I learned this week that another valued colleague has “retired” due to the stress of office practice brought on by insurers and government. He went to take a part-time VA job. His patients are scrambling to find someone to provide their care. The sick ones are learning that nobody is eager to help them.

Why do we have this state of affairs? In 1996 the government took over the pay scales for Medicare, Medicaid, and Tricare. For several years, they kept the system as it was set up to provide a fair reimbursement that was tied to the cost of care. However, Congress required that they pay the doctors less whenever the cost of the program grows. Since more and more people are going onto Medicare all the time, the cost of the program has grown. Each year Congress has had to act to prevent what are now draconian cuts in pay (over 30%) mandated by the law, and laws have been passed to keep the rates stable or increase 1%. The situation has resulted in the current payments being 25% below 2000 levels, and well below the cost of providing the care. YES I SAID THE GOVERNMENT PAY SCALE IS BELOW THE COST OF PROVIDING THE CARE (By about 25%). Furthermore, it is illegal to collect more, without leaving the Medicare system entirely, and having the patient sign a contract. In that case, we have to leave Medicare at least TWO YEARS, and if a patient were to see us, the patient cannot submit the claim to Medicare for reimbursement (Patient gets no money from the government for the care).

This is the madness we are dealing with. Every 4-6 months. Due to Congress (president gets the blame also for lack of leadership).

Right now we are told that next month we will be paid more than 30% less for the same work. Since this is about half the cost of caring, this it like saying the government will shut us down in a month. And we put up with this crazy scenario multiple times a year.

So our cost to provide a complex visit may be $200, and we are allowed to charge $160, get paid $140 by the insurer, and they patient has to pay $20, that means $40 has to come from someone else. I am told by my wife that her hair salon visit can run over $200.

In a strange quirk, the system pays the doctor less for every additional minute spent with a patient. This means if I spend 45″ with each patient (often required for a complex case), I get paid half as much per minute as doing simple work which could be done in 15″.  This means doctors either have to lose money taking care of ill people, or refuse to take care of them.

The government has also tweaked the numbers from the originally fair system in 1996 in order to cheat the system further. For example, if you have a procedure with an expensive piece of equipment which requires specialized personnel, the rate is supposed to take into account the cost of maintaining the equipment and how often it is used. So they just adjust the numbers from using it 10% of the time to 90% of the time and pay us less. The other result of the 1996 law, is that they have the last say in setting the rate. We cannot sue, appeal, or have any means to correct the insanity. We can of course write a letter. Wow.

This problem is made worse by several additional factors beyond our control. First, the government in many cases prevents us from collecting the balance. If someone who is poor on Medicaid and Medicare, we are preventing from charging them for anything. This means if the doctor will not accept their insurance, we either give them the care for free or do not see them. In our state and many others, it is ILLEGAL to charge people with Medicaid, so even if someone else wants to pay from them to see the doctor, they cannot do it. This is healthcare prison of course. Did you know that the ObamaCare plan will extend this to most Americans?

Only because the government set these rates, all the insurers now demand them as well. So where does it come from? Nowhere in many cases. Large institutions have market power to negotiate better rates.

So how do some doctors cope? Some quit, especially older good ones. Others have stopped seeing Medicare patients. Some overuse tests which help cover the overhead.

Others do poorer quality care. I have colleagues who see a complex case in less than 10 minutes, don’t review any of the history or records, and shove the patient out the door with a half-baked opinion and fraudulent documentation of what was done during the encounter. They make a lot of money like this. They are called “productive”. This care is unacceptable. These doctors seem to experience little reprisal for this dismal care, indeed, they make a lot of money doing this,  and I have many patients who recount the behavior to me in disbelief. The experienced consumer of health care, who is the chronically ill person, can easily distinguish these doctors. They ask me what should be done about them. I always ask, “did you report what happened to the hospital/medical board/etc?” They never do, and the bad care continues, and the doctor continues to be paid well for doing this bad job.

Other doctors order unnecessary tests. Some practices do multiple tests on everyone like a mill. Usually they are treating the poorest patients on Medicaid. The system pays them and they see many patients and order many tests it is quite profitable. But they will not care for the sicker patients.

Doctors can’t insist on more money from government or insurers. Doctors are BY LAW prevented from negotiating as a group with insurers. We would go to jail. We are not permitted to strike. We always will see someone in an emergency.

How will the system change? Good care is always available, but it will cost you. The good experienced doctors will be inaccessible to people on Medicare, Medicaid, TRICARE, and many of the more profitable insurance companies (United, CIGNA, Aetna). You are going to see more nurses, get lots of mediocre care if you do not act more choosey, and pay more out of your pocket for good care. Why? the government and the insurers are pocketing the savings of paying less than the cost of the care.

The younger generation of doctors is not as committed as the older one. I have interviewed many of these folks and many want to take home a paycheck, work half-time, and have no responsibility. They don’t want to work for the outcomes and feel just as entitled as the patients to good treatment. It is not going to be pretty when they enter the new Obamacare era.

You can change it by insisting that Congress fix the Medicare system properly.

by SAMUEL F. HUNTER, M.D., PH.D. on FEBRUARY 3, 2012