"Half of primary care physicians in survey would leave medicine ... if they had an alternative." -- CNN, November 2008
"Doctors are increasingly leaving the Medicare program given its unpredictable funding." -- Forbes, January 2013
Doctors, it seems, love medicine so much ... that they're always threatening to quit.
In some cases, it's all in how the question is asked. (Because of methodology, several eye-catching surveys have since been discredited.)
But physicians' mounting frustration is a very real problem, one that gets to the heart of how health care is delivered and paid for. Is the Affordable Care Act helping or hurting? The evidence is mixed.
Doctors' Thoughts on Medicare: Not as Dire as Originally Reported
The Wall Street Journal last month portrayed physician unhappiness with Medicare as a burning issue, with a cover story that detailed why many more doctors are opting out of the program.
And yes, the number of doctors saying no to Medicare has proportionately risen quite a bit -- from 3,700 doctors in 2009 to 9,539 in 2012. (And in some cases, Obamacare has been a convenient scapegoat.)
But that's only part of the story.
What the Journal didn't report is that, per CMS, the number of physicians who agreed to accept Medicare patients continues to grow year-over-year, from 705,568 in 2012 to 735,041 in 2013.
And other providers aren't turning down Medicare, either. The number of nurse practitioners participating in the program has only gone up, Jan Towers of the American Academy of Nurse Practitioners told California Healthline.
That's not to overlook doctors' feelings about the program; "the reality is that Medicare has caused some very real frustration," according to Reid Blackwelder, president-elect of the American Academy of Family Physicians.
But that frustration isn't new, Blackwelder told California Healthline; the "tipping point was 2003" -- when Medicare's much-maligned Sustainable Growth Rate to calculate physician payments began to kick in -- "and it's been an ongoing stressor since," with temporary patches that can lead to uneven reimbursement.
And actually choosing to opt out is still a big leap for many doctors, given that the program represents so many potential procedures; Medicare patients make up 24% of the patient population for AAFP members, Blackwelder says.
There's more than finances at stake, too. In an informal survey of a half-dozen doctors, most told California Healthline that they felt ethically obligated to stick with the program. Turning down Medicare, "well, that's saying no to a nice little old lady ... who could be your mom or grandma," one doctor said.
Physicians' Medicaid Participation: A More Serious Issue
However, working with Medicaid patients -- who tend to be younger, poorer, and much more diverse -- didn't provoke the same reaction.
"Now that I've built my practice, I don't feel like I need to see [Medi-Cal] patients," given the program's mediocre reimbursement rates, one private practice physician said.
And that lack of pay -- Medicaid reimburses a fractional rate compared with private payers for the same procedures -- is a major factor behind many doctors' ongoing reasons to opt out. Fewer than 70% of doctors nationally participated in Medicaid in 2012, and that problem is worsening; a recent Health Affairs study found that about 33% of primary care physicians didn't accept new Medicaid patients last year.
The pending Medicaid expansion under the ACA may change the dynamic, slightly for better but potentially for worse, experts say.
- To incent more doctor participation, the health law includes a 30% pay hike for PCPs in 2013 and 2014 who treat Medicaid patients.
- However, that pay raise has been implemented very slowly, leading to new complications and concerns that participating doctors may further hesitate.
- And the sheer volume of new patients -- as many as 16 million Americans are expected to gain coverage through Medicaid -- means that doctors who treat Medicaid beneficiaries may be overwhelmed by demand.
The Role of Evolving Dynamics
Doctors' broader unhappiness with trends in health care also may reflect the changing of the guard, with a generation of doctors who came into the field during an era that allowed them to be free-ranging "cowboys" now being confronted by more programs and paperwork that attempt to force them into joining pit crews.
And Blackwelder agreed that some new federal provisions -- like the push to adopt electronic medical records -- could help drive older doctors to hang up their stethoscopes. (But the problem isn't just the introduction of new programs, he says, but also government inertia around fixing ongoing concerns like SGR.)
Meanwhile, if doctors really do stop seeing Medicare and Medicaid beneficiaries, does that create an opportunity for other providers -- say, nurse practitioners -- to step into the void?
"It might," Towers concedes. "We're here to help fill a need. [And] if there's a backing out on one side, there are NPs who are very willing to see all these patients."
Around the nation
Here's a quick look at what else is making health reform news this week.
Meet the hospitals facing readmissions penalties. Writing for Kaiser Health News, Jordan Rau takes a look at the ACA's hospital readmissions reduction program.
Obamacare isn't destroying jobs. In an op-ed at Politico, Jared Bernstein and Paul van de Water argue that the ACA's effect on part-time work is overstated.