Hoopdriver

My annual checkup a few weeks ago was my first visit under Medicare. I am still covered by my former insurance as secondary. I had been seeing this doc for over 5 years and always found him willing to listen to my concerns, discuss issues, explain options, and respect my care choices. I expected the same this time but found that he flew through the exam, was dismissive of my concerns, and hurried me out for my labs. Was he just having a bad day or is this a time-saving strategy for visitors who are perceived to have a less lucrative insurance plan?

Also, I had been getting my lab reports with good explanatory notes from the Dr, but this time he just left a terse order (with multiple typos) to his nurse to call me to ask if I had any questions.

Is this what I should expect from medicare providers from now on? Should I wave the "hey, I do have other insurance" flag? I am looking for a new doc, BTW.

Marlin

I have seen the same doctor for over 20 years, 10 pre medicare and the last 12 under medicare, with a secondary insurance. I have not seen any change at all in the time he spends with me, or my care and treatment. Actually, as I have aged, I have needed to see him more and receive more attention the last ten years than in the first ten. I have had couple of issues that required additional time from him, and he spent as much time as we needed.

FBinNY 

Don't blame Medicare. Blame the doc.

The reality is that while Meducate reimbursements nay be worse than some private carriers, seniors should be treated well because they tend to be cash cows.


Many of the regular tests authorized and paid for by Medicate generate good income for doc.

But for good doctors, the money is a necessary part of the blame, but not the game itself. They care about their patients and will do what's right by them.

Unfortunately, the system now calls for docs to produce volume, and so there's less time to actually engage with their patients. My old doc used to say that he could learn more in a 10 minute conversation with me, than with a multitude of tests. However, the system doesn't pay for contact time, it pays for tests and treatments. Things with a reimbursement code, and the medical equivalent of a flat rate chart.

bobwysiwyg

https://blog.medicaremadeclear.com/p...care-covers-2/

shelbyfv

I have friends who have encountered docs who will not treat patients who have Medicare. I would not knowingly be treated by one of these arrogant ingrates. They are educated largely at public expense and our government regulations secure the closed system that allows them to charge far more than they could in any other civilized country. JMO

canklecat

It's the doctor, not the system. Maybe he was having a bad day.

My mom has been on Medicare for almost 20 years. She gets great care from the local public hospital that's also a teaching hospital, part of the university system. Her primary care doctor tends to treat mom's visits as social occasions and they spend almost too much time gabbing, but they've known each other for 20 years.

Her specialists -- neurologists, etc. -- vary according to temperament, nothing to do with Medicare or the public hospital system. Most of her specialists have been patient and attentive, although they tend to have only 5-15 minutes per patient on busy days. And the nurses are very patient and considerate if anything else comes up.

Medicare is fairly portable now and most folks have a wide choice of providers. Mom could go to a more prestigious hospital/health care system, but I don't see any reason to switch. We go outside the system only when her regular provider lacks a particular medical specialty or diagnostic lab.

TGT1

No difference with one, actually more attentive with the other.

ModeratedUser150120149

Actually, yes. Many of my friends and acquaintances have had to find new docs after becoming Medicare recipients. Others, including myself, could not find a specialist to treat them. Even with additional insurance Medicare rules, for the most part.

The other obstacle is "Evidence Based Medicine". That is insurance code for not allowing people to be treated as individuals. So, unless you have a good PCP who will fight for you, and even then sometimes, certain diagnostic procedures are not allowed.

sch

Another possible factor is the EMR (electronic record) which are generally enormous PITAs and require 15-25% more time to fill out
than paper records. If the MD has changed EMRs or switched from paper since your last visit, this may account for the behavior as well.

John_V 

I've been on Medicare for 6 years, my wife for 5. We've had the same doc since he came out of med school, over 40 years ago. He's taken care of our children and grandchildren. Our care from him is no different now than before we got on Medicare. However, since he started with his new EMR system, he does spend more time with his patients and that's only because it takes so long to enter everything required by the software. It could be your doc was having a bad day or was falling way behind, with patients waiting to be seen, because of the EMR and you just happened to be one that he rushed through to catch up.

Before you go doc hunting, give him/her another chance. If the behavior doesn't change then "Happy Hunting!"

TiHabanero

I am a few years away from Medicare, however my doc took his staff and another doc and his staff with him to another outlet. The big hospital in town (Spectrum Health) owned his time and business and he was told to see X number of people each day, regardless of the visit type. Now that he is with a smaller outfit, he is far happier and very willing to spend a few extra minutes discussing the visit.

JohnDThompson 

OTOH, EMRs can be a good thing as well. I was travelling with my 87 year old mother in Hawai'i a couple years ago when she lost her blood pressure pills. We went to a walk-in clinic to get a new prescription (her blood pressure at the clinic was 200s/100s, so quite high), and the physician there was able to pull up her medical record from Wisconsin, verify medication and dosage and other pertinent history, and write a new script.

brianmcg123

He probably had a tee time and was getting behind.

_ForceD_

Right! I don't think they work on commission...do they?

Dan

jon c. 

Sadly ironic that there are people who have made fortunes billing the medicare system, but few of them are actually doctors.

scott967

Here, you can't find a PCP who will take new Medicare patients. I'm 64 and lose my current insurance when Medicare kicks in, and will have to find a Doc some how. The trend is for Docs to give up private practice to become "hospitalist" wage-slaves. The Gov't wants you to have a "medical home" which really means, you get a Nurse Practitioner who can only provide the "standard of care". Mainly that means they can order you tests.

scott s.
.

mwalsh5757

My wife is already on medicare and has our Disney PPO for her secondary, while for me the Disney PPO is my primary. We have always been able to find the best doctors and neither of us has ever had treatment any different from the other. In fact, my wife probably gets more attention than me, being as she sees them all on an ongoing basis while I only go in once a year or if there's something "wrong".

I actually had my first experience with a Nurse Practitioner a couple of months back as a new patient with my wife's Internal Medicine guy - she did most of the work while the doctor just breezed in to say "Hi!" and go back over what she'd already discussed with me. I didn't think I got short changed by the experience and was actually very pleased with the NP's bedside manner. YMMV.

JohnDThompson 

If they're part of a group practice, they may have bean-counters breathing down their necks to make sure they only spend a limited, arbitrary length of time with each patient. If there's any indication that more work-up is called for, they're expected to schedule a follow-up appointment at a higher charge level rather than pursuing it during the current appointment.

Hoopdriver

This provider has been doing EMRs for at least 5 years. Given the scantily worded notes, inaccuracies, etc., it's hard to imagine that they are spending much time on them. Nevertheless, they are a source of knowledge about the patient's history. Though I would expect a doc to scan this history before seeing a patient, there was no indication that this happened during my last visit.

I had a PA as a PCP years ago and it was great. PAs usually start in some sort of medical career and then seek to become a PA. This means that they are motivated by their profession. MDs on the other hand usually decide on their careers as undergraduates and thus may have a different motivation. Said differently, PAs typically know what they have signed up for, future MDs may not. I realise this is a huge generalization and my intent is not to offend, but I have yet to meet a dismissive PA or NP.

Thanks for the responses. I have labeled this as a doc's bad day, but think that given that I am trusting my care to a person who sees me once a year, I should not have to accept it. I'm resolved to find another doc.

jppe

My doctor intentionally scheduled my last physical just prior to my going on Medicare. He mentioned that the physicals under Medicare are not as detailed as normal insurance. So, I’m thinking there must be a difference. When I signed up for a Medicare supplement, the agent made the point that the negotiated doctors and facility fees are a lot less than normal insurance. It sounds like some physicians react to the lower compensation by adjusting what they provide**********???

Ogsarg

If you were happy with the Doc before, I wouldn't change due to one bad experience, or at least not before discussing it with them first. There are lots of possible explanations why they may have been in a hurry for your last visit. I wouldn't assume that it is how you will always be treated.

bargeon

Why not take the issue up with the doc? In a polite, concerned tone of course, especially if you have been satisfied till now. Maybe not easy, but there may be a reason for the problem.

I've been with the same doc for a decade or more. No change when I went to medicare, though I can tell if she's having a bad day.

TCR Rider

I became Medicare primary last July. I had a total knee replacement in Sept and I did notice a difference from the level of care I received from the hip replacement I had a few years ago. Not so much from the surgeon, I had the same doc. for both procedures, but the hospital itself. I wanted to get a second opinion from another Surgeon and was told that he did not accept medicare at all.
When I had the hip replacement I went to an inpatient rehab after I left the hospital. I had intentions of doing the same thing after the knee but I found out medicare wouldn't cover it since it was a single joint replacement and I didn't meet other criteria such as being over 85 yrs of age or a BMI of over 35. I guess it pays to be a big fat load.
I'll be going for my first annual checkup since becoming medicare primary so I'll be curious to see if I receive different treatment.
In reality the whole health care system has suffered in recent years. I think Dr John Mandrola summed it up here.

Dr John M

--------------------------------------------------------------------------------
A Corrosive Force in Medical Care

Posted: 17 Oct 2017 04:58 AM PDT

It comes in a large white envelope each month. It’s marked confidential.

When I hold it up to the light, I can see through the envelope. I can’t see the details, but the colored graphs give it away.

It’s my monthly productivity report. Most employed doctors get these graphs.

These “dashboards” of value include your own productivity as well as many graphs on how you stack up with other doctors across the country. It shows your employer if you are a hard worker.

The measure of productivity we use is called the relative value unit or RVU.

Doing an ablation, cath, stent or valve replacement earns a bunch of RVUs.

Listening to patients, examining patients, counseling patients, hugging patients earns very few RVUs.

Doing important research, teaching colleagues, and reading the medical evidence earns zero RVUs.

Too often, in too many medical systems, RVUs have become the primary unit of success.

No, you can’t be a mean and nasty doctor. And no, you can’t be a totally unskilled doctor who has too many complications.

But short of those extremes, if you make few waves, have good templates on your electronic health record so documentation is complete, and do tons of procedures, you are valuable.

If, on the other hand, you like slow conservative medicine, or narrative notes rather than templates, or worse, if you are thoughtful and frank about silly policies, you become an outlier. If you do these things, your RVU tally usually does not reach the 75% of standard. Then trouble can come to you.

These trends are not so problematic for people close to the end of their career.

What’s really scary, though, is that this is the milieu in which a younger generation is learning the craft. I was shocked to learn that a major teaching center (will remain nameless) has its teaching faculty on 100% productivity compensation. Imagine that. Teachers of young people whose paychecks are determined by how many RVUs they generate.

This, my friends, is happening in many of the places you go to get health care.

It’s why I tweeted this yesterday.

I'm concerned about the practice of Medicine. "Productivity" is slowly but surely extracting care from healthcare. It's bad. Really bad.

— John Mandrola, MD (@drjohnm) October 16, 2017


Productivity and the RVU has no place in medical care. There needs to be a different system of valuing the care of people with disease.

JMM

Related posts:

Struggling with the (relative) value of humanistic medical care —
Measuring quality of medical care. How can a consumer know?
People are not units — US healthcare policy obstructs good doctoring

MikeWMass

Medicare does not cover "Physicals". There is a "Welcome to Medicare" visit which comes closest, but also involves a lot of documentation that is arguably not the most productive use of time.


After that, there is an "Annual Wellness Visit" which involves listing all the providers involved in the patient's care, reconciling medications and allergies, social history (habits, employment, marital status, etc.), family history, surgical history; assessment for depression, cognitive function, mobility and fall risk, safety and safety nets, and general physical and psychological wellness. The patient is to be provided a written list of recommended screening and monitoring test/parameters. Nowhere does it mandate a physical examination, although in my area most docs do an exam as part of the visit.


Medicare also covers only a small number of screening exams (mammograms for women, pap every 2-5 years, LDL cholesterol every 5 years, blood sugar every 5 years, colonoscopy every 10 years) if there is no diagnosis that would require the testl


Medicare Advantage plans typically do cover physicals and a lot more screening.

justtrying