Dr Gray’s Thoughts

Why I’m going back on Medicare……….(am I nuts?).

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As you probably know from a previous post, I opted out of Medicare in 2009. It’s been a great run without the burden of that bureaucratic behemoth dragging me down into the mire. I’ve been able to breath more fully and easily. I haven’t had to concern myself with “Meaningful Use 1” or its sequel, “Meaningful Use 2”. I haven’t had to fret over whether Congress would come up with a last minute fix to the payment formula and the threatened massive cuts in Medicare fees. No threat of a RAC audit. None of it has applied to me…and it’s wonderful!! The Medicare patients that have stayed with me pay cash for their visits. They pay at the time of their visit, so there is no delayed payment, no justification to Medicare for the fee, nothing like that at all. Hassle free. So why would I even consider returning to the fray with Medicare? Am I nuts?

There have been some down sides to opting out……….

1. I end up seeing a significant number of patients for free. I have some Medicare patients who don’t have two nickels to rub together and they definitely don’t have enough money to pay for my office fee of $59 for a 20 minute appointment. So I end up just seeing them for nothing.

2. I undercharge a lot of my Medicare patients. If the office visit goes to 30 or even 40 minutes, my fee schedule calls for a higher fee than the baseline $59. But I know some of my patients struggle to pay even the $59, and to pay a higher fee would tax them even more. So, I charge the lower fee to give them a break.

3. Because they are paying out of pocket, many of my Medicare patients delay office visits until they are sicker than they should before seeking medical attention.

4. For the same reason as in point #3, many of my Medicare patients increasingly are asking for telephone medicine instead of coming to the office. This isn’t good medical practice.

5. There are patients on Medicare that I know I could help, but they are reluctant to come to me because they don’t want to pay out of pocket to see me.

6. I see patients at nursing homes at times…..how do I charge them? Half the time, they don’t even know I’m there. How can they write me a check?

So, in the interests of the patients that are loyal to me but struggle making ends meet, I am going to go back on  Medicare. I may regret it, but probably not. I guess I am a little nuts.


Can patients that sign up for Obamacare benefit from Access Direct Care?

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I’ve had quite a few patients ask me if Obamacare will have any impact on my practice. As you know, I have a blended practice of traditional insurance third-party billing, plus a large contingency of patients with no insurance at all or high deductible plans (the highest I’ve seen so far is $10,000, but $5000 has been rather commonplace). So, how will the ACA (aka Obamacare) affect my practice? The short answer is: favorably. Why is that? Most of the Obamacare plans that I’ve seen are high deductible plans, with deductibles in the $5000-plus range. That means, the first $5000 of medical expenses will come out of the patient’s pocket. That means, they can get a lot more healthcare at my office than at the big-box clinics, where prices are inflated. For example, the lab work that I usually order for a complete physical examination (complete blood count, comprehensive metabolic panel, cholesterol panel. thyroid stimulating hormone, urinalysis, prostate specific antigen) would cost $300-$400 at the big clinics. In my office, they cost $50-$60. A complete physical examination office visit fee at one of the big clinics is $225. At my office, it’s $119.  So, why would someone pay twice as much money for the same commodity when they can have the same exact thing for half as much? Good question.


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I opted out of Medicare in October 2009. In case you don’t know exactly what that means, let me explain. Opting out means that I am “out of network” for Medicare. I can no longer send in bills to Medicare for reimbursement and neither can my Medicare patients. In fact, I have to sign an affidavit stating that I won’t submit any bills to Medicare, and if I do, I can be penalized.

Opting out was not an easy decision. It was one that I wrestled with for a couple years. I didn’t want to let down those elderly patients

But why did I opt out in the first place? Let me explain. Back in 2008 and 2009, my expenses were very high, but my gross revenues were shrinking by the day. There were times when I didn’t pay myself at all in order to meet payroll for my staff and pay the mortgage on the office building. That’s not a good feeling – to work 50-60 hours a week, and receive no income, zero, nada, zilch. People mistakenly think that all doctors are rich. Well, I’ve got news for you – it just isn’t so. So, I had to take a hard look at my practice and what I was going to have to do to survive. The first thing I checked was my patient mix. I found that about 50% of my appointments were for patients with Medicare. In other words, half of my practice was made up of Medicare patients. And you will be shocked to learn that  Medicare accounted for only 17% of my income. Let me repeat those numbers. Medicare accounted for 50% of my patient volume and my time, but only 17% of my income. That was quite a revelation. And that’s a pretty pathetic ratio. I could see from a purely survival perspective, it wasn’t a tough decision. Many doctors wrestle with this, thinking that they could never survive without Medicare. But in the worst care scenario, I figured that if ALL of my Medicare patients left me, I would have 17% less income, but 50% more time on my hands.

But the revenue aspect wasn’t my only reason for leaving Medicare. Most people don’t realize this, but Medicare has over 132,000 pages of rules and regulations that must be obeyed under penalty of steep fines, and even jail time. Imagine that….I make an honest mistake, and under Medicare rules, I could end up serving jail time. What kind of system is that? It’s a miracle to me that so many doctors choose to participate in such a draconian system.

But the straw that broke the camel’s back for me was the institution of RACs (Recovery Audit Contracts). In order to look for fraud in the Medicare system, the Medicare administration has hired independent contractors to perform random audits on doctors’ office charts looking for evidence of fraud. On its face, this sounds like a good thing, right? After all, a doctor who is defrauding the Medicare system by charging for services that were never performed or intentionally overcharging for services that were performed only makes good sense, right? Right. But wait a minute. Here’s what is actually happening…. I read about a urologist that had 100 of his patient visits randomly audited. The auditors found no evidence of intentional fraud. But they felt that 20 of those patient visits were mistakenly overcharged, based only on the amount of documentation that they found in the patient’s chart. In other words, there wasn’t enough documentation in the chart to satisfy the auditors that the amount Medicare was charged for that visit was warranted. So what did they do? They extrapolated that 20 out of 100 visits to the entire year and made the assumption that 20% of the charges for that entire year must be in error, and the doctor therefore owed a refund of 20% of the money he was paid by Medicare for that year. That’s a LOT of money for a busy urologist. So he had to hire a lawyer and fight it in court. He ended up winning mostly, but he still had to pay a lawyer, and go through the hassle of fighting a faceless bureaucracy. But here’s the kicker to the whole thing…….guess how the auditors are paid? They are paid a percentage of the money they recover!!! In other words, the are highly incented to find whatever they can find, legitimate or not. In my mind, that stinks.

So, in the end, I opted out. And you know what? My practice did slow down some. I see fewer patients a day. But i can spend more time with them. And getting out of Medicare was like lifting a huge weight off of my shoulders. I could breath again. Freedom is sweet.

Check out this link: http://www.kevinmd.com/blog/2014/08/love-old-people-will-accept-medicare.html


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One of our goals at Access Direct Care is to provide excellent health care at a reasonable price. In practice management literature, it is reported that the average office visit with a primary care doctor (like myself) is around 6-8 minutes. The question is: how can a doctor take a good history, do a thorough examination, reach a diagnostic conclusion or plan of action, and explain it to the patient all in the space of 6 minutes? The answer is: it’s impossible. So, instead, what we can get is an abbreviated visit, lots of unnecessary testing (it’s easier to order a CT scan than to do a thorough history and physical examination), and substandard depersonalized care.

But, let’s go back to the root cause of this. Why is the average office visit only 6 minutes long? When we are honest with ourselves and cast aside all of the excuses, it all comes down to money and survival. And the reason money has become such a big part of the problem is the involvement of third-party payors like Medicare, Medicaid, and commercial insurance companies. These big companies and government entities call the shots when it comes to how much a doctor gets paid for a given service, test, or procedure. Over the last 20 years, those payments have been squeezed down lower and lower to the point that there is just barely enough payment coming in to cover the expenses of doing business, let alone having anything left over to put food on the table. The natural outcome of this dilemma is to increase volume to maintain a sufficient level of income. Two important things happen when patient volume increases: 1) the doctor has to hire more staff. The more patients a doctor sees, the more staff it takes to see them. There are more phone calls, more refills on medications, more tests to order and keep track of, more insurance claims to file, etc. You get the drift. 2) patient care suffers. Let’s just take it to extremes to make a point. Which doctor would you rather go to? The doctor who sees 40 patients a day, spending 5-8 minutes with each one, or the doctor who sees 10 people a day and spends 30 minutes with each one?

So, let me get back to the point behind insurance companies (aka “third party payors”). Third party payors have corrupted the medical system by: 1) dictating what care is given, how often, how much, etc. They are like the big brother in every examination room across the country. And you thought you’re going to see your doctor…..no, you’re seeing your doctor under the auspices of big brother      2) increasing the cost of medical care by adding another layer of expenses (the extra staff, computers, postage, phone time, paperwork filled out by the doctor, etc, etc that I mentioned earlier). The third party payors add expense without any added value. 3) by ratcheting down their payments to doctors, they have encouraged a culture of increased “productivity” amongst doctors which has led to shorter appointments.

As a result, I am slowly weaning myself from the insurance trough. I’m trying to get off of the insurance merry-go-round for a number of reasons. The most important reason is that I’m tired of having my care and interaction with my patients dictated by an ever-present third party in the mix. The way things are when we deal with insurance is that there are three parties in the exam room: the doctor, the patient, and the insurance company. And unfortunately, the insurance company decides which medicine you will receive, which test you will have, which consultant you will see. There’s something wrong with this picture, isn’t there? Healthcare should be between a doctor and a patient. PERIOD! In addition, all your private, personal health information gets forwarded to the insurance company. They know your diagnosis. They know what medicines you are taking. Sometimes, they ask for a copy of my office notes that document your visit with me (ostensibly to justify payment at a given level of service). This information can be highly personal…but they have a right to it. After all, you and I both had to agree to it in order for them to agree to pay the bills. So, patient privacy is a huge reason to be free of insurance. Your notes stay in my office and no one ever has to see them.

So, how does ridding my medical practice of insurance companies help you, the patient? Number one, it costs less. Since I don’t have to have the extra staff to process the payments, the extra nurses I would need to see lots of patients, the computer software costs, the postage costs, etc., my overhead is much lower, and therefore, I am able to charge considerably less and still make a living. Instead of charging $89 for a 15 minute visit, I can charge $49. Instead of charging $400 for the labs that I do with a complete physical exam (CBC, comprehensive metabolic panel, lipid panel, urinalysis, and PSA), I can charge $80. Those are just two examples. Last year, I had a complete physical examination with my doctor, who is a fine doctor with excellent credentials and excellent clinical skills. I have a high deductible insurance plan, so the entire cost of the visit was out of pocket for me. For the examination alone, the charge was $220. For the same exam, plus all the blood tests I mentioned a couple sentences ago, plus an EKG, I charge $199 total. Number two, my appointments are longer. Instead of an 8 minute appointment, my appointments are more like 20 minutes, and often longer. More time means a more thorough, reasoned approach. Number three, my schedule tends to be a little more open, so I usually see people that call with acute problems on the day that they call. I send very few of my patients to walkin clinics. Walkin clinics serve their purpose, but who wants to go to one when you already have a doctor of your own?

You might ask “OK, that’s great for people with no insurance or for those with high deductibles, but what about those of us with regular health insurance. Why should I pay $49 for an office visit when I would only pay a $20 copay if I went to a doctor in my network?” That’s a great question. There are a couple possible answers. Number one: many people that have stayed with me even though I am no longer in their network end up ahead financially even if they pay for their visits out of pocket. Here’s how: they pay for the visit out of pocket (let’s say $49 for a 15 minute visit). They then submit the paperwork to their insurance company and ask for reimbursement at out-of-network rates. The insurance company, in turn, sends them a check for $30. Total out-of-pocket cost: $19. I’ve had some people that were reimbursed 100%. One patient, who used to have a $25 copay for her visits got reimbursed $40 for a $49 visit resulting in a $9 out-of-pocket cost. She ended up $16 ahead by seeing me out of network………again, because my fees are so low. The second reason to stay goes to the issue of value. If you value your relationship with me, if you have come to trust me as a physician, how much is that worth to you? For people that see me once a year for their hypertension or arthritis, and leave me because they have to pay $49 instead of the usual $20 copay once a year, I guess I wasn’t much of a doctor to them. It wasn’t even worth an extra $29 a year to stay with me. But I would hope that my care is worth something more than that. It’s ultimately up to you.

A couple of excellent websites that review the effects of third party payors on the health care system are www.aaps.org, the website of the Association of American Physicians and Surgeons, and www.medibid.com.