THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Sunday, August 21, 1994 TAG: 9408220202
SECTION: FRONT PAGE: A1 EDITION: FINAL
SOURCE: BY DEBRA GORDON, STAFF WRITER
LENGTH: Long : 150 lines
Her blood pressure was sky-high, she felt lightheaded and dizzy, and she couldn't find an internist or general practitioner who would renew her prescription.
So Madeline Nevala, 73, frustrated after a six-month search for a doctor who would accept her Medicare insurance, stumbled into a kidney doctor's office.
``What are you doing still walking around?'' he asked incredulously after checking her blood pressure.
And so she told him:
Of the more than 40 phone calls she'd made to doctors in Virginia Beach, none was accepting new Medicare patients.
About the office employee who told her the doctor couldn't accept more than 13 percent Medicare patients, because then he wouldn't make a living.
Of going six months with her history of hypertension and diabetes, and not having a primary-care doctor on whom to rely.
``I'm a nephrologist,'' the doctor she finally saw told her. ``But I'll be your general practitioner until you find someone else.''
Six months later he moved, and it took Nevala three more months to find a general internist.
The whole episode left her angry and disgusted. ``It didn't seem like America. It didn't seem like theUnited States that you had to beg to find someone who would take care of you.''
Nevala is not alone. Agencies that work with the aging report increasing complaints from their clients about finding a doctor who accepts Medicare, the government's health insurance program for the elderly and disabled.
A Medicare directory lists 528 doctors or practices in South Hampton Roads that accept the insurance. But calls to those doctors, listed as family practitioners and internists, reveal:
Fifty-two percent of them are specialists, no longer practicing or won't take new Medicare patients.
Twenty-five percent who accept new patients practice only in urgent care centers and usually can't follow patients in the hospital.
Twenty-three percent of private practitioners will see new Medicare patients.
``Here is this insurance program where you can go to any doctor of your choice, and they can't find doctors to accept it,'' said Kathleen S. Blanchard, assistant director for programs at the Southeastern Virginia Area Agency on Aging.
Doctors would like to accept Medicare patients. But they also like making a living, and the two are often mutually exclusive.
``We enjoy the Medicare patients,'' says Dr. Daniel R. McCready, whose Virginia Beach family practice is one-third Medicare patients. ``They're interested in good health and preventive health care; they enjoy their relationship with their family doctor and internist; they keep their appointments.''
But if he saw every Medicare patient who called for an appointment, he'd be working seven days a week, 12 hours a day and still putting himself out of business.
``They're a challenge medically because many have multiple medical problems,'' said McCready, whose four-doctor practice is closed to new Medicare patients. ``A 20-year-old you see two or three times a year for a sore throat, that's fairly quick. A Medicare patient has high blood pressure, diabetes, arthritis, heart disease, etc. You have to keep all those problems in your mind when you evaluate them and you spend a significant amount of time and energy to do a good job. It's a quality of care issue as much as anything else; you reach a saturation point.''
But part of it is financial. Family practitioners and general internists don't make the big bucks of the specialist. In a good year, family practitioners average about $100,000. If they saw only Medicare patients, that figure would drop to $40,000. ``People see the number of patients I see and say, `You must be rich,' '' McCready said. ``But no, not really.''
In fact, other doctors at the hospital laugh when he drives up - in his 1982 battered station wagon.
What people don't realize, he said, is that most doctors don't start in practice until they're 30, by which time they owe thousands of dollars in student loans.
Relying on Medicare reimbursements alone would be disastrous.
``Except for Medicaid (the government insurance program for the indigent), Medicare is one of the worst payers, period,'' says Greg Mertz, executive director of the Virginia Beach-based Professional Practice Management, which consults with and manages physician practices throughout the country.
He recommends practices limit Medicare patients to 25 percent of their patients.
``Anything higher than that, you end up shifting that lost revenue to the private payer, or the provider ends up having a lower income.''
It was so bad in Dr. Marc I. Gaines' Virginia Beach practice, which is 50 percent Medicare, that he found himself struggling to pay salaries and overhead. ``The cash flow was terrible,'' said the internist. And it became a Catch-22: The more Medicare patients he and his partners saw, the more paperwork they generated, so the more staff they had to hire to process the claims and the more money it cost to run the office - at a time when they were bringing in less money.
Last year, Gaines and his partners quit private practice. They joined Tidewater Medical Group, called TMG, a group practice started by Tidewater Health Care in January. By managing overhead and billing for physicians, TMG relieves doctors of business and administrative worries. Plus, the larger number of doctors in the group - 23 physicians in 11 sites throughout Virginia Beach - provides economies of scale in purchasing, and reduces overall costs.
Even more important are Tidewater Health Care's deep pockets, which enable it to recruit new doctors into the area and set them up in practice, thus relieving the access crunch, notes Vicky G. Gray, senior vice president at Tidewater Health Care.
It worked with Dr. Samuel Wittenberg, who recently left Eastern Virginia Medical School, where he'd spent seven years, to go into practice in Virginia Beach with TMG. Wittenberg was terrified of tackling the administrative and business end of a private practice. Without the support TMG provided, he said, he might have joined a health maintenance organization as a staff doctor. Instead, his new practice is open to any patient, even Medicare patients.
People like Nevala. ``The money seems more important than saving lives or helping the seniors or helping anyone get well,'' she said, still angry months after her search for a doctor ended. ``They all seem to have lost their sense of what they're there fighting for.'' ILLUSTRATION: Graphics
MEDICAL FEE COMPARISON
STAFF
SOURCE: Tidewater Health Care
[For complete graphic, please see microfilm]
MEDICARE FACTS
Sixty-eight percent of primary care physicians in the United States
accepted new Medicare patients in 1992, a 4 percent decrease from
the the previous year, noted a report by the American Medical
Association's Center for Health Policy Research. Nine percent said
they would accept no new Medicare patients at all, the rest
typically limited new patients to family members - usually parents -
of existing patients.
HOW IT WORKS:
Overall, Medicare reimburses about 50 percent of physician charges.
Private insurance and health maintenance organizations typically
reimburse about 85 percent of physician's charges. Physicians who
agree to accept Medicare assignment cannot bill their patients to
make up for lost revenue; even those who don't accept assignment
can only bill patients 20 percent more than Medicare reimburses.
by CNB