Do you know what your doctor gets paid by Medicare for seeing you? You might say, “why should I care as long as she keeps seeing me?”
I would argue that we should care.
Have you noticed that as we are aging and retiring, so are our doctors? Given the low reimbursement rates to the doctors most essential to us, getting new doctors willing to accept us as patients is going to be a problem.
For many of us, our primary care doctor is usually an internist or a geriatrician. We see them on a regular basis and it is their expertise that detects the early warning signs that often prevent more serious consequences from developing. When necessary, they refer us to specialists for tests or specific procedures. Despite their importance in our lives, you may be as surprised as I was to learn that internal medicine and geriatrics are among the lowest reimbursed of the medical professions.
If you were planning to become a doctor today and knew it would take you years to pay off your medical school debts, would you choose a specialty that is not going to earn you as much money as other specialties?
I asked Dr. Sharon Brangman, professor of medicine and division chief of geriatrics at SUNY Upstate Medical University, what she sees happening in her field. Brangman, a geriatrician, is a rare bird in our community. Because she is one of only few practicing geriatricians in Central New York (there is another one at Upstate and one full time and one part time at the VA) she is the type of endangered species we need to be worried about.
Brangman is in the business of training new doctors as well as treating patients. In her role as treasurer of the American Geriatrics Society, she is working at the national level to get the message across that not enough medical students are choosing to go into primary care or geriatrics. And at a time when the demand of the Baby Boomer generation for medical care is growing, this crisis of available care will impact us personally.
Let’s look at some facts—Medicare currently offers higher rates of reimbursement to doctors who perform procedures like arthroscopy, colonoscopy, reading MRI’s, doing sleep studies, doing cardiac catheterizations and so on.
But consider the day of an internist or a geriatrician. If an older person who is depressed or has dementia comes into the office, there are no special procedures that are used to make these diagnoses.
Time needs to be spent doing an evaluation, talking to the patient and their family and then deciding how to treat the patient. Older patients are also more complex to care for since they usually have several medical problems and are taking many different medications.
Once a diagnosis and decision has been made, even more time needs to be spent discussing the challenging social issues that the patient and family will be facing, explaining all the medicines and how they are to be taken and what to watch for if problems arise. The doctor often has to help coordinate care across various specialists and services in the community such as home care agencies, visiting nurses, meals on wheels and so on. Usually the time spent in these activities is not reimbursed at all; but that coordination is very important in the care of the patient.
What Medicare is saying by reimbursing primary care doctors and geriatricians at low rates, is that the time the doctor spends talking to the patient and family, which is absolutely essential to them, is not considered as important as doing a procedure.
“We do not have enough geriatricians in our country to meet current or future needs as the population ages,” says Brangman. “It takes approximately 12 years to train a high school senior to become a geriatrician. Many medical students are graduating with debt that rivals that of a new mortgage, leading them to choose a career in one of the more lucrative, procedure-based specialties of medicine.”
What can be done? —Brangman has some ideas. “Medical schools must adjust their curriculum to train all medical students in geriatrics. Geriatrics should be integrated into all residency training so that every physician has basic geriatric skills. New York state ought to consider loan forgiveness and other financial incentives to new physicians who choose a career in geriatrics and promise to work in our state. There are other solutions to increase the number of geriatricians which will require partnerships between medical schools, government and consumers.”
What can we do? Now that you understand the issue, when you have the opportunity, spread the word. You can also contact your Congressional representatives and talk to them about this situation.