Milestone or Millstone? Medicare Access in Midsize Metros
Abstract: There has been an overall decline in the number of physicians who accept patients with Medicare. Consequently, patient access has declined. Understanding Medicare trends can help inform policymakers of potential access problems, aid business efforts, and also direct healthcare resources in their recruitment of physicians. In this commentary, the authors describe the results of their study, which assessed recent Medicare access trends at a local level, specifically in a midsize metropolitan city and the possible social desirability bias with physician reporting in Medicare surveys.
Key words: Medicare, access to care, primary care, acceptance.
Florida has the nation’s highest proportion of older residents, and most rely on Medicare for their healthcare needs.1 High-quality primary care of older adults is time-consuming; it requires physicians to manage patients with multiple comorbidities and medications, to have regular communication with family members, and to navigate a complex social service network.2 Given the time required to provide optimal care and concerns about adequate reimbursement, some primary care physicians have begun to limit the number of new Medicare patients they accept into their practices; some even consider not accepting Medicare payment at all (ie, non-participation or “opting out”).2 In 2003, the American Medical Association and the American Academy of Family Physicians found that nearly one-quarter of primary care physicians were not accepting new Medicare patients and that nearly half of the physicians surveyed planned on restricting the number of new Medicare patients accepted into their practice.2 Other reports have shown that there is an overall decline in the number of physicians who accept patients with Medicare in the United States, with about 7% of physicians reporting that they do not accept new Medicare patients.3,4 In a recent report in the Wall Street Journal, the Centers for Medicare & Medicaid Services reported that 9m539 physicians who had accepted Medicare opted out of the program in 2012, up from 3,700 in 2009.5 Furthermore, in rural Florida, there has been a dramatic reduction or elimination of physician services among physicians who treat older patients.1
When it comes to Medicare, physicians can presently choose from one of three options: (1) to be a participating physician, which are those who accept assignment; (2) to be a nonparticipating physician—those who do not accept assignment, but can bill their patients up to 15% more and can request payment up front; or (3) to be a provider who has legally opted out of Medicare.
Tallahassee, FL, is typically considered a midsize metro, with a city population of 182,965, and has general characteristics similar to other midsize cities, such as Madison, WI, and Athens, GA.6 These cities are sometimes referred to as retirement-oriented communities. Businesses in communities like Tallahassee aggressively recruit retirees, who generally have high rates of disposable incomes. But one concern that retirees have when considering moving to a new area is the quality and accessibility of healthcare. Geriatricians in the area have anecdotally noted that new patients in Tallahassee frequently have difficulty finding a compatible doctor who will accept new Medicare patients. Also, they are concerned that physicians may report that they accept new Medicare patients on surveys, but in actuality do not accept new patients when a patient calls for an appointment.
We conducted a study to determine the acceptance of Medicare by primary care physicians in the Tallahassee area, and if there is a discrepancy between physicians’ reported claims of accepting new Medicare patients on a survey and actual acceptance of physicians accepting new Medicare patients by using a “secret-shopper” style survey via telephone. From this study, we were able to compare Tallahassee’s percentage of nonparticipating Medicare physicians to the national average.7 To our knowledge, this is the first study to assess recent Medicare access trends at a local level, specifically in a midsize metropolitan city, and also the first to assess the possible social desirability bias with physician reporting in Medicare surveys. We believe that a clearer understanding of Medicare trends can help policymakers address potential access problems, aid business efforts in recruiting retirees to an area, and also direct healthcare resources in their recruitment of physicians.
We included all practicing primary care internists and family physicians in Tallahassee in our study, with the exception of those mandated to accept Medicare patients and any physicians whose contact information could not be located. The Florida State University Institutional Review Board approved the study. The physician sample was populated through the Florida Department of Health’s license profile database, along with physician contact information. Seventy-nine eligible primary care physicians’ offices were identified. An electronic survey was e-mailed to each physician’s office asking whether they currently accept, limit, or do not accept new Medicare patients, and their reasons for either limiting or refusing new Medicare patients. The physician or the business manager was asked to reply to the survey. More than half of the physicians (67%) did not respond to the survey after the initial e-mail, even after two reminders were sent. Of the 26 respondents, 21 were physicians and five were business managers.
After obtaining the results of the electronic survey, we used a “secret shopper” approach to verify which physicians actually accepted new Medicare patients. The secret shopper posed as a son inquiring about the care of his elderly father who had multiple chronic conditions and was living independently in Tallahassee. A standardized script was used to query if each respondent’s office accepted new Medicare patients. Data was then analyzed using descriptive statistics.
The demographics of the respondents are illustrated in the Table. Of the physicians who accepted Medicare assignment, 40% accepted new Medicare patients, 44% did not accept new Medicare patients, and 16% limited the acceptance of new Medicare patients. Approximately 7.7% of the respondents reported not being a participating Medicare provider. The Figure lists the reasons that physicians gave for limiting new Medicare patients. In the 50% of respondents who indicated “other” as a reason, some physicians reported that they “require more nonreimbursable or poorly reimbursable services.” The Figure also lists the reasons that physician gave for not accepting new Medicare patients. Forty-five percent of these physicians reported “other” reasons, such as “the increasing burden of paperwork.” In the “secret-shopper” calls, all of the respondents who had indicated they were accepting new patients actually did accept new Medicare patients.
The national average of Medicare nonacceptance among primary care physicians is 7%. We calculated that the average in Tallahassee is slightly higher at 7.7%. However, it is more alarming that of those physicians accepting Medicare assignment, the majority were either not accepting or were limiting acceptance of new Medicare patients. With only 40% of the physicians accepting new Medicare patients, this could lead to a substantial obstacle for access to care for older persons. More than three-quarters of the physicians cited inadequate reimbursement as a primary reason for limiting new patients. This is particularly concerning with the threat of further decreases in Medicare payment as determined by the Sustainable Growth Rate (SGR) reduction. As of late February, the House and the Senate reached an agreement to repeal the SGR formula, but this legislation has not yet been approved, and Congressional negotiators are working to identify ways of funding it.8
While inadequate reimbursement was the most frequent reason for limiting new patients, other administrative reasons were also important; one-half noted billing requirements, high clinical burden, and practices being too full to accept new patients. Furthermore, for those who have decided to not just limit new patients, but to not accept new Medicare patients altogether, the main reasons behind the decision was that their practice was too full and that these patients produce a high clinical burden. Policymakers must acknowledge that Medicare fee levels and payments are only one of the several healthcare system issues that affect the decision for physicians to refuse or limit new patients. It is likely that if more physicians in a community accept new Medicare patients, problems of having a full practice and too many complex patients will be spread over many different providers.
Contrary to anecdotal reports of physicians claiming to accept Medicare and then refusing when an actual patient calls the office, our “secret-shopper” method did not reveal any physicians who refused a new Medicare patient if they had responded to the survey that their practice was open to new patient; therefore, no social desirability bias was found.
Many communities are actively developing programs to recruit older persons to relocate. This is especially true for communities with large universities, in part because retirees with higher disposable incomes often desire opportunities for continued lifelong learning. Tallahassee is a community with two large public universities and an active senior education program. Recently, in a study conducted by the Washington Economics Group, Tallahassee ranked number one in an analysis of selected US cities that are attractive to older retired adults.9 There may be novel opportunities for communities partnering with healthcare systems or physician groups to expand primary care recruiting opportunities, particularly with innovative practice models, such as Accountable Care Organizations or patient-centered primary medical homes.
Our study has several limitations, with the primary ones being the small sample size and low response rate, which greatly limits generalizability. However, the participation rate compares similarly with state and national studies of physicians.1,2 Survey responses were self-reported, which carries inherent limitations, such as recall bias and ability to lie. More research is needed in a variety of cities with different profiles and that includes larger and more representative sample sizes.
Our findings suggest that some primary care physicians are reducing access to new Medicare patients for a number of reasons, which may reflect a trend in midsize metros. This reduction is occurring at a time when 10,000 baby boomers are turning 65 every day.10 Policymakers, medical organizations, and society as a whole must develop strategies to ensure access to care for older Americans before the so-called “Silver Tsunami” hits.
- Gunderson A, Menachemi N, Brummel-Smith K, Brooks R. Physicians who treat the elderly in rural Florida: trends indicating concerns regarding access to care. J Rural Health. 2006;22(3):224-228.
- Chou WC, Cooney LM Jr, Van Ness PH, Allore HG, Gill TM. Access to primary care for Medicare beneficiaries. J Am Geriatr Soc. 2007;55(5):763-768.
- Bishop TF, Federman A, Keyhani S. Declines in physician acceptance of Medicare and private coverage. Arch Intern Med. 2011;171(12):1117-1119.
- Connelly J. Doctors are opting out of Medicare. New York Times. April 2, 2009:F9. http://www.nytimes.com/2009/04/02/business/retirementspecial/02health.html?_r=1&. Accessed February 6, 2014.
- Beck M. More doctors steer clear of Medicare. Wall Street Journal. July 29, 2013. http://online.wsj.com/article/SB10001424127887323971204578626151017241898.html. Accessed February 6, 2014.
- Leon County, Florida. State & County QuickFacts. United States Census Bureau website. http://quickfacts.census.gov/qfd/states/12/12073.html. Accessed February 6, 2014.
- Cunningham P, Staiti A, Ginsburg PB. Physician acceptance of new Medicare patients stabilizes in 2004-05. Track Rep. 2006(12):1-4.
- Agreement reached on SGR repeal bill. Annals of Long-Term Care: Clinical Care and Aging. http://annalsoflongtermcare.com/news/sustainable-growth-rate-formula-sgr-agreement-reached. Published February 19, 2014. Accessed March 4, 2014.
- The Washington Economics Group picks Tallahassee, Fla., as number one retirement destination for baby boomers [news release]. Washington, DC: The Washington Economics Group; April 16, 2012. http://www.scribd.com/doc/89655229/The-Washington-Economics-Group-Picks-Tallahassee-Fla-as-Number-One-Retirement-Destination-for-Baby-Boomers. Accessed February 6, 2014.
- Baby boomers retire. Pew Research Center website. http://www.pewresearch.org/daily-number/baby-boomers-retire/. Published December 29, 2010. Accessed February 6, 2014.
Jesse G. O’Shea, MS (MD Candidate); Kenneth Brummel-Smith, MD; Suzanne Baker, MA; LaVon Edgerton, BA
Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL
Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Jesse O’Shea, MD, 1115 West Call Street, Tallahassee, FL 32304; email@example.com