The Medicare Mess

I just received a check from Medicare for $2.41. What's up with that? It probably cost more to cut the check and mail it. And what exactly did they think I did with the patient that was so quick, so valueless and so ill-starred that would lead to this draconian downgrade? For better or worse, goodness knows, there certainly was no validation or audit involved.

2001: A Space Odyssey

A small check like that also implies a fair degree of disrespect and disregard for what we all do. It certainly reflects a lack of professional effort and oversight on the part of the faceless denizens of the vast Medicare paper mill. At the least, it represents a seriously flawed software system that proceeds upon its own, sort of like Hal in .

Philosophical and ethical questions aside, it provides an extreme, silly example of just how archaic the whole structure has become. Unfortunately, there are serious consequences for the nation, for the patient and, to our point, the financial future of the physician.

Each of us has heard, or worse can tell, stories of Medicare extremes that highlight the need for an overhaul. Nationally, everyone now knows that our health care costs alone are leading us to a financial Götterdämmerung.

Coinciding with an increasing stream of silly checks (I've also had others, I am sad to report), is the concurrent "audit" review, also by computer. I have been receiving a stream of envelopes looking to claw back small sums. The envelopes are filled with appeal procedures that represent a bureaucratic smirk, because they know full well that I am not going to tie up six months of trading letters and forms and records over $24 or $37 or whatever. So I just return a check and cut my losses.

I suppose that as taxpayers, we should be happy that some effort is being made to police Medicare, but it has been characteristically inept. In aggregate, I am sure that they will extract some millions from us doctors, but it really is just a drop in their bucket. And of course these small gestures — for that's what they really are — fail to address in anyway the flawed underlying assumptions that got us into this mess in the first place.

The other unintended consequence of this chaotic program of gestured checks and balances is that it all comes across as nickel and diming petty annoyances to us as end users. This has led, and will lead to more, doctors dropping Medicare coverage entirely. And I can see down the line how the exploding Baby Boomer cohort will be aroused to march their lobbyists on Congress when they find the pool of doctors taking care of them rapidly shrinking. Congress will be forced to act by mandating coverage and so on. If you don't like the situation now, stay tuned, for it will get even uglier before it gets pretty.

As Oliver Hardy used to blame Stan Laurel: "Another fine mess you've gotten me into." In this case, the obvious bad actor is the Congress, which has simply failed to take responsibility and correct a major national problem that is far beyond the scope of private business to rectify. Please see last week's column for more about our general unwillingness to step up and Do What is Necessary. You can blame the sad sack politicians, but in truth they are just models for the rest of us sad sacks who can't get it together for a consensus either.

So if you are in a small private practice, or even a policy maker for a large group, what is to be done about coping with the current travails and methods involved with Medicare? One road I alluded to earlier is simply to drop Medicare as long as that is a legal and/or financial option. For many, this is not viable because of the heavy penetration of their practice by Medicare, and for some there are ethical issues involved in excluding seniors from their practices.

The rest of us will muddle on. Some will throw up their hands and see more patients and work more hours to make up for the increased costs and losses of various types. Others will spend more time and effort to get the coding and forms right and make sure that they have the right software in their billing to minimize mistakes and maximize revenues. Some will be incentivized to alter what they do, continuing the trend to more highly paid procedures, cash work such as cosmetics or even following the trend to give up their independent business in favor of joining a group.

Groups do have the benefit of more clout with insurers, a bigger budget for computers, consultants and staff to do some of the administrative work that drove you there in the first place. Oh, and the regular paycheck replacing the end of the month lottery that so many doctors have been reduced to playing.

I

s that where Medicare as the bellwether of American medicine is leading us, to salaried staff jobs in large groups? Likely so, but it's not death by beheading, it's the death of a thousand cuts. And one of them for me is a check for $2.41.