Is Medicare spying on doctors?

Jun 27 2011 Published by under Medicine

The short answer is "yes"; of course they are.  Normally, if Medicare wants to check up on a doctor (rather than doctors) they simply order an audit.  If Medicare (or Blue Cross or whomever) is paying the bill, they are certainly going to check to see if they are getting what they pay for.  If they audit you and don't agree with your charges, then your charges are wrong. As another doctor once told me, "The money Medicare gives you is borrowed; if they disagree with you, they can and will take it back at any time." But what is Medicare paying for?  Are they paying only for the services rendered? Or are they paying for "physician availability"?

The Centers for Medicare and Medicaid Services (CMS) is (sic?) deeply involved in US medical care, which includes subsidizing post-graduate medical training. CMS wants to know if their patients are being seen or turned away, and if the latter, why.  That sounds like due diligence to me.  But...

Primary care medicine is a tough job (a good one, but tough).  If CMS wants to know more about the supply and demand aspect of primary care, this survey seems a weak tool (and for some reason it gives doctors the heebie jeebies).  Doctors have the right to serve or not serve whomever they wish, given they meet any contractual obligations with insurers and ethical obligations to established patients (more or less).  Most internists take Medicare, but less often Medicaid.  We see many elderly people, so closing off to Medicare is usually a bad idea, but Medicaid rarely pays enough to justify the costs of seeing the patient.  Many of us give back in other ways (seeing patients pro bono through charitable institutions, etc.).  If we as a nation decide that service is mandatory for doctors, that's fine, but there must be an incentive that sends people into medicine.  Most primary care docs know that they could have made  a much better living using their talents in the business world but still chose medicine.  If we change our model of primary care to require service (not a bad idea), then we have to pour more subsidies into educating and training docs.  The salary alone is not incentive enough to convince good students to choose primary care (which currently attracts 4% of US medical grads).

But aside from this and the generally hostile feelings engendered in physicians by "being spied on", the sample questions and the approach taken by the research firm is problematic.  Most PCP offices have enough trouble fielding legitimate phone calls.  Adding even a few interferes with the care of real patients.  More important, the questions are, for lack of a better word, stupid:

Mystery shopper: “Hi, my name is Alexis Jackson, and I’m calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don’t yet have a primary doctor, but I need to be seen as soon as possible.”

Doctor’s office: “What type of problem are you experiencing?”

Mystery shopper: “I’ve had a cough for the last two weeks, and now I’m running a fever. I’ve been coughing up thick greenish mucus that has some blood in it, and I’m a little short of breath.”

If a Medicare patient (i.e., elderly) I had never seen before gave me this story on the phone (or more likely, gave it to my front office), I would most likely direct them to the nearest urgent care or emergency room:  they sound really sick, and since I've never met them to have any other basis for making a judgment, I'd like them to get seen right away.   It's also a crap shoot as to whether I can crowbar them into my schedule quickly enough to be seen.

I might do it.  But I might not, and I wouldn't fault any doctor who directed them elsewhere.  It's the wrong question.  A better question might be, "My blood pressure has been running high, in the 160's, but I feel OK, how soon can I see the doctor?"

For what it's worth, I don't think doctors should be whining about being "spied" on; CMS can snatch away your money any time they think you've screwed up, and they can stop paying you any time the Congress screws up themselves.  All of this is simply another symptom of a fundamentally broken health care system, and no one in government has the guts to propose real solutions, ones that tear down our current system and rebuild it on a model that recognizes health care as a fundamental right, and finds a just, ethical, and cost-effective way to provide good health care to everyone within our borders.

2 responses so far

  • Ed says:

    Oh I don't think it is a symptom of a broken health care system. I am in Canada, and they do much the same things here. I have read blogs from doctors in the UK and there are similar problems.

    In any government benefit system, they always claw back the promised benefits in whatever way they can get away with, whether it is medicare or disability insurance or whatever. This is one of the ways they do that, basically. Present one face of the program to the voters, and the other to recipients.

    First, refuse to pay market prices (real prices) for the service, then by making each dollar spent through medicare less worth than a dollar to the recipient, because it comes with all these strings. And because they can't actually find a doctor that accepts it or whatever. Then by making it too hard to get through the hoops to get on medicare to exclude some people, then by threatening to kick people off if they use it too much or any other excuse. The list goes on and on.

    You may never have heard of examples of this happening, but I guarantee it does wherever the gov can get away with it.

  • Lorenzo says:

    The fundamental problem with US healthcare is it reimburses doctors for activity and not results. Until we can figure that out we will probably get nowhere.

    That said, Medicare should be looking at doctors who bill for more patients than they could possibly see, and likewise with with excess tests.

    With all the billings to Medicare there should be sufficient data to highlight, at least the big abusers of the system. They should be found out and really hung out to dry. When the penalty gets really high, less doctors will game the system.