Not Walking Away From Medicare

This past week, the NYT New Old Age Blog featured a post about me and my practice. Titled “Walking Away from Medicare,” it describes my decision to opt-out of Medicare and create a different kind of geriatric practice.

It has generated quite a lot of comments: 163 at my latest count. Most of them judge me pretty harshly. It seems that many people feel that I’m doing this for the money. And that I don’t care about society or older people.

Of course, if you know me or if you’ve been reading this blog, then you’ll know that nothing could be further from the truth. My practice is fairly small, in part because my goal in having this practice was to have a way to keep working with patients and families, while having the flexibility to pursue my other professional interests. Since I started the practice, I’ve spent most of my time writing for this blog, learning about the worlds of digital health and healthcare innovation, and thinking about how we can teach geriatrics directly to caregivers.

Although I’ve phased out working with Caring.com, I’m thinking about how I can build on what I learned there, and keep connecting caregivers to resources that leverage geriatrics expertise.

This morning, I gave a talk to a group of family caregivers, at a retreat sponsored by Family Caregiver Alliance. We talked about what caregivers should know about the geriatric approach to care, and how they can learn more about medical care that is tailored to the needs of aging adults. We talked about delirium, and how caregivers can recognize it and get better help from clinicians.

We talked about participatory medicine — they were all savvy, experienced caregivers but none had heard of the e-patient movement — and the Beer’s criteria, and then we got into how tech tools might help caregiving feel more manageable. (More on those in future posts!)

I loved every minute of it, doing this session with family caregivers. I can’t wait to participate in more events with caregivers.

So why am I writing all this? Mainly because I hope to illustrate in a time of geriatrician shortage, there many ways we can be of service to society, even if we make the decision to leave Medicare, or otherwise aren’t as available to serve patients in a one-on-one fashion.

The Future of Geriatrics

Just for the record, I don’t think the future of geriatrics should be that geriatricians leave Medicare en masse and require that patients pay them an hourly rate, out-of-pocket, for services.

Instead, I hope my own story and struggles will foster more conversation on the following topics:

  • How should we — as a society — best deploy a very limited supply of geriatricians, given an aging population and inadequately prepared healthcare workforce? The projections are sobering.
  • How can we make practicing geriatrics attractive and sustainable for geriatricians? Most geriatricians I know love caring for older adults, but many complain of stress and burnout. (Some have emailed me this past year, having heard of my practice.)
    • What changes to reimbursement or work structure would attract more clinicians to geriatrics?
    • How can we make practicing geriatrics within Medicare feel more sustainable? (Answer: we may need to think beyond debt relief and 10% salary increases.)
  • How can we make geriatric care doable for ALL front-line clinicians? As people age, they benefit from a geriatric approach to their care. And for the foreseeable future, that approach will have to be delivered by non-geriatricians: the primary care clinicians who will hopefully have had some geriatric training, but didn’t do a fellowship.
    • With front-line clinicians already suffering from high levels of burnout and dissatisfaction, how can we support them in effectively caring for a growing number of older patients?
    • Earlier this year I proposed that the job of PCP for complex Medicare patients be doable within 35 hours, which could help retain all those empathetic clinicians with young children. Other ideas?

Food for thought and future conversations, I hope.

Leslie Kernisan, MD, MPH, has been practicing geriatrics since 2006, and is board-certified in Internal Medicine and in Geriatric Medicine. She is a regular THCB contributor, and blogs at GeriTech, where this post originally appeared.

12 replies »

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  2. Medicare is a wide term and it deliver several kind of beneficial medical and health care facilities to the user and people; therefore in most of the regions we have found that health care organizations are offering several kinds of health care reform programs. Therefore according to health experts we should not be far away from Medicare issues

  3. Hi Leslie, thanks for sharing this post. Really very useful information shared about geriatrics. Awaiting for more posts like this.

  4. hi Mr. Byron, thanks for these questions.

    I write the posts but THCB writes the headlines.

    It’s true that at the federally qualified health center (FQHC, aka community clinic), they did the billing. I still had a lot of paperwork because that’s what’s involved in primary care these days: prior authorizations, forms for assisted living, referral forms, med refills, etc.

    At the FQHC, although all doctors are salaried, the clinic gets a fixed sum of money for every face-to-face visit with a billable provider. They do not get paid extra when a geriatrician takes better care of older adults. So…they did not want me to have longer visits in order to properly attend to the needs of older patients. For financial reasons (and funding is very hard these days for these clinics) they really needed all primary care docs to be productive: 10-12 patients per half day. This doesn’t leave one with much time to address paperwork and phone calls, and with complex older patients, there is more work that needs to be done outside the visit. I burned out, I left. (Bear in mind that a lot of my stress came from the pressures of being medical director, which included trying to get the docs to adopt new electronic systems, and having to hear about *their* frustruations with the ongoing changes to the clinic.)

    In other words, my leaving the FQHC was partly about the stresses of primary care practice in that environment, and partly about the particular stresses of trying to care for the elderly in that environment.

    As for my own practice, I did have to do some paperwork to opt-out, but now I don’t do any insurance or billing paperwork. This is a big advantage since I have a part-time solo consultative practice, and means that most of my time working is directly related to patient care. Otherwise, the catch in opting out is that you have to stay out for two years at a time.

    Federal law does require opted-out physicians to have all Medicare beneficiaries sign a contract, which specifies that the beneficiary understands that the physician has opted-out.

    Hope I’ve answered your questions; thanks again for your interest!

  5. Dr. Kernisan

    I must admit I am still confused (but then again I qualify to be a patient of yours).

    I read the blog post above that seems to in no way answer the question in the headline. I also note that although the blog post has your name on the byline, you left the first comment in a way that suggest you didn’t write the blog post. I also read the NYT story quickly when it came out (because I read almost everything about Medicare). I kind of knew you weren’t doing “this” for money because — assuming you have even minimal overhead in your new practice (printer paper, phone bills, Internet charges, malpractice insurance?) — $200 an hour is kind of somewhere between what a lawyer that handles only foreclosures charges and what a plumber makes (the plumber makes the most).

    But you need to define “this” because it does not come across in either the NYT article or in this blog entry or in your comment. Just to be clear, you no longer “accept assignment,” correct? You make your patients sign an agreement that they understand that you do not “accept assignment,” correct? It might be interesting to Medicare beneficiaries and others if you would explain to the reader what you did to initially “accept assignment” and what you had to do more recently to no longer “accept assignment.”

    Further I assume when you worked at a community clinic that its administrators did all the paperwork of getting you on Medicare as well as billing your procedures through to your region’s MAC insurer and Part C insurers (if the clinic accepted C). So apparently you did not leave because you personally had to do a lot of paperwork.

    Conversely, to get out of Medicare you probably did have to do a lot of paperwork (And offer the government your first born? Or sign something in blood?)

    If you are going to run a headline saying “Not Walking Away from Medicare,” but you do not accept assignment, try one more time. What did you actually do as it relates to Medicare?

  6. Digitized medicine is an experiment using the doctors, nurses, and patients as the guinea pigs to benefit the CEOs and shareholders of the Digital Industrial Complex.

  7. Doctors are used to prefer advanced medical service to deliver quality health care service to the victims therefore in most of the occasion we have found that doctors are following Concierge medicine or direct pay medical practices to repair the current medical and health care condition.

  8. The only people could read what you have written and believe, even for a moment, that you don’t care deeply and passionately about your patients are people who have never done what you do and have no understanding of what is involved. Illegitimi non carborundum

  9. Thanks for clarifying, Dr. Kernisan. It shows that the media sometimes doesn’t get a nuanced message, and healthcare certainly needs more than the polar extreme, overly simplified explanations that are out there now.

  10. Hey there THCB, I appreciate your reposting this!

    Just to clarify: I am not walking away from helping older adults and their caregivers. And I’m not walking away from my personal mission to help foster change in our healthcare system so that we can provide compassionate effective healthcare to an aging society.

    I did, however, after careful consideration, decide to step away from Medicare, when it came to my own personal practice. This is in the context of wanting a small geriatrics practice that can allow me to keep learning & connecting with families, while I pursue other professional interests. Also, I needed a practice situation that was more compatible with the needs of my kids and family.

    ok critics, have at it!