Medicare - Is There a Doctor In The House?

Dear Friends and Colleagues:
Attached an interesting article from the Wall Street Journal (08/21/06) describing the increasing difficulties that seniors face finding a doctor who either still accepts new Medicare patients or is still in practice.
As predicate the diminishing Medicare reimbursement is adversely affecting the quality of care and access to medical care.
It can only get worse unless the SGR is not changed.
See you in Orlando.
Bernd

Is There a Doctor in the House?
It's becoming tougher to find -- and keep -- the medical providers you need in later life, particularly in retirement hot spots. Here are some strategies to get the care you're looking for.
By KELLY GREENE
August 21, 2006; Page R1
Jeane McDade, a retired legal assistant in Santa Cruz, Calif., feels like her doctors are going through a "revolving door."
Since January, her internist and neurologist have left town, and two other specialists who treated her have retired. Three primary-care doctors turned down her request for an appointment, saying they weren't taking new Medicare patients.
Ms. McDade, 83 years old, finally begged an appointment with an internist who is married to one of her other doctors. As far as finding a neurologist, "I'll just have to take whoever I can get," she says.
It's a predicament that's marring retirement for older Americans in pockets dotting the country, particularly temperate, picturesque spots like Santa Cruz that are a magnet for retirees. Finding and keeping a doctor for some patients is becoming a trial, and health-care executives and patient advocates alike are concerned that the situation will only get worse as the number of retirees grows dramatically in coming years.
"Come 2011, when the baby boomers hit 'Golden Pond,' we're just not going to have enough doctors," says David Reuben, president of the American Geriatrics Society and geriatrics chief at the David Geffen School of Medicine at the University of California, Los Angeles.
Money, of course, is part of the problem. Some doctors are leaving towns like Santa Cruz because of the relatively low payments they get from Medicare, the federal health-insurance program for people 65 and older. The government reimburses doctors in Santa Cruz County using the same system that's been in place since long before the Northern California real-estate boom. That means doctors make 15% to 20% less for seeing Medicare patients there than they do in neighboring Santa Clara County.
But even in places where Medicare pays relatively well, other factors are making it tough for older patients to get face time with doctors. Demand for medical services is increasing, a reflection of advances in technology used to diagnose and treat medical problems, along with extended life spans and the resulting increase in the number of chronically ill patients. What's more, doctors are less likely than before to set up their own practices and stay put. Instead, they are forming ever-larger group practices or are going to work for hospital systems that are adding staff -- all to better negotiate with insurers. That mobility can exacerbate local physician shortages. Meanwhile, among the new wave of retirees are many doctors, who aren't necessarily being replaced in the same places or specialties.
Even when doctors can be found, patients may have to wait weeks or months for an appointment. And many patients may feel that their doctors don't set aside enough time for consultations, either during office visits or when questions arise.
So, how can you get the medical care you need in the face of predictions of worsening doctor shortages? We asked health-care experts, geriatric-care managers and patients themselves to pinpoint strategies that you can pursue. Here's their advice:
LOCATION, LOCATION, LOCATION
If you're planning to move in retirement, you're probably already thinking about such considerations as climate, housing costs and tax rates. Now, there's another question you should add to your list: How many of the well-regarded doctors where you want to live are accepting new Medicare patients?
"If I were the son of an elderly person moving to a retirement community," says Dr. Reuben, the Los Angeles geriatrician, "I would want to know more about what's available in terms of medical resources. You have to find out how good a payer Medicare is. There are some states where they don't want any Medicare business, it's such a poor payer."
Unfortunately -- beyond the tedium of checking with individual doctors -- there's no simple way to find out how Medicare payments in a particular locale are affecting the availability of services.
Overall, there seem to be enough doctors to go around. In fact, 73% of doctors nationwide reported accepting all new Medicare patients in 2004 and 2005; only 3% closed their practices to the group, according to a January report by the Center for Studying Health System Change in Washington.

And a July report from the Government Accountability Office found no more than 7% of Medicare patients reported problems finding a doctor from 2000 through 2004. Still, the same report says the proportion of those reporting major difficulties varied by as much as 12 percentage points from state to state.
Retirees and health-care experts we interviewed have seen doctors close their doors in pockets of states ranging from California and Idaho to Florida and Virginia -- places that are popular with retirees and where government payments to physicians haven't necessarily kept up with rising living costs.
If you find that you have choices among doctors who are accepting new patients, you may want to weigh how long each doctor has been in practice. That's because doctors who are more established in a practice are less likely to move away, health-care experts say, especially doctors who own the buildings they practice in and do their own hiring.
Dean Kashino, a family practitioner in Santa Cruz, suggests that if you're planning to relocate in retirement, you do so before you turn 65 and qualify for Medicare. "That way, you have a better chance of latching onto a physician" who will retain you as a patient after you become eligible for Medicare, he says.
THINK LIKE A SALESPERSON
In other words, don't take "no" for an answer -- and push doctors to acknowledge your request for help.
Ireta Metchik, a geriatric-care manager in Boston, says she has the most success getting patients appointments with coveted doctors, or rare spots in treatment facilities, by making personal connections and then arguing her case. For example, she recently was worried that a client with multiple physical and psychiatric issues "might die." Even though the patient had adequate financial resources, "I could not get him admitted to a good geriatric psychiatric hospital," she says.
After visiting her client at home, and finding him weak and depressed, Ms. Metchik called his primary-care doctor, clinical social worker, and the doctor's secretary "on a continual basis for two days" to enlist their help. Meanwhile, she checked out the patient's insurance so the primary-care doctor would know that the patient's hospital stay would be covered. Finally, the doctor "realized -- perhaps by sheer repetition -- the seriousness of it, and the connection I had to this man," and admitted him, she says.

Don't expect success every time you squawk. Robert Kane, a geriatrician and professor at the University of Minnesota School of Public Health in Minneapolis, organized an advocacy group called Professionals With Personal Experience in Chronic Care. The group comprises geriatricians, gerontologists and other health-care professionals who have struggled to help their own relatives get access to appropriate medical care.
"My epiphany came around 2000 when my mother had a stroke," Dr. Kane says. "I'm a geriatrician and I have written policy books, but basically I spent three frustrating years with my sister trying to organize care for my mother. If somebody who knows as much as I do and knows as many people as I do couldn't get the system to work, what chance does anyone have?"
His advice for advocating for yourself or an older family member: "First, recognize that it may take a while to find a doctor -- and it may take even longer to find a doctor who you want. Second, you need to be proactive to make the system work. Keep a very clear record of your medications. Ask a physician when he's ordering a drug if he's aware of the other drugs you're on." In other words, "you need to become your own advocate. If you can't do that, that's where your family comes in."
HIRE A LOBBYIST
Many people don't realize there are professionals they can hire to help older patients get the care they need.
Geriatric-care managers, who can help assess health-care needs, arrange for medical treatment and schedule home services, can be located through an online directory at CareManager.org10, the site for the National Association of Professional Geriatric Care Managers. The site also lists questions to ask when hiring a geriatric-care manager -- an important step, since most states don't license managers. The cost of the services typically ranges from $85 to $200 an hour.
Check out your employee benefits, as well -- and your children's. Some big companies, such as Ford Motor Co., provide their employees' elderly relatives with a free or reduced-cost visit by a geriatric-care manager. The manager assesses the subject's health, writes a report detailing the findings, and develops a care plan. A few organizations, including Fannie Mae, the Washington-based mortgage agency, have hired their own elder-care case managers to help workers.
BEYOND THE DOCTOR'S OFFICE
Healthy patients who are tired of fighting for a spot with an internist and are interested primarily in prevention may be able to get the screenings they need for blood pressure, blood sugar, cholesterol and so forth through local health fairs, often held at shopping malls. Medical schools typically house clinics that can meet the same needs.
If you're looking for more continuity in your care than that, you could try seeing a nurse practitioner, particularly to help manage chronic conditions. (A nurse practitioner is a registered nurse with advanced training and education.) There's a national directory at NPClinics.com11.
For minor medical problems that can be handled over the phone, TelaDoc Medical Services Inc., a round-the-clock telephone consulting service based in Dallas, charges about $4 a month for membership and $35 for each consultation. Calls are toll-free. Information on the service can be found at TelaDoc.com12.

For the frailest patients, some doctors -- particularly geriatricians -- make house calls, partly because they can get paid more by Medicare than for office visits. In most cases, this is limited to dense metropolitan areas such as Washington and New York, but a few doctors in areas like Reno, Nev., and Southern California have made a go of it. The Web site for the American Academy of Home Care Physicians (AAHCP.org13) has a listing of such doctors.
BEFRIEND YOUR PHARMACIST
Another valuable resource outside the doctor's office is a pharmacist. If the one at your local drugstore doesn't offer enough help, you can hire a few hours of advice from a consulting pharmacist who specializes in drug interactions and in the ways that older adults react to medications.
Some pharmacists with that specialty take a test and get certified through the Commission for Certification in Geriatric Pharmacy in Alexandria, Va. There is a directory of certified geriatric pharmacists at the commission's Web site, CCGP.org14.
If you can't find a pharmacist near you or your parent who has taken the certification test, don't give up. Many pharmacists have a lot of experience counseling older customers about potential drug interactions and helping them sort things out when side effects surface.
The American Society of Consultant Pharmacists, based in Alexandria, Va., offers a directory of "senior care" pharmacists at SeniorCarePharmacist.com15.
'DISEASE MANAGEMENT' PROGRAMS
There are several resources to consider for patients with chronic diseases.
Fledgling programs designed to manage chronic illnesses as long-term diseases, rather than to battle them like short-term crises, are often buried within the bureaucracy of big hospital systems or insurance companies, and a lot of patients who could use them don't know they exist.
Also, some large employers and health plans hire "disease management" companies to counsel employees and members, mainly by phone. Older people still working, or retirees who still have health benefits through former employers, may have access to such programs, says Molly Mettler, senior vice president of Healthwise Inc., a supplier of online and printed health information based in Boise, Idaho.
If you have a choice between traditional Medicare insurance and a Medicare managed-care plan, you may want to consider the latter to get more counseling for special health needs, says Marc Hoffing, medical director of the Oasis Independent Physician Association in Palm Springs, Calif., which contracts with managed-care plans. For the sickest patients in the Medicare managed-care plans that Mr. Hoffing's association serves, case managers are available 24 hours a day.
FIND A SUPPORT GROUP
In Washington state, Colorado, Northern California and a few other pockets around the country, doctors who work with older people are experimenting with grouping those patients together for appointments, even if, in some cases, they suffer from different health problems.
Such visits have proved so popular at Group Health Cooperative in Seattle that the nonprofit health-care system has expanded its pilot project to 20 locations, says Martin Levine, Group Health's medical director for senior care. Patients in the groups use the emergency room less, a big cost saver, and have seen their health improve in other ways.
The group visits start with an icebreaker, then move into a 30-minute discussion about a topic the patients agreed on the previous month, such as how to manage your medications, what happens if you're traveling and get sick, how to monitor high blood pressure, how to manage vision and hearing loss, and so forth. Then the group takes a coffee break, during which the doctors check in with people individually. In the last 10 minutes, the group decides what to talk about the following month.
"The patients come in with a whole mix of problems -- diabetes, heart disease, lung disease, arthritis," says Dr. Levine. "Over time, they realize they don't need their one-on-one visits so much." The patients often benefit from hearing their doctors' advice reinforced by people their own age, he adds.
"One doctor saw someone with headaches that had no explanation for eight years," says Dr. Levine. The doctor "ran out of things to offer her and told her to go out there, stay active, go for a walk. At a group visit, one woman told her, 'I go for a walk every day. You should go for a walk.' The woman with the headaches said, 'That's a good idea,' and they traded phone numbers." The two became walking partners, and the headaches went away.

LEARN MORE ABOUT HEALTH
Take the time to learn about health basics like nutrition or what preventive tests are appropriate at what ages.
One basic tool: a self-help health-care manual, such as "Healthwise for Life," co-authored by Ms. Mettler of Healthwise Inc., or the "Merck Manual of Health and Aging." Forty percent of patients in one study in Southern California who were given a self-care book reported saving a trip to the doctor's office; 39% said they saved a trip to the emergency room.
You also should get copies of your medical records, either online or on paper, says Beverly Bernstein Joie, president of Elder Connections Inc., a geriatric-care-management company in suburban Philadelphia. You are entitled to your medical records by law.
For instance, when you see a specialist, such as a cardiologist, ask for a copy of your cardiogram and the report that goes to other physicians. That way, Ms. Joie says, if results and reports don't make it to other doctors, you have a backup copy and can still get the most out of future health-care appointments.
MOVE OFFSHORE
It might sound extreme, but some retirees are moving to Costa Rica, Mexico and other countries where health-care costs are appreciably lower and the quality of service, they say, is significantly better.
Several years ago, Robert Preston, an actuary in Sarasota, Fla., was frustrated with the lack of medical and custodial attention his father, the retired chief financial officer of a large pharmaceutical company, was receiving in Florida. Expenses totaled $10,000 a month for a room in a nursing home in Venice Beach, as well as personal attendants.
Mr. Preston started thinking about pursuing care for his father in another country. He settled on Costa Rica after a friend returned from a trip there, singing the praises of the country's medical services. Eventually, Mr. Preston's father settled in a private home in Costa Rica, with a house manager, chauffeur and three attendants -- all for about $3,000 a month. Instead of being confined to a nursing home, his father attended church every Sunday, took a large group to brunch afterward, went out to dinner several times a week -- and occasionally even went on a date. (Mr. Preston flew down to see his father once a month on a four-hour flight to San Jose, rather than a three-hour flight to Florida.)
Mr. Preston's father died in 2001. Since then, two of Mr. Preston's friends have moved family there.
"In Costa Rica, the medical system is excellent. My father's doctor there would call me up in Connecticut," Mr. Preston says. "I couldn't get doctors in Florida to return my phone calls."