Sunday, November 23, 2003

Medicare: Opt in or Opt out?

I spoke with Charlie's wife today (see previous entry). He is hanging in there, helped with some steroids. But he is very weak and getting out of bed is very hard for him. They haven't pursued any other course of treatment, I suspect because it is all so overwhelming. I got info from the clinical trial using pancreatic enzymes, and while it looks like he could be a candidate, I'm not sure he can wait for them to reply if we sent in all the info now. His family is more or less resigned to the inevitable and are trying to enjoy their time with him.

So I went ahead and ordered some pancreatic enzymes myself ($300) and am having them shipped overnight. I believe it's worth a try, and if it buys him some extra time, then it would worth more than $300. I charged it out of my business charge account, so I figure I can write it off as a business expense even though I don't intend to ever make any money from this. I have arranged to go over to Charlie's house on Wednesday since I have never met him, and just wanted to say hello (and I figured that would be a good time to bring over the enzymes, too). Isn't this what being a doctor is all about? Helping others for the sake of helping, rather than financial gain. Wouldn't that be a wonderful world if it could work just like that all the time?

This is my final (regular) work week at Kaiser. After this week I am taking a "terminal vacation" until my final resignation day on Jan. 5th, although I did agree to work 3 days in December as an urgent care doctor to help handle the expected spike in colds and flus. I am looking forward to the end of this week very much, mainly because it is the beginning of the end for me. I'll be able to finally catch up on everything, without accumulating any new patients or labs or calls.

I'm in a holding pattern with my solo preparations. Awaiting to hear from the malpractice insurance company, so that I can tell the hospital credentialing department, so that I can submit my applications for participation in Aetna/Blue Cross/Healthnet, etc. I've been waffling back and forth over Medicare participation. I'm not so concerned about the low reimbursement; it's more the fear of being prosecuted for minor unintentional violations of one of Medicare's regulations.

From a 1997 article in Family Practice Management:

The Medicare reimbursement system for physician services is complex, contradictory in the dual worlds of fee-for-service and managed care, and dangerous for those who would ignore its pitfalls. Because the rules continually change, Medicare offers a full plate of management challenges for physicians who seek its benefits but also must guard against its threats. Although the prospect is daunting, preventing false claims is manageable when taken in small bites. Physicians who had to be good students to become doctors need only approach this system the same way.

And that's from a positive take on Medicare. There are lots of negative opinions on Medicare such as this. But I have to say, this "fringe" group of the Association of American Physicians and Surgeons (who are these guys anyways?) would seem more credible if they didn't also call for a halt to requiring new vaccinations.

On the other hand, I do want to help elderly patients with their healthcare. But not at the cost of my future livelihood or career. Maybe I'll be like Gordon Moore and just not charge Medicare patients. Which way to go? Opt in or opt out? I'm getting a headache.

OK. This doesn't look so good. Medicare's Resident and New Physician Guide is only 168 pages long. Migraine alert!

I asked one of my patients at Kaiser last week what he would consider to be a reasonable fee for a regular office visit (if he didn't have insurance). He said he thought $40-50 would be a fair price. And that seems fair to me, too. I have a hope that there might be enough patients in my local area who may or may not have insurance but feel that $50 is a fair price for a 15 minute office visit, too. And if I opt out of Medicare, perhaps that is not too much for seniors to pay? I could offer a senior discount. That is something I could not do if I accepted Medicare. Even if a Medicare patient wants to pay me more than the reimbursement limit of their own free will, I would be forbidden from accepting it. How much sense does that make?

Part of the reason I'm leaving Kaiser is for greater autonomy. I'm trading Kaiser's job security for professional freedom. It would appear that in accepting Medicare, I lose both security and freedom. Perhaps it's not such a tough choice after all. Now where's my Extra-strength Tylenol?

Countdown: 43 days until target start date