By John Kurt Frederick, M.D.
He slowly totters into the exam room with his daughter-in-law in tow. The plastic grocery bag holds all his pill bottles and his metal walker looks like it has been well used. A faint smell of urine wafts from him and his shirt is stained with breakfast. He manages to make it into the room. With difficulty he turns stiffly and lands his bottom in the exam room chair.
He is my newest Medicare patient, an elderly parent of a friend. He recently moved to the area to be nearer to his only son, his existence now too difficult to manage alone. His medical problems are myriad and complex and he takes a recipe of pills several times a day. I smile and welcome him to Austin as I gently grip his gnarled hand. We converse briefly before I dive into the box of medical records and the sack of pill bottles, many expired, many duplicated, and all powerful and dangerous in their own right.
He’s here because his son made many calls to many doctors, and quickly became frustrated and humbled by the repeated insensitive response that the doctor wasn’t “taking new Medicare.” One of the first offices he called was mine. After searching and reaching some point of desperation, my friend called me directly and asked me to make an exception for his father. Of course I will.
And of course it should be a privilege to take care of this man who worked a farm his whole life, raised a family in many trying circumstances, and was pliable and loving enough to be married for 57-and-a-half years to the wife he only recently lost. But why is it that, inside, just for a brief moment, I secretly groan as I become faced with the task of caring for him? Why have I instructed my staff that I will not be available for new patients who have Medicare as their insurance, a decision that many of my colleagues have also made?
Perhaps it is because I let myself think as a businessman.
From my perspective as a family doctor, Medicare’s payment system seems skewed toward doing, not thinking and managing. It would take 10 examination visits to my office to equal the payment that a specialist can receive by putting an endoscopic tube in one of his orifices or performing a surgery, both of which can be done in a fraction of the time. In the time it would take to fix one of his cataracts, I would still be wading through and signing orders for his home health care, and I would make a fraction of the reimbursement. I will likely make numerous time-consuming phone calls dealing with multiple facets of his care—to pharmacy benefit companies, home health agencies and worried relatives. Should he need multiple specialists to adequately meet his medical needs, then I will be responsible for maintaining order and cohesion to his care, all mostly done without reimbursement. And as his health invariably fails there will be multiple conversations concerning end-of-life care. Yes, there are ways of billing Medicare for certain aspects of “coordination” of medical care, but the specifics are too arcane and arbitrary and the payment too low to justify spending time pursuing it.
The time pressure on my office staff will also increase.
Medicare comes with all sorts of tag-along cottage industries to service the many potentially covered benefits. Many of the companies have done so well they now have their own television commercials. If you need a motorized scooter, just get your doctor to sign a form. From mail-order diabetic supply companies to exercise equipment peddlers, benefits are just a doctor’s signature away. The distinction between what is wanted and what is truly needed gets blurry. But the faxes and requests will come. Such decisions are fraught with subjectivity, ripe for abuse and require even more uncompensated time. Fee increases or balance billing are impossible—the price of my time is dictated by the government, and that price often fails to cover my costs. So, the decision not to care for more Medicare patients is based simply on financial survival. I also have children to feed and educate.
Yet I want to help this man. He looks visibly reassured as I place my stethoscope and remark on the strength of his heartbeat. I gently probe with questions and touch, and a bond is quietly established. I am now his doctor, and I will take care of him regardless of the implications to my business. I finish with him and reassure him that I’ll be here should he become ill. The gratitude that I sense in his and his daughter-in-law’s faces make it all worth it.
As he slowly gathers his things to leave I wonder if there will be anyone to care for me when I am him. The statistics are frightening. Primary care doctors are becoming scarcer every day as medical students, for whatever reason, choose other paths. Perhaps it’s the medical school debt that they must satisfy, or the burden of paperwork and administrative hassles that much of primary care medicine has become. Or maybe it is the lure of glamour, fortune and excitement providing for the vainest of us. I put these thoughts out of my mind. This visit has thrown me behind and several patients express frustration over the wait. So I move on.