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Medicare malaise

Low reimbursement and massive paperwork force physicians to limit the number of elderly patients they treat. Some seniors can't find a doctor

Bill Husum signs his name a lot ' even for a doctor.

Half of Husum's 1,950 patients are enrolled in Medicare. The federal health-insurance program requires physicians to sign all their orders ' stamped signatures aren't accepted. Every time one of Husum's elderly patients needs an X-ray, or an MRI, or a new prescription, or a wheelchair, he has to scribble his name.

It's totally time-consuming, he said Thursday, clutching a sheaf of patient orders waiting for his signature. It takes hours. Once I tried to count how many times I sign my name, but pretty soon I lost interest in counting anymore.

One day last week, 41 patient files decked with dozens of sign here stickers were waiting for Husum by — p.m. He and his colleagues at Southern Oregon Internal Medicine sign their names so often that their office staff recycle the little yellow-and-red stickers.

Medicare paperwork drives physicians crazy, burning up hours they would prefer to spend seeing patients, but they have even more serious problems with the federal health care program. Medicare pays Southern Oregon doctors so little for their services that some have dropped out of internal medicine, the specialty that focuses on older adults. Most physicians have set a limit on the number of Medicare patients they'll see.

That means growing numbers of Jackson County seniors can't find a primary care doctor.

It was kind of disconcerting at first, said Quentin Randall, 70, of Medford, who spent most of a year searching for a doctor. Basically I'm in good health. I must have called everybody. I just went through the Yellow Pages. They all said they're not taking any new patients. Finally I found a doctor who had opened a new business.

For newcomers who have never had trouble finding a physician, the search can be especially frustrating.

It never occurred to me that it would be hard to find a doctor, said Addie Goethe, 75, who moved to Medford from Arizona four months ago and still hasn't found a doctor. I spent so much time and energy trying to find somebody, I just gave up. If I need a doctor real bad, I'll go to the (hospital) emergency room. They'll have to take care of me.

The problem isn't unique to Southern Oregon. Many sparsely populated areas of the United States receive far less in Medicare payments than more crowded metropolitan areas. The disparity dates from the origins of Medicare in the 1960s, when legislators used insurance companies' data for usual and customary fees in each region to set federal payment standards.

Areas that were spending lots of money on health care for the elderly when the program began, such as Florida, were allotted larger Medicare payments than regions where physicians watched their money more carefully, such as Southern Oregon. The payment disparity continues, nearly four decades into the program, despite cries across the country for Medicare equity.

We're being punished for good behavior, said Dr. John Jackson of Medford, chief executive of Providence Medical Group (local physicians who work for Providence Health System).

Jackson and other doctors don't like to turn down elderly patients, but they say they have to limit their Medicare patients because government payments barely cover their office costs ' and leave nothing to pay them for their time.

What Medicare is saying to physicians is, 'You can keep your office open and work for us for free,' said Mike Bond, who manages PrimeCare, Jackson County's association of independent physicians.

Bond offered numbers to support the physicians' claim. Many medical offices track their revenue and operating costs in terms of units of service as defined by Medicare. (One unit of service would be similar, but not identical, to a brief office visit with a doctor.) Medicare pays &

36;34.10 per unit of service in Southern Oregon. Physicians spend about &

36;34 per unit of service to keep their offices open ' but that doesn't include any compensation for their time.

Medicare patients produce about 70 percent of the money that comes into Husum's practice. He says taking more seniors could force him out of work.

If 70 percent of what you do is losing money, you can't keep the doors open, he said.

At least four local internists already have closed their doors.

People have left for greener pastures where the reimbursement is a little higher, Jackson said. Or they became VA doctors (for the federal Department of Veterans Affairs) or hospitalists (physicians employed by hospitals) or medical researchers.

The departures leave 33 doctors of internal medicine in Jackson County who see Medicare patients. Bond said that by several measures of physician/patient ratios, Jackson County could employ an additional 18 internists.

That gap isn't likely to be filled any time soon. Medical schools are graduating fewer internists. Husum said just 370 American-trained medical school graduates this year plan to continue their studies in internal medicine for more than one year.

If that trend continues, Husum said, in five years when the baby boomers are coming into Medicare, there isn't going to be anyone to care for them.

The competition to hire new internists already is fierce. Southern Oregon's quality of life still attracts physicians, but many new doctors start their practices with debts of more than &

36;100,000 from medical school. If they want to work with older patients, they can go to other areas of the country, such as Florida, New York or Southern California, where Medicare compensation can be as much as 66 percent higher than it is in Medford.

Jackson said recent recruiting efforts here have been disappointing. We interviewed 15, and offered jobs to many. We got one. A national search firm told us for what we could afford to pay, we wouldn't get anybody.

Paperwork and inadequate pay aside, physicians also take issue with Medicare's cumbersome anti-fraud regulations. Medicare requires each patient service to be coded for payment, but choosing the appropriate code is often confusing. Husum cited a study that looked at emergency room coding, in which several coders who examined the same patient data could agree on the proper code only 20 percent of the time.

Physicians who code improperly are subject to audits and fines as high as &

36;10,000.

Doctors can try as hard as they can to code correctly, Husum said, but the decision is up to the investigator.

Medicare has forced Husum and other physicians to make business decisions that conflict with their philosophical commitment to serve patients.

In medical school I never thought it would be like this, Husum said. I never imagined there would be a time when I couldn't see patients. It's possible if these trends continue, it will develop into a crisis, and very quickly.

Registered Nurse Suzy Eastgate stands behind piles of documents that her boss, Dr. Bill Husum, must sign before he goes home for the night. Medicare?s paperwork and low reimbursements are driving some internists out of the field. Mail Tribune / Bob Pennell - Mail Tribune Bob Pennell