Rock Star Physician Rebels Against Medicare Bureaucracy

Confident DoctorsRebekah Bernard, MD, who wrote a book titled How to Be a Rock Star Doctor:  The Complete Guide to Taking Back Control of Your Life and Your Profession, has written an open letter to her Medicare patients. Here are the choice bits:

For every office visit that we spend together, I spend at least as much time on what Medicare deems as necessary documentation, especially a new program called meaningful use.

To comply with Medicare requirements, I’ve had to spend thousands of dollars and massive amounts of time instituting electronic health records, adapting my practice to conform to the computer technology that wasn’t created to help me, your physician.

And next year the whole ballgame changes for physicians as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) goes into full effect, with a complete paradigm shift in Medicare payment from “fee-for-service” (I send a bill for your medical care, Medicare pays me), to “value-based payment” (I submit a bill, and I get paid if Medicare thinks that I’ve done a good enough job).

The kicker is that the pot of money remains constant – so even if every doctor makes an ‘A’ grade, half of them will be paid less money, just by nature of this “budget-neutral” payment system.

Up to this point, I have managed to play by the rules that Medicare has set.

In 2017, this may no longer be the case.

As a policy analyst, not a physician, I have to report a mixed response to this letter. I have great sympathy for the message: It hits two policy issues that NCPA has addressed forcefully: So-called Meaningful Use of Electronic Health Records (EHRs) and the fundamental reforms to physician payment in this yeare’s “doc fix” legislation, MACRA.

Meaningful Use of EHRs refers to the $30 billion of taxpayers’ money that was flushed away on EHRs that are (at best) ineffective at improving the quality of care. Rebellion against the program has increased since the money was paid out, and it should be abandoned.

MACRA was a disgracefully bipartisan bill that was rushed through Congress by physicians’ professional societies, which effectively sold out their members in order to increase the societies’ power over payments. Practicing physicians had no time to organize themselves to respond. It is good to see them finally pay attention.

On the other hand, physicians cannot just complain about how little Medicare pays them. Medicare is in a fiscal crisis and doctors who think they can go back to a time where their claims were just processed without question have unrealistic expectations. Unless and until they accept that giving Medicare patients power over medical prices and payments is the only way to reduce government bureaucracy, their Medicare problems will get worse.

Further, the threat to quit Medicare next year is one which I have heard physicians make for about 15 years. Although more physicians have recently dropped out, the number of physicians treating Medicare patients is growing in line with the number of Medicare beneficiaries, according to a recent report by the Medicare Payment Advisory Commission (MedPAC, see page 80).

In other words, the signal to noise ratio for physicians’ frustration with Medicare is very low. Until that changes, we can expect government to continue stumbling and bumbling around the program.

Comments (22)

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  1. Devon Herrick says:

    I’m not exactly sure what a “Rock Star Physician” is. Presumably it’s not a doctor that quit her day job to play rock & roll in smoky bars and clubs at night and then became famous. Like John, I can sympathize, but at the same time I know most doctors accept Medicare because treating Medicare patients brings in a little money and fills the waiting room. However, few doctors can afford to dedicate their entire practice to treating Medicare patients.

    It sounds to me like her reference to 2017 was not a veiled threat. Rather, is was a hint that she is considering converting her practice to a concierge, retainer-based practice in 2017.

  2. Perry says:

    My bet is that physicians who continue to see Medicare patients will be hospital employees. Oh, they will still be frustrated and burnt out, but they will do what they have to in order to stay employed, and not have to deal with the expense of compliance on their own.
    Many of the docs in my area are looking for either non-clinical jobs, urgent care or getting out altogether.
    I also think docs don’t have as much of a problem with what they get paid, as to the hassle factor and the work to pay ratio, and the interruption of patient care time to fill out computer checklists. Many docs have to do their documentation late at night after seeing patients.
    As to the government continued stumbling and bumbling, I heartily agree.

    • Devon Herrick says:

      It’s sort of amazing isn’t it. Doctors are in short supply; they are rushed during their appointments. But they spend an increasing amount of their time not seeing patients, but documenting what they did when they saw patients earlier in the day. The former benefits society and generates revenue. The latter keeps CMS happy and makes the public health researchers happy — due to the treasure trove of data on inputs.

      If we were paying our own physician bills, we would judge the quality of our physician encounters based on the time spent and how attentive our doctors are. But because we rely on a third party to pay our medical bills, out doctor spends less time with us and more time documenting what he/she did for the payer.

      • Alan RN says:

        I switched to a cash-pay practice recently. I pay the bill and do the insurance run around. My recent visit with my doctor lasted an hour. An hour with your physician is unheard of in the HMO world.

  3. Rebekah Bernard says:

    Thanks for publishing my blog!

    My definition of a Rock Star Doctor is someone who attracts and maintains a great patient following without burning out, and the book tries to encourage younger docs on ways to do that by “working-around” the gazillion administrative challenges that we face every day.

    I am considering transitioning to a Direct Patient Care (DPC) practice – not concierge, but rather a low-fee based subscription type model. This practice type is picking up momentum and has the potential to bring back the physician-patient relationship that we all miss so much.

    Hopefully if I do this, at least some of my Medicare patients will stay with me. It will be hard for me to leave them.

    • Perry says:

      Best of luck, Rebekah.

    • Fred S says:

      I believe the fee based supscription model will prove to work out great for many practices – and patients as well – in the years to come.

      Fred @

    • Devon Herrick is a Rock Star Economist.

    • Stephen Ely says:

      Being ignorant of “how the system works” cause I’m not from this country, I have dedicated my efforts to focusing on my patients to get them and keep them healthy. We see all the same physical maladies that normal people face and we take steps do deal with them as they occur, all while we reinforce the concept of preventative lifestyle that provides results most people want. We have attracted a growing number of patients who have enjoyed the paradigm shift for their benefit. It is possible and realistic and it provides for the patient and my family. And I’m still a sole practitioner.
      Thanks for the article.

  4. Michael Gorback says:

    CMS has turned physicians into the world’s most expensive data entry operators.

    I have refused to adopt EMR. It costs too much to implement, the “meaningless use” program is a rip-off, and productivity sinks about 20%. If I’m forced into it, I will probably take early retirement (I’m 62).

    The penalty for not using EMR is a cut of 1% of my fees this year and 2% next year. It’s worth it compared to the cost of implementing an EMR and the loss of productivity.

    The quality of my personal doctor visits has gone down. They spend all their time staring at a computer screen and typing. I refuse to do that. I can jot down a note on paper and be back looking at the patient before the guy with the tablet can even open the drop down menu.

    “few doctors can afford to dedicate their entire practice to treating Medicare patients”

    Actually that’s not true. You’re more likely to go broke seeing only United Healthcare patients since UHC has been paying many doctors well below the Medicare rate. Yes, people pay UHC $10,000/year in premiums for private insurance with horrible deductibles and UHC pays doctors perhaps 85% of Medicare. In addition, Medicare doesn’t require pre-authorization.

    I dropped my UHC contract last year. I noticed they were paying me 85% of Medicare, which was not the contracted rate. I tried to get it addressed for 6 months and just got a runaround. I dropped Aetna years ago because it seemed like every bill was denied the first time. With Medicare if you know the rules and color inside the lines it’s much easier.

    Doctors can threaten to drop Medicare but for many specialties it’s not feasible. It’s hard to make a living practicing adult cardiology if you don’t take Medicare. If you’re hospital-based (pathology, radiology, anesthesiology, hospitalist, ER, etc)the hospital will insist that you accept Medicare.

    Family docs such as Dr. Bernard have the most leeway since without billing and collection overhead they can structure a fee schedule that many people can afford. A heart surgeon trying to live off of cash patients will have a rough time.

    • Alan RN says:

      UHC is the devil’s spawn IMHO. My employer offers that plan. I took the lowest premium, HSA eligible plan and I switched to a cash-pay physician. I love it. My office visits are paid with a MasterCard connected to my HSA.
      The last time I went to an HMO doc, he sat in front of a keyboard interviewing me and filling in the boxes.
      Front line docs can make that transition to cash at time of service but hospital based specialties will have to continue to take MCare. However, as those practices get absorbed into the Borg of health “systems”, the business side will be handled more and more by the hospitals.

  5. Wanda J. Jones says:

    What an important topic. The physicians obviously are reflecting the disdain CMS shows for their profession. The hassle factor is too great, and the time wastage is enormous. Let us all take heed, as single payer advocates need to understand the ignorance, and willful over-regulation by staffs of Medicare and the large insurers. Keeping doctors at work and seeing patients is not a goal. the belief is that the patients are in the program for good, and the doctors have to be where the patients are, despite low payment and stupid rules.

    It is a shame how the AMA and Societies have betrayed their members.

    I have one specialist who types her notes in front of me for about 75% of the visit; one doctor only goes to find his notebook computer when he has to look something up. So far, I have note who routinely transmit notes to my other 5 doctors and it hasn’t hurt me at all.

    When my cardiologist, who has kept me alive for years past my sell date, bills Medicare $180 for a routine visit, and Medicare says they approve $120.00, then pays $80.00, something is vastly wrong with the power equation. Medicare can do what it damn pleases. As citizens, we should be wary of this much arbitrariness on the part of any government agency.

    If I were a physician, I would go into the theater–much more secure.

    Wanda Jones
    San Francisco

  6. Narayanachar S. Murali, MD, FACP, FACG says:

    This is an asteroid moving fast toward ALL practicing doctors who see mostly medicare patients and expect to be paid based on what they are doing to help patients. Those in comfortable slumber because you sold out to a hospital thinking you would be shielded from this complex mess due to the administrators warm hands around your heart, the comfort of base pay + RVU+ Bonus….Beware! The pain of not even being to value your own work and letting CMS decide whether you have met some foggy, mostly unattainable quality measure or index of performance for every code you submit ought to be unsettling. I am not surprised that physicians are not even talking about this! That is the power of laced Koolaid…

  7. PJohnson says:

    Per Milton Friedman there are 4 ways to spend money in rank order of declining efficiency:

    1) Spend your own money on yourself.
    2) Spend your own money on somebody else.
    3) Spend somebody else’s money on yourself.
    4) Spend somebody else’s money on somebody else.

    It should come as no surprise the Medicare falls under #4. At the heart of the “health care crisis” is that glaring fault.

  8. Jon Schwartz says:

    totalitarian Statism was described by de Tocqueville in the early 1830’s… applies to today, after 100 years of progressivism which has accelerated under the extra constitutional Obama…… usual. the Left solves problems with what caused the problem in the first place. This is one of the major flaws of so called liberal thought is one reason progressivism is an impossibility…….

    it covers the surface of society with a network of small complicated rules, minute and uniform, through which the most original minds and the most energetic characters cannot penetrate, to rise above the crowd. The will of man is not shattered, but softened, bent and guided; men are seldom forced by it to act, but are constantly retrained from acting. Such a power does not destroy, but prevents existence; it does not tyrannize , but compresses, enervates, extinguishes and stupefies the people, till each nation is reduced to nothing better than a flock of timid and industrious animals, of which the government is the shepherd.-Alexis de Tocqueville.

  9. Rebekah Bernard MD says:

    I suppose since my article cited here it will be ok to plug my book!

  10. Rodney says:

    I agree with Dr. Bernard. But the problem is not pointed at just Physicians. It is a problem that is also facing the HME Industry. I believe one of the Biggest issues with Medicare is that it is ran / dictated by the Government.

    Medicare is going to be the cause of larger unemployment figures. There way to fix the problem is to put people out of work and by drowning them in required paperwork.

  11. Wanda J. Jones says:

    Dear All—Where is there a deep retrospective, analysis, psychological history of Medicare and Medicaid?!! People in this country at all levels are so accustomed to these programs that they do not grasp that the flaws are so deep and wide that they are not working as they should and never will, unless freed from the features that make them so hard on everyone on the front line. AARP needs to think of both future and current members. Congress needs to do the same. And the healthcare field needs to accept the ethical duty to clean up the way it bills.

    There will be a hecka clean up after Obamacare, no matter what the replacement policies are.

    Wanda Jones
    San Francisco