[BrianL99]

With all this talk about Medical Billing and Medicare over-billing, the people who are paying attention to what's being posted, should be getting an education on how ridiculous the US Medical System has become.

A Primary Care Physician, fresh from certification and Residency, gets paid somewhere around $250,000 per year. One with 10 or so years of experience, is likely around $300,000/year.

With the burden at 40% (medical insurance, FICA, unemployment insurance, benefits, etc.) the cost of a medical provider to employ a primary care physician, is between $350,000-$400,000/year. That works out to a cost of $187/hour (2000 working hours per year).

Medicare (for example) pays about $187 for a 1 hour office visit. Assuming a Doctor spends 40 hours per week with patients (no non-productive time doing paperwork, researching, thinking or having lunch), the money from Medicare just covers the Doctor's salary. Where is the provider coming up with the money to cover admin staff, overhead and profit?

Which might lead someone to conclude, the only way medical providers stay in business, is for Primary Care Physicians to "sell" other services. Lab work, tests, procedures, etc.?

I guess it's no big secret why providers are pushing PA's & NP's as doctor replacements.

What am I missing?

[retiredguy123]

Why does the insurance company pay the same amount for a PA or an NP and the patient copay is the same as when you see the physician? Personally, I refuse to make an appointment with a PA or an NP, unless it is an emergency. I also refuse to pay a $25 copay for the physician to call me with test results, which takes about 5 minutes, when I can read the results myself. The insurance companies are driving up the cost by paying exorbitant rates for non-physician and non-medical interactions. When you see a PA or an NP, or just talk to the physician on the phone, the cost should be less than for an in-person visit with a physician.

[Rainger99]

Originally Posted by retiredguy123

Why does the insurance company pay the same amount for a PA or an NP and the patient copay is the same as when you see the physician? Personally, I refuse to make an appointment with a PA or an NP, unless it is an emergency. I also refuse to pay a $25 copay for the physician to call me with test results, which takes about 5 minutes, when I can read the results myself. The insurance companies are driving up the cost by paying exorbitant rates for non-physician and non-medical interactions. When you see a PA or an NP, or just talk to the physician on the phone, the cost should be less than for an in-person visit with a physician.

In 2021, my wife took a covid test and had a $25 copay. They said that we could get the test results tomorrow so we told them that we would call the next day. They said that they couldn’t release the results over the phone. Instead, we had to stop by the office and get the results in person - which required another copay of $25. The doctor’s office was about 30 minutes away and we were both working so I asked if we could get the results over the phone if I paid the copay while we were in the office for the Covid test.

Amazingly, once they got the second copay, they told us we didn’t have to come to their office the next day but, instead, they could give us the results over the phone!

[CoachKandSportsguy]

Brian's calculation is why a retirement community/mostly Medicare patients, is a money losing proposition for most physicians, see some of my other financial medical posts. Throughout the USA, there is a mixture of private pay, employed people and families, as the larger portion of a hospitals' patients and reimbursements, and to become profitable, there is a limit of the size of the Medicare visits which one can take in before becoming unprofitable.

However, CMS understands this, and therefore there are CMS improvement targets to care results which provide a one time annual "bonus" from CMS, which can make or break the physician's profitability in a year. CoachK is heavily involved in that process at a major medical center in MA. There are improvement targets set at the beginning of each year. Medicare for hospitals has 2 penalty programs which affects the medicare reimbursement rates in future years, and one improvement programs. There are requirements for qualifying, etc. . . One of CoachK's former supervisors went to CMS at a high level to help improve Medicare outtcomes, however, it's also very complicated, and not easily explained as each hospital is different. .

So, just start with the assumption that a PCP with medicare only patients will have a difficulty/impossible being profitable, which means staying in business, with all the EMR and reporting requirements, as a stand alone office. This scenario is also why there is consolidation in the healthcare hospital industry, where small, rural category hospitals have merged with medical centers for reducing overhead expenses for increased profitability. The biggest expense being Electronic Medical Records. I went to a local stand alone physicians' office with my mom, and they actually were resource incompetent when asked about retrieving records from the mandated state immunization database. they declared they knew nothing about it, yet its a state required for all residents from medical offices

gotta run

[Caymus]

Some practices limit the number of Medicare patients.

[BrianL99]

Originally Posted by CoachKandSportsguy

Brian's calculation is why a retirement community/mostly Medicare patients, is a money losing proposition for most physicians, see some of my other financial medical posts. Throughout the USA, there is a mixture of private pay, employed people and families, as the larger portion of a hospitals' patients and reimbursements, and to become profitable, there is a limit of the size of the Medicare visits which one can take in before becoming unprofitable.

Originally Posted by Caymus

Some practices limit the number of Medicare patients.

Attached is Blue Cross Blue Shield of MA, information on the cost for various doctor visits.

Apparently the reimbursement rate for typical doctor visits in a non-medicare environment, is about the same.

Just as an aside to the issue. I regularly played golf with the Lakes Region Hospital's head surgeon (Lakes Region Hospital went bankrupt, a few years ago and blew about $150M. Creditors Wrangle Over Bankrupt Laconia Healthcare Company’s Assets | New Hampshire Public Radio).

He was there for about 5 years. He left and went to do a Fellowship as a Plastic Surgeon. He told me he was never again going to treat a patient who relied on an Insurance company to pay. He's only going to do "private pay" work.

[Michael G.]

We should of sent all our kids to medical school when we had the chance.

[BrianL99]

Originally Posted by Michael G.

We should of sent all our kids to medical school when we had the chance.

Doctors are apparently the most underpaid professionals in the USA.

If I pick up the phone and call me Lawyer's office, it's $350 an hour if I get his associate, $650/hour if I get him ... & I'm getting billed whether he's talking, typing or just plain "thinking".

I'm a consultant. If I answer the phone, it's $100 minimum & $50 for every 15 minutes after that.. I have no where near the education of a Physician and surely not as smart as most of them.

The Prevailing Wage for an Electrician in Massachusetts, is $90/hour. $56 in the envelope + $13 Health Benefits + $21 Retirement.

Doctors are working for $200/hour? Crazy!

[Rainger99]

Originally Posted by CoachKandSportsguy

Brian's calculation is why a retirement community/mostly Medicare patients, is a money losing proposition for most physicians, see some of my other financial medical posts. Throughout the USA, there is a mixture of private pay, employed people and families, as the larger portion of a hospitals' patients and reimbursements, and to become profitable, there is a limit of the size of the Medicare visits which one can take in before becoming unprofitable.

However, CMS understands this, and therefore there are CMS improvement targets to care results which provide a one time annual "bonus" from CMS, which can make or break the physician's profitability in a year. CoachK is heavily involved in that process at a major medical center in MA. There are improvement targets set at the beginning of each year. Medicare for hospitals has 2 penalty programs which affects the medicare reimbursement rates in future years, and one improvement programs. There are requirements for qualifying, etc. . . One of CoachK's former supervisors went to CMS at a high level to help improve Medicare outtcomes, however, it's also very complicated, and not easily explained as each hospital is different. .

So, just start with the assumption that a PCP with medicare only patients will have a difficulty/impossible being profitable, which means staying in business, with all the EMR and reporting requirements, as a stand alone office. This scenario is also why there is consolidation in the healthcare hospital industry, where small, rural category hospitals have merged with medical centers for reducing overhead expenses for increased profitability. The biggest expense being Electronic Medical Records. I went to a local stand alone physicians' office with my mom, and they actually were resource incompetent when asked about retrieving records from the mandated state immunization database. they declared they knew nothing about it, yet its a state required for all residents from medical offices

gotta run

?
If limiting your patients to just those on Medicare Advantage is unprofitable, why doesn’t TVH take non-Medicare patients?

When I first moved here I was on my employer’s medical plan and TVH wouldn’t take me until I was on Medicare Advantage.

[biker1]

It wasn't always that way. From 2014 to 2021, I used The Villages Health Care with private insurance from my employer and obamacare. It sounds as if they had a change in policy, I guess because of demand from those on MA plans.

Originally Posted by Rainger99

?
If limiting your patients to just those on Medicare Advantage is unprofitable, why doesn’t TVH take non-Medicare patients?

When I first moved here I was on my employer’s medical plan and TVH wouldn’t take me until I was on Medicare Advantage.

[BrianL99]

Originally Posted by Rainger99

?
If limiting your patients to just those on Medicare Advantage is unprofitable, why doesn’t TVH take non-Medicare patients?

When I first moved here I was on my employer’s medical plan and TVH wouldn’t take me until I was on Medicare Advantage.

I think that's the $1,000,000,000 question.

Shear speculation: When TVH started up, they made some sort of deal with Insurers, to channel residents/members to a specific program, for marketing and operational purposes. Sort of like Henry Ford's, "give them any color they want, as long as it's black".

[Angelhug52]

Originally Posted by BrianL99

Doctors are apparently the most underpaid professionals in the USA.

If I pick up the phone and call me Lawyer's office, it's $350 an hour if I get his associate, $650/hour if I get him ... & I'm getting billed whether he's talking, typing or just plain "thinking".

I'm a consultant. If I answer the phone, it's $100 minimum & $50 for every 15 minutes after that.. I have no where near the education of a Physician and surely not as smart as most of them.

The Prevailing Wage for an Electrician in Massachusetts, is $90/hour. $56 in the envelope + $13 Health Benefits + $21 Retirement.

Doctors are working for $200/hour? Crazy!

And professional athletes get paid millions.. Seems people are OK with athletes getting big bucks.Yet a teacher or medical professional aren't valued.

[elle123]

Originally Posted by BrianL99

With all this talk about Medical Billing and Medicare over-billing, the people who are paying attention to what's being posted, should be getting an education on how ridiculous the US Medical System has become.

A Primary Care Physician, fresh from certification and Residency, gets paid somewhere around $250,000 per year. One with 10 or so years of experience, is likely around $300,000/year.

With the burden at 40% (medical insurance, FICA, unemployment insurance, benefits, etc.) the cost of a medical provider to employ a primary care physician, is between $350,000-$400,000/year. That works out to a cost of $187/hour (2000 working hours per year).

Medicare (for example) pays about $187 for a 1 hour office visit. Assuming a Doctor spends 40 hours per week with patients (no non-productive time doing paperwork, researching, thinking or having lunch), the money from Medicare just covers the Doctor's salary. Where is the provider coming up with the money to cover admin staff, overhead and profit?

Which might lead someone to conclude, the only way medical providers stay in business, is for Primary Care Physicians to "sell" other services. Lab work, tests, procedures, etc.?

I guess it's no big secret why providers are pushing PA's & NP's as doctor replacements.

What am I missing?

It's the insurance companies pushing physcian assistants and nurse practitioners. It's also the insurance industry that's absconding with billions. Privatized Advantage Medicare allows for greater fraud. "Private Advantage Medicare plans are paid based on a "risk score" that correlates with a patient's health. To increase profits, some plans or their contractors exaggerate patients' diagnoses, making them appear sicker than they are to receive higher payments from the Centers for Medicare & Medicaid Services (CMS)."

In addition, "some health plans and brokers offer illegal incentives to gain enrollment, which violates regulations designed to protect beneficiaries.

Insurers pay brokers illegal kickbacks to steer beneficiaries toward their specific MA plans, rather than recommending the plan that best suits the beneficiary's needs." That's probably what happened in The Villages and explains why the facility rejected regular Medicare.

[golfing eagles]

Originally Posted by elle123

It's the insurance companies pushing physcian assistants and nurse practitioners. It's also the insurance industry that's absconding with billions. Privatized Advantage Medicare allows for greater fraud. "Private Advantage Medicare plans are paid based on a "risk score" that correlates with a patient's health. To increase profits, some plans or their contractors exaggerate patients' diagnoses, making them appear sicker than they are to receive higher payments from the Centers for Medicare & Medicaid Services (CMS)."

In addition, "some health plans and brokers offer illegal incentives to gain enrollment, which violates regulations designed to protect beneficiaries.

Insurers pay brokers illegal kickbacks to steer beneficiaries toward their specific MA plans, rather than recommending the plan that best suits the beneficiary's needs." That's probably what happened in The Villages and explains why the facility rejected regular Medicare.

And your expertise in health care administration to make such accusations is........
Yep, I thought so.

PS: For people who want the facts, NPs and PAs are paid 100% of the physician fee if the visit is "incident to" an existing problem and 85% if it is a new issue.

[retiredguy123]

Originally Posted by elle123

It's the insurance companies pushing physcian assistants and nurse practitioners. It's also the insurance industry that's absconding with billions. Privatized Advantage Medicare allows for greater fraud. "Private Advantage Medicare plans are paid based on a "risk score" that correlates with a patient's health. To increase profits, some plans or their contractors exaggerate patients' diagnoses, making them appear sicker than they are to receive higher payments from the Centers for Medicare & Medicaid Services (CMS)."

In addition, "some health plans and brokers offer illegal incentives to gain enrollment, which violates regulations designed to protect beneficiaries.

Insurers pay brokers illegal kickbacks to steer beneficiaries toward their specific MA plans, rather than recommending the plan that best suits the beneficiary's needs." That's probably what happened in The Villages and explains why the facility rejected regular Medicare.

If The Villages Health accepted Original Medicare, I would be concerned that these facilities, that were built for the convenience of Villagers, would become overcrowded with non-Villager patients. Federal law prohibits descrimination based on where a patient lives. So, they would need to treat all Original Medicare patients on a first-come, first-served basis.