Many physicians have struggled to remain independent as the costs of practicing medicine have escalated while Medicare payments have fallen or remained relatively stagnant over the past decade.
When Joan Murphy turned 65 this year and joined Medicare, she found out that some doctors didn't love her as much as they used to.
An orthopedic specialist she had been referred to for a back problem sent her elsewhere: He doesn't take Medicare. That already had her worried when she recently called her gynecologist and was turned down for an appointment when she revealed she was now on Medicare.
"It's a very frightening situation, " said Murphy, a Clayton County resident who is retired.
At a time when 10,000 baby boomers are aging into Medicare every day, the federal health plan for the elderly and disabled is no longer attractive to many doctors. Medicare payments to doctors have remained virtually flat over the past decade, while the cost of providing care has jumped by about 20 percent.
Plus, in recent years, doctors have faced the annual prospect of an automatic cut in fees of 20 percent or more. While Congress always averts the cuts, which were built into a measure designed to control Medicare spending, Washington has not fixed what everyone agrees is a dysfunctional system.
Some doctors have decided they have had enough and have simply dropped out of the program. Others keep their current Medicare patients but won't take any new ones. The growth of Georgia's Medicare-age population --- projected to jump from about 1 million today to 1.4 million by 2020 --- will only exacerbate the problem.
"People are getting to be afraid of what is going to happen with Medicare paying less and less to doctors, " Murphy said. "I'm concerned that more and more doctors are going to quit taking new and current patients and that it's only going to get worse."
1 in 5 doctors limiting Medicare patients
It's hard to measure how widespread the problem is. About 1 in 5 doctors nationally said they were limiting Medicare patients in their practice because of low payments and the threat of future cuts, according to a 2010 survey by the American Medical Association. The federal government studies the issue regularly to assess whether Medicare patients have difficulty finding a doctor. So far, the surveys haven't identified a significant problem. But some doctors wonder.
"Although the federal government would like to tell you there are not access issues for Medicare, I don't think that's true, " said Dr. Kay Kirkpatrick, a hand and wrist surgeon at Resurgens Orthopaedics, which has offices across greater Atlanta. "A lot of my patients who are looking for a primary care doctor can't find one who will take them on Medicare."
Many doctors are limiting Medicare, said Dr. Sandra Reed, an ob-gyn from Thomasville who is president of the Medical Association of Georgia, a trade group for physicians. "They are taking care of the ones they currently have and that's pretty much what we're seeing across the state, " she said.
Kirkpatrick said Resurgens still takes Medicare patients, but that's a cause for concern among the practice's doctors.
"We really have tried very hard to continue to see the Medicare population because we do like taking care of seniors, " Kirkpatrick said. But she said it's becoming harder to stay in the program.
"The increase in the amount of Medicare patients because of other groups bailing out is highly problematic for us, " Kirkpatrick said. "I do not know what we will do six months from now or a year from now."
Doctors get less pay for more time
Medicare pays, on average, about 80 percent of what private insurers pay for the same services under rates negotiated through PPO contracts, according to the Medicare Payment Advisory Commission. Kirkpatrick says that Medicare payments can be less than half of what a private insurer will pay.
While Medicare pays less than other plans, its patients usually need more time and attention. "They are usually complicated patients with multiple medical problems, " said Dr. Cynthia Mercer, an ob-gyn who practices in Athens.
Mercer said her practice still sees Medicare patients but has had to limit the number of new Medicare patients it will accept --- especially after another large practice in Athens stopped taking any Medicare. "We have had to limit ours just from a business standpoint because you cannot cover your overhead by just having a Medicare practice --- the reimbursements are so low."
Most women on Medicare still need a gynecologist for wellness exams as well as for medical issues that can arise as they age.
Dr. John Moore, an ob-gyn at an Atlanta practice with more than 60 doctors, said his practice stopped taking Medicare entirely.
"It's not necessarily a happy choice we have made, " Moore said. "We want to take care of our patients. But federal rules and regulations just became so onerous."
He said Medicare fined the practice years ago because the coding one of its doctors used resulted in undercharging for visits. "We just decided we couldn't run the risk of something like that and the reimbursements aren't great, " he said. "I like my Medicare patients and I hate to tell our patients I can't see them anymore."
Moore said he usually offers to continue seeing the patients at a reduced fee if they pay out of pocket.
"It's a very big concern that if the doctors are not able to afford to take care of Medicare patients --- who is going to take care of them?" he said. "The few doctors left are inundated... It's a very scary situation right now."
Medicare-only practice subsidized
Atlanta's Piedmont Healthcare had enough concerns about access to a doctor for people on Medicare that it established a Medicare-only primary care practice that it subsidizes, said Dr. Quentin Pirkle, chief medical officer for the Piedmont Physicians Group.
Pirkle said about 60 percent of Piedmont's primary care practices in the Buckhead area are not taking new Medicare, but they continue to see their current Medicare patients or those who age into the plan. The other 40 percent are busy, he said, and getting an appointment can be difficult.
While small group practices couldn't afford to dedicate a doctor to Medicare only, Pirkle said Piedmont's size allows it to support such a practice. Piedmont set up Dr. Kila Dabney-Smith to see fewer patients a day than most of its primary care physicians because of the complexity of the Medicare population.
Pirkle said 18 Medicare patients a day is about the maximum in primary care, while other physicians with a mixture of Medicare and non-Medicare patients can see between 25 and 30 patients a day. The total can go up to 50 a day for doctors who use a physician assistant or nurse practitioner to help out.
"It's a good solution to the problem, but I can tell you the (Piedmont) system makes a significant investment to make that practice work, " he said
Executives at both Emory Healthcare and the WellStar Health System say their physicians still welcome Medicare. Both systems also take Medicaid --- the government health plan for low-income children, pregnant women and some elderly and disabled people --- even though it pays even less than Medicare.
"It's a challenge for us to do it, " said Dr. Wright Caughman, chairman of Emory Healthcare.
As the head of an institution that trains doctors and runs hospitals positioned around Atlanta, Caughman and others at Emory are focused on trying to come up with new ways to deliver health care so that the country can afford to take care of an aging baby boom population while it also copes with a doctor shortage.
In the coming weeks, Medicare's future will be part of the public discourse as the presidential candidates debate their policies. Congress will once again face the need to pass a "doc fix" bill to avoid the automatic cuts in physician payments. Congress will also have to deal with another automatic cut to Medicare payments that was part of the deal to raise the debt ceiling in 2011.
The focus of most of these public policy debates is to devise ways to curb future Medicare spending --- and doctors worry about the possibility that what's to come could make Medicare even harder to take.
Doctors need an incentive to treat Medicare patients, said Dr. David Satcher, a former U.S. surgeon general who now teaches at the Morehouse School of Medicine.
"It's very hard to defend a reimbursement system that barely covers the cost of managing the service, " he said. "We've got to open our eyes."