed? While this type of data does not show anything about the quality of care rendered, in 2012, the Medicare data confirms that I did not perform spinal fusion surgery on the Medicare population. While the revenue of $82k is significant, that was for providing Medicare services for 423 unique beneficiaries. As a business entity, some will say that I needlessly terminated relationship with a reliable income stream. I say I gave up that income stream so I can develop a practice devoted to personalized care, not volume care.
Blog is the personal opinion of John Shim MD based on over 20 years s a spine surgeon in private practice