No Room for Medicare Patients

When I went into solo practice of internal medicine in 1981, it was very easy to get a doctor to see a Medicare patient. All I had to do was make a phone call. A courteous receptionist answered. If the doctor couldn’t come to the phone right away, I could count on a prompt callback.

Consultants saw patients quickly, and generally called me to discuss their findings and advice. And very often there would also be a letter in the mail: “Thank you for referring this delightful patient to me.”

How things have changed! Now a doctor gets the phone menu, just as the patients do, and it often ends in voice mail. It might be a few days before a staff member calls back—usually with the news that “we are not accepting any new Medicare patients.” At best, my patient might be offered an appointment in several months.

One very fine gentleman, who had recently moved to a rural area, found it easier to fly to Tucson to see me than to get in to see a local internist. That was in 2009. Recently, he has become unable to travel, so I needed to find him a local doctor.

I tried to expedite matters by ordering him an immediate diagnostic test: an abdominal CT scan. I don’t think anyone could argue that it wasn’t indicated under the circumstances. One little problem: I am not enrolled in Medicare and don’t have the proper government-issued number to enter into the computer. A license to practice medicine is not enough. This National Provider Identifier (NPI) is supposed to protect the system against being defrauded. Without that number, the imaging facility could not get paid by Medicare.

“Why not use the radiologist’s number?” I asked. After all, he was the one who would get paid. Nope, a referral was required. How about a self-referral from the patient? Nope, we can’t allow patients to decide what tests they need. “The patient is willing to pay for his own test,” I said. Nope, if he’s on Medicare, they aren’t allowed to take his money.

They gave the patient 24 hours to find a properly enumerated doctor to countersign my order. Fortunately, he found a specialist willing to do so, and assume potential criminal liability for committing “waste, fraud, and abuse” by ordering a “medically unnecessary” study. (Fortunately for the patient, he turned out not to have cancer, but that could be bad news for the doctor.)

So this is the status of retired Americans. They can’t just walk into a facility and request a medical test, and pay for it with their very own money.

A man may be qualified to pilot a 747 across the Pacific, but once he’s on Medicare, he is unfit to make an unsupervised decision about his own medical care.

I did find my patient a doctor. None of the internists within a 150-mile radius who “take Medicare” are willing to take on a new Medicare patient. But through the website of the Association of American Physicians and Surgeons (, I found a link to the Medicare carrier’s list of opted out physicians. They don’t “take Medicare,” but many are pleased to see older patients, for a reasonable fee. There was one internist on the list, 150 miles from my patient. She has a courteous and helpful assistant who actually answers the phone, and told me the charge for a new patient visit: $300.
Things could be worse—and already are much worse in Canada. The “soul-destroying search for a family doctor” is described in the Globe and Mail on Aug 21. The Ontario government’s program called Health Care Connect manages to link only 60 percent of patients with a doctor—although you might find a concierge doctor for $3,000 a year.

That’s the cost of medicine when it’s “free”—if you can find it at all. If ObamaCare is implemented, all Americans will be in the same boat. And guess who will get thrown overboard first.

1 comment to No Room for Medicare Patients

  • Frank Rezny

    I would challenge the manner in which you have painted Canada’s health care system. While it is true that there are many people who can not find a regular family physician, there are hundreds (nay thousands) of walk in clinics in Canada – in every province that will see patients without charging exorbitant “concierge” fees.
    It sickens me to hear how the vested interests of the American, for profit, medical insurance industry twists the reality, dare I say lies, to misrepresent the Canadian system. It astonishes me that the healthy US public at large has been so co-opted by the insurers that they fight any attempt at reforming a system so seriously broken that millions of Americans are bankrupted by medical costs.
    The lack of a regular family physician can certainly be an issue in ensuring continuity and coordination of care. Walkin clinics, while not ideal, do provide some degree of continuity with the requirement for record keeping (better if they are using an EMR). Patients referred for testing and consultations will not be refused appointments or follow up care. They will not have to pull out a credit card, check book or cash in order to be seen and treated. The vast majority of lab tests are covered under the provincially administered health insurance plans – at both public and private health labs.
    Consultations require a referring physician but no patient can be denied for insurance coverage reasons. Specialists can allow patients to “self refer”. In this case, the specialist may not bill for a consultation fee by definition. A consultation fee includes preparing a report to be sent to the referring physician.
    Physicians are paid under fee for service, salary and/or capitation models, largely depending on their practice locations and environment. I would also note that payroll and administration overhead costs for a clinic in Canada would tend to be much lower due to the single payer system. Physicians need not write off large amounts in accounts receivables from disallowed claims and fees patients can’t afford to pay. Canadian physicians receive payment for services rendered from the single payer system in most provinces in 2 weeks. Claim rejections from the various provincial insurance plans are largely due to out dated or incorrect health insurance numbers. Very few physicians in Canada need to have staff members dedicated to credit and collection activities.
    The Canada Health Act ensures portability across Canada with reciprocal billing arrangements for every province and territory except Quebec. Patients from Quebec are still covered by the RAMQ when traveling in other provinces but may be asked to pay directly for the services rendered and submit their claim to be reimbursed. Under the Canada Health Act, physicians are not allowed to “extra bill” or charge additional fees for a service that is covered under the provincial insurance plans.
    I have no doubt Canada does face some challenges with the rising costs of medical care – but health care costs in Canada remain far below the ratio to GDP seen in the US and many other countries.
    Health care in Canada is not free. It never has been. Every provider of care is paid. Those payments come from the collective that is the Canadian taxpayer – and so far, our taxpayers have been prepared to pay for the services we get.

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