The risks of physicians dropping Medicare

Becker's connected with nine physicians to discuss the risks the increasing number of physicians electing not to accept payments from Medicare pose to care delivery as a whole.

Note: These responses have been edited lightly for length and clarity.

Question: Thirty-five percent of physicians surveyed by Medscape said they are not sure if they will continue to accept Medicare. If those physicians were to drop Medicare patients, how will this affect patient care? How will this shift healthcare delivery as a whole?

M. Shafeeq Ahmed, MD. President of Johns Hopkins Howard County Medical Center (Columbia, Md.): I do understand that there are issues on both sides of this, but this trend does concern me. There is a real need to find a permanent "fix" for this issue, as it is detrimental to have this continual mismatch between the actual cost of care increases and Medicare reimbursements. With this in mind, the immediate effect on our Medicare patient population who will not be able to receive outpatient care would also be problematic. Specifically, there are already long-standing trends of lower primary care availability in many communities. 

If this pressure were added to the other existing factors that cause a low supply of primary care, I would be concerned that the health outcomes for this vulnerable population would also be negatively affected. Cutting out specialty care options for Medicare patients would only further exacerbate this issue. 

From a population health standpoint, having sicker patients present to costlier inpatient settings without adequate outpatient care or follow-up is not the best care delivery model and will likely drive up the total cost of care in the long run. I am hopeful that more can be done to proactively address the gaps and help avoid such consequences.

Ebrahim Barkoudah, MD. System Chief of Hospital Medicine and Regional Chief Medical and Quality Officer at Baystate Health (Springfield, Mass.): The uncertainty among physicians regarding Medicare acceptance is a cause for concern, as it directly affects access to healthcare for millions of Americans. As the population ages and healthcare costs continue to rise, Medicare serves as a vital lifeline for many patients. Therefore, it is crucial that physicians have a clear understanding of their stance on accepting Medicare. While the current reimbursement system may not be sustainable for physicians, it is important to also consider the impact on patients and their access to quality healthcare. Finding a balance between fair reimbursement for physicians and affordable care for patients should be a top priority in any Medicare reform efforts. Additionally, more support and resources should be provided to physicians who do choose to accept Medicare patients, as they play a crucial role in ensuring access to healthcare for vulnerable populations. Ultimately, it is important for all stakeholders involved to work together toward finding a solution that benefits both physicians and patients. As data-driven decisions are made regarding Medicare reimbursement, empathy and understanding for the impact on both physicians and patients should also be considered. It is my hope that through collaboration and consideration of all perspectives, a sustainable and fair Medicare system can be achieved. 

With low reimbursement rates, physicians may feel pressured to see more patients in order to maintain financial stability. This can lead to burnout and negatively affect the quality of care they provide. It is important to address this issue in order to support the well-being of physicians and ultimately improve patient outcomes.

While traditional fee-for-service reimbursement may not be sustainable for all physicians, there are alternative payment models that could incentivize high-quality care while also providing financial stability. These options, such as bundled payments or value-based reimbursement, should be considered and explored in order to create a more equitable Medicare system.

Richard Beigi, MD. President at UPMC Magee Womens Hospital (Pittsburgh): This could significantly challenge many patients' ability to get both timely and comprehensive healthcare and could have significant negative impacts for a sizable percentage of citizens. It could lead to delayed care and diagnoses, missed diagnoses, delayed treatment, all of which can cause significant worsening of thousands of seniors' health. Not to mention the loss of preventive care efforts, which is likely to have sizable negative impacts down the road.

Ajay Dharod, MD. Vice Chair of Informatics and Analytics, Internal Medicine at Atrium Health Wake Forest Baptist (Winston-Salem, N.C.): If a large percentage of physicians stop accepting Medicare, one can imagine the burden of care for these complex and often elderly patients may shift to under-resourced healthcare systems still accepting Medicare — potentially furthering healthcare disparities and healthcare inequity while concomitantly exacerbating the current provider-patient supply-demand mismatch.

Peggy Duggan, MD. Executive Vice President, Chief Physician Executive and Chief Medical Officer at Tampa (Fla.) General Hospital: Historically, Medicare reimbursement rates have not covered the cost of providing care for patients. This gap has grown in recent years with rising prices due to global inflation and higher labor costs as a result of our national workforce shortage. I can understand why providers are concerned that the current model is not sustainable over the long term. 

But hospitals like Tampa General serve as safety nets. We are committed to providing safe, efficient and world-class care for all, regardless of a patient's coverage. Patients depend on us for exceptional care, whether it's a complex medical condition or a common illness, and we deliver day in and day out. 

As providers consider opting out of the Medicare program, we expect more patients will turn to healthcare systems like Tampa General for access to care. To ensure we're ready to meet the demand, Tampa General is pursuing innovative solutions to disrupt the traditional model of healthcare. Through innovation, we can break down barriers to access and create efficiencies that will allow us to meet the growing demand for care.

Tyler Hill, DO. Chief Medical Officer at Sierra Nevada Memorial Hospital (Grass Valley, Calif.): It is very concerning to see the continued decline in reimbursement for providing care to Medicare beneficiaries. Individual physician offices and hospitals are strained to a more significant degree as a result of declining reimbursement for such a large group of patients and at risk for closure. As an increasing number of physicians decide to no longer take Medicare patients, this will create disruptions in the continuity of care and delays in care for these patients. This poses a threat to their overall health. The burden of care is shifted to acute care environments. These typically include emergency departments and hospitals, along with urgent care clinics. Ultimately, this has the risk of increasing the overall cost of healthcare, not just to these individual patients, but for the entire system. 

Kelly O'Malia, MD. Physician at Marathon Health (Mentor, Ohio): The fact that one-third of physicians may potentially stop accepting Medicare patients under the traditional fee-for-service model reflects a broader dissatisfaction within the medical community regarding the constraints and limitations of this system. While this doesn't necessarily mean they won't care for patients over the age of 65, it signals a desire to move away from a model focused solely on relative value units and toward more patient-centered approaches.

More and more physicians are opting to practice in nontraditional healthcare delivery settings like direct primary care and Medicare accountable care organization models with small patient panels. They are voting with their feet, aiming to break free from a system that often results in short, unsatisfactory visits for both patients and providers. Within these newer models like Marathon Health direct primary care centers, physicians have the autonomy to spend more time with patients, addressing not only immediate concerns but also delving into preventive and chronic care needs within the same appointment. This comprehensive approach to care has the potential to yield both better health outcomes and higher patient satisfaction rates.

The shift away from traditional Medicare fee-for-service models may initially disrupt the healthcare landscape, but it also presents an opportunity for innovation and improvement. Ultimately, the dissatisfaction among physicians and the growing preference for alternative care models will likely drive broader changes in healthcare delivery. As more providers embrace new approaches that prioritize quality of care over volume, we can anticipate a convergence toward models that prioritize provider satisfaction, patient-centered care, and ultimately, improved health outcomes for all stakeholders involved.

Usamah Mossallam, MD. Vice President and Medical Director of International Initiatives at Henry Ford Health (Detroit): The 35% figure may be misleading as many physicians — pediatricians for example — do not see Medicare-aged patients. Therefore, they may not have a need for Medicare contracts.

The data would also be interesting to note as to employed versus private practice physicians. Most employed physicians don't have a choice in what contracts their employer chooses to engage in.

As to physicians who treat and care for adult patients and patients over the age of 65, I cannot see how their practices will remain sustainable. Our population is rapidly aging, and Medicare remains a key payer. Yes, Medicare reimbursement is not great, and oftentimes is below costs; that is a source of concern for many of us. Medicare is also part of many value-based contracts. We cannot exclude that key piece.

As to Medicare managed care, that is a different issue. I expect CMS to step in to hopefully help better manage the physicians and health system concerns with how that is being administered by health insurance companies.

Seetha Venkateswaran, MD. Site Director at Weston (Fla.) Family Medicine: Medicare has undergone significant reforms to their payment model in the past decade and there are implicating and real word consequences as a result. The payment has declined by 26% when adjusted for the rising healthcare costs, in turn affecting the ever-growing reimbursement gap for physicians and downstream consequence in patient care.

As a result, there have been direct effects reported with increased hospital rates due to delay in care because of issues in accessing their respective primary care physicians in a timely manner, especially for minority patients. In addition, physicians who have large and active Medicare-based patient panels, regardless of the type of subspecific Medicare plans, have been penalized with decreased reimbursement rates even with risk adjustments made based on the level of complexities with their patients. In addition, many of the physicians are unable to meet their performance-based incentives as a result of the changes in Medicare reimbursement rates.

Since the biggest challenge is underpayment, it affects all specialties and facets of care, in terms of the monetary resources being allocated for treatments such as procedural care, which includes divisions in operating costs for providers, rooms and other ancillary services. When Medicare payments do not close the gap in rising patient care costs, the biggest question presented to physicians and accountable care organizations is the net benefit/loss margin associated with taking care of this patient population. In turn, many of these Medicare patients are turning to seeing physicians assistants and nurse practitioners, though improving access on the surface but not necessarily equivalent to timely or appropriate care leading to increased emergency room utilization and hospitalization costs, a trend that we may continue to see if reimbursement cuts don't improve with Medicare reform.

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