Anybody familiar with Medicare is likely aware of the ever-changing nature of this government program. Annual modifications made by the higher-ups as well as the insurance companies have a wide-ranging scope of consequences, primarily regarding what services are covered as well as the costs of monthly premiums, out-of-pocket payment rates, and prescription drug prices. These consequences undoubtedly influence those who are eligible to receive treatment through Medicare, but another group who is often overshadowed in this equation consists of those who provide said treatment: the doctors, practices, and the hospitals.
According to Kem Anderson, a senior Medicare Advisor in the North Texas region for the past eight years, there has been more disruption in terms of which physicians are unwilling to work with Medicare over the last two years than there had been in roughly a decade before. More and more doctors are electing not to work with Medicare, and while there are a multitude of factors in play, it all boils down to reimbursement. Medicare enrollees may be forced to pay extra money out of pocket for scheduling a visit with their doctor if he or she happened to no longer be in the network specified by their Medicare plan. This has become known as “surprise billing.” While the Medicare system remains stable, this tricky dynamic appears set to continue for at least the next calendar year, and possibly into 2017.
The Affordable Care Act has certainly played a part in this migration. While the ACA has afforded millions of Americans the opportunity to have access to healthcare, it hardly provides incentive for doctors to work with Medicare patients moving forward. There was a 10 percent bonus that Medicare paid physicians from 2011 to 2015, but that expired as the calendar recently flipped to 2016, further straining physicians who were already under pressure to treat these new low-income patients on top of their already jam-packed schedules.
“Medicare is a cornerstone for many peoples’ retirement plans. The system is under a lot of pressure now, but we remain optimistic that it will further stabilize in the next 12-24 months,” Anderson said. “More doctors will return to treating Medicare patients, and even more so if the upcoming election impacts the current regulations of physician reimbursement.”
Since 2011, hospitals that have frequent avoidable readmissions have been subject to a 3 percent reduction in payments from the Centers for Medicare & Medicaid Services. This measure, known as the Readmissions Reduction Program, was intended to ensure that patients received proper care during and after their hospital stay. However, it has had a detrimental effect on hospitals that treat a high percentage of low-income patients, who studies have shown have a higher rate of recurring health problems.
Additionally, CMS imposes penalties on practices who don’t meet specified e-prescribing levels, are not complying properly with Electronic Health Record implementation standards, or are not actively using the Physician Quality Reporting System. Such penalties are currently in the 5 percent range, but could rise to 7 percent by 2017. Furthermore, the influx of younger enrollees into the marketplace has some practices placing more emphasis targeting them to break up their client-base demographics, rather than dealing primarily with elderly Medicare patients who often have more medical needs.
“Over the last decade, the medical system has become increasingly more complex, time consuming and less profitable for many doctors to operate in. As a result, many of them are simply electing to opt out,” Anderson added.
These conditions have led to many doctors becoming more selective in terms of which types of insurance they will take. It has become increasingly common for a certain hospital to belong to a specific insurance network, while a doctor working within those same walls will not. This is because of the relationship between the insurers and the doctors themselves, as insurers can offer lower payouts in exchange for an increased number of patients, but it is ultimately up for negotiation as to who they will or will not see. Medicare is especially delicate to navigate in these types of situations, as the scope of care that the many differing plans cover can vary to an extreme.
In closing, Mr. Anderson offered this piece of advice: “Even the most vigilant people can fall victim to surprise billing, but the more educated one is on the subject, the better one’s chances of avoiding an unwanted, undeserved invoice. The key is simply to call ahead when the time comes to schedule an appointment with a physician, especially if it has been six months or more since the last visit, to ensure that they have remained within the same network. A chat with the establishment’s insurance coordinator(s) may be necessary, but a few minutes of your time pales in comparison to paying a few thousand extra dollars for what seems like a relatively simple procedure. Medical costs tend to pile up quickly, and taking this simple step could instantly pay significant dividends.”