Some Kansas physicians limit Medicare patients

March 13--When internal medicine physician Jeanne Kroeker bought a practice in 2004, it already had a cap on the number of new Medicare patients it accepted.

"I sort of inherited it. I thought about it and debated it," said Kroeker, physician-owner at Wichita Internal Medicine Associates.

Ultimately, she decided to keep the cap.

While the number of doctors in Kansas who accept Medicare has increased over the last five years -- from 6,174 in 2009 to 8,006 in 2014 -- some are limiting the number of Medicare patients they will see.

"Generally, we're not taking new Medicare. Anyone who rolls over, we don't boot them out. Some offices do," Kroeker said.

As a small practice, Kroeker said it's essential to have a mix of payers.

The reimbursement rate to physicians for the same service as someone who has Blue Cross Blue Shield or Aetna can be between 10 and 35 percent less for those with Medicare, she says.

"It's hard to tell people 'no' based on the insurance they have," Kroeker said. "The patients are generally not surprised -- they've heard it so many times before."

Thousands of baby boomers -- those born between 1946 and 1964 -- are becoming eligible for Medicare every day.

In Kansas, the number of Medicare recipients has grown from about 398,000 in 1999 to about 448,000 in 2012, according to the Kaiser Family Foundation.

A December 2013 study by Kaiser found that nationwide less than 1 percent of physicians have formally opted out of the Medicare program.

Roughly 135 physicians have formally opted out in Kansas, and most of those practice in the Kansas City area, according to the Wisconsin Physicians Service Insurance Corporation, the Medicare contractor for Kansas. The largest practice area among those opting out is psychiatry.

Most physicians won't formally opt out of the Medicare program, Kroeker said, but they may limit the number of new Medicare patients they see.

"They're not announcing that they're not taking new patients. ... Many groups don't want to say they have a cap on Medicare, so they have wiggle room."

A 2012 National Ambulatory Medical Care Survey by the Centers for Disease Control found about 90 percent of physicians say they accept new Medicare patients in Kansas, according to Kaiser.

For larger physician groups, it's typically easier to take on additional Medicare patients, especially in family practice groups because their patients are a mix of young and old, Kroeker said. Internal medicine is limited to adults.

Paul Huser, a family medicine doctor with West Wichita Family Physicians and president-elect of the Medical Society of Sedgwick County, is part of a larger group that hasn't had to make that decision.

Physicians have to strike a balance between care and business, since every practice has overhead, he said.

"I don't think it's a choice physicians want to make," Huser said. "Medicine is one of those very unique career areas. There's such a privilege helping people take care of their health, and there's a certain responsibility with that, but yet you have to balance it with the business side."

"Most people are comfortable with business models until you bring in health."

'Doc Fix'

For the past 12 years, physicians have faced proposed cuts in the sustainable growth rate formula, which is used to reimburse providers who care for Medicare recipients. But although the budgeted cuts loom as a means to control Medicare's growing costs, no reductions have been permanently implemented by Congress in the last 10 years.

"That's one of the fears that has led to a portion of physicians either capping or pulling out of seeing patients with Medicare," Huser said.

Congress is currently working on a bill to change the formula, but doctors aren't holding their breath.

The proposed "sustainable growth rate formula" cuts were part of the Balanced Budget Act of 1997. The cuts -- which if put in place would now total 20 or 30 percent -- started to become a possibility in 2002 when Medicare costs started exceeding the targets for expenses.

For the past several years, a temporary funding patch -- called the "Doc Fix" -- has been used by Congress so that physicians didn't see reductions.

But when it's applied retroactively, it delays payments and creates cash flow problems for practices.

Washington media outlets The Hill and Politico have reported that the fix is now being tied to the Affordable Care Act's individual mandate by House Republicans, a move that won't likely pass the Senate, where Democrats hold the majority.

"You have to have a certain tolerance, keep moving forward and taking care of patients and hoping the government does right," Huser said.

Along with the health industry, the AARP is lobbying Congress to change the reimbursement formulas and eliminate proposed cuts, said Maren Turner, senior state director for AARP of Kansas.

"When it comes to Medicare access, one of the things our members care about is the whole issue around the 'Doc Fix,' " Turner said.

"It does impact access. If you look at the Medicare physician payment formula, it's very flawed. ... It needs to be replaced so doctors and other providers are paid fairly for the services they provide."

Although the numbers of physicians who take Medicare payments have grown in Kansas, Turner said the AARP is still concerned about the mix of physicians and whether there will be enough primary care physicians to care for the growing number of Medicare recipients.

Non-physician participation

The number of non-physicians who take Medicare payments also has increased in Kansas, from 3,271 in 2009 to 4,983 in 2014.

"As the population grows and ages, we're all going to be needed," said Betty Smith-Campbell, chair and professor at Wichita State's school of nursing.

About 85 percent of nurse practitioners see patients covered by Medicare, according to the American Association of Nurse Practitioners.

At GraceMed, a safety net clinic, there was a 23 percent increase in Medicare patients from 2012 to 2013, according to CEO Dave Sanford. Most of the clinic's Medicare patients do not have a supplemental Medicare plan.

"All of our physician and mid-level providers (other than pediatricians) are enrolled as Medicare providers," Sanford said in an e-mail.

"This is part of our new provider process -- to ensure mid-levels as well as physicians can provide care for Medicare folks."

Reach Kelsey Ryan at 316-269-6752 or [email protected]. Follow her on Twitter: @kelsey--ryan.

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