Medicare makes sense?
I disagree with the statement " . . . some physicians will stop serving patients who stay in original Medicare and instead opt to provide care only through new plans that pay them more." (Making Sense of Medicare+Choice," October ACP-ASIM Observer, p. 1). In reality, the new plans do not have as much to offer physician providers.
For example, since Medicare pays MediRisk programs 95% of the average adjusted per capita cost of the preceding year for the beneficiaries in their area and the MediRisk carrier takes another 15% off the top for administration of the program, providers receive only 80% of the monies. In addition, most MediRisk programs offer more benefits, such as a $500 per year pharmacy benefit, and tests, such as Pap smears and PSAs, than does Medicare. In effect, the MediRisk carriers offer more services while providers are paid less.
On the other hand, under the standard Medicare fee-for-service program, the physician provider can provide services over and above what Medicare considers medically necessary simply by having the patient sign a disclaimer. It follows that the average physician would opt for Medicare over MediRisk programs. In fact, my entire group of five internists has already come to this decision.
MediRisk programs will be forced to hire physician assistants and nurse practitioners, with one doctor supervising. Patients will receive a level of medical care that is different from what they are used to, creating widespread dissatisfaction. Older voters will force the issue of private contracting, and a two-tiered medical care system will result.
Louis H. Felder, FACP
In recent years, I have watched with dismay the destruction of the medical environment. My wife and I were rural physicians in Texas, but Medicare's inappropriate reimbursement policies to rural hospitals financially destroyed us, and we had to move.
Each of us pays the same taxes, but what we get depends on where we live. If you are in the right location, Medicare reimbursement covers medications, dental care and eyeglasses. In the wrong place, you get nothing. In fact, if your Medicare HMO pulls out you can't even get back your MediGap policy.
Richard H. May, ACP-ASIM Member
I agree with the Federation of State Medical Boards' recommendations to more closely regulate postgraduate residency programs ("New rules for regulating residents?" October ACP-ASIM Observer, p.1). However, the requirement that blocks reporting substance abuse if the abuser has sought the protection of a physician's assistance program contradicts the whole purpose of the regulations—that all state medical boards be aware of the resident's employment background.
The problem is not merely one of state boards being in the dark regarding resident behavior but that everyone is so afraid of being sued that they are unwilling to share any negative information about a job applicant.
As a director of a residency program, I have never received any written negative comments and have almost never received any oral negative comments on residents who have been later found to be chemically challenged, sexual harassers, bankrupt and/or sociopaths.
I believe the problem stems from our litigious society. Directors and others are afraid to say anything for fear the applicant will retaliate legally. Several years ago, we were evaluating a resident applicant who had been released from a neighboring program. The program would write us nothing substantive, so I called the director who had been an intern with me. He wouldn't tell me anything, even after the applicant signed a release. This didn't help the resident. This didn't help me. Whom did it serve?
More recently, an applicant's director neglected to inform us that the applicant had been dismissed from his program because of a felony conviction. The resident was fully approved by the state licensing board, but six months later a private citizen notified us that the applicant was under sanction and supervision by the same state licensing board.
I believe we need a Good Samaritan law regarding the release of applicant information. Any material information, while open to contradiction by the applicant, should be free of reprisal. In addition, a source's confidentiality should be as important as an applicant's. This, of course, would have to be taught to a whole generation that has been silenced by fear of litigation.
Michael Plunkett, MD
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