A Difficult Choice

It is with deep frustration and regret that I announce Medicare has opted to discontinue paying ThriveAPC for home visits, effective April 1, 2022. Reimbursement from Medicare for Telemedicine billing claims has also significantly been scaled back

These adjustments to reimbursement for my practice have been instituted with parameters that are too complex to be managed without a professional billing service.  Whereas going that route would fly in the face of why I opened my own practice to begin with, which was to reintroduce simplicity and transparency to the workings of my profession as a Primary Care Physician.

Once upon a time, a “family doctor,” or “personal physician” had meaning; it evoked the image of a friendly face, black bag in hand, seated bedside in the home of an individual who is ill.  Bringing this imagery back to life in my patients’ experiences has been the joy of my career. 

However, there’s a reason it has become exceedingly rare for physicians to perform home visits.  It is this nagging aspect of operating an organization, known as “overhead.”

No one likes to think of a physician practice as a “business.”  But as a professional seeking to practice medicine, I have a choice.  I can hop aboard current conventions and be hired into a large corporate organization, or I can try to go it on my own.  I’ve done the “large multispecialty group practice” thing.  I chose independence, because I was tired of being professionally handcuffed by a system that claimed to share my values but overtly did not.  Five years ago, I stepped out of what felt like the Empire’s Death Star into an abyss of emptiness where I repeatedly found myself face-to-face with maleficent meteors and consumptive forces of all shapes and sizes, myself merely a tiny traveler now unprotected by the “system” that had it all figured out in advance, while I found myself trying to build a vessel from scratch while on the fly.  Failure threatened from every angle, time and again.

But I’ve never regretted the decision.  To choose freedom. 

Any day of the week, I would still prefer to face all demons that threaten to consume me with my own armament of ingenuity, instinct and altruism than subject myself to manipulation within a system that usurps these virtues to make me a pawn.  I trained too hard for too long and sacrificed too much of my youth to give in to that now.

Ironically, the “great abyss” of unvarnished society is not actually an empty space at all.  Instead, it is a tangled morass of human nature, contrived institutions, intelligent machinery, and countless other nameless, faceless influences that flow and interconnect into a sea of obstacles.  The analogy of truth is much easier to conceptualize as an ocean, rather than outer space.  At the terrestrial level where we live, “monsters of the deep” do exist.  And all too often, we deify them.

Many of these influential deities exist as laws and mores, and I accept that I am subject to them.  I am bound to an oath I took upon graduating medical school.  I am bound by law to protect the privacy of my patients.  I am also bound by shrewd sensibility to script contracts between myself and any individuals or entities with whom I engage dealings, whether it be the owner of the property I occupy, the laboratory that processes blood and urine specimens I submit, the insurance agencies that promise to protect my assets if someone slips and falls while under my auspices… etc.

I understand social and legal norms, and remain adherent to such commitments.  Altogether, they form a fairly rigid structure within which I can practice my profession.  However, the structure is still far less rigid than the corporate system that contained me as an employee. 

And because I am less duty-bound by employment contract to generate revenue with specific activities as a physician… I have been able to be a better physician.  I sit and chat with my patients until we develop trust.  I go to bedsides with a black bag in hand to see people who are too sick to make it to the office to come see me. 

I am still responsible for the operational costs of running my practice, and what I’ve gotten paid for doing what I do barely pays the bills.  In fact, there have been so many instances where it did *not* pay the bills, that I’ve restructured and restructured to stay open – and through it all, through novel practice models that do not translate to my geography, through a pandemic, through instability of staff turnover… we’re still here.  

Seeing patients in their own homes.  “Old school” style.  I’ve taken pride in it.

But this activity has been deemed by algorithmic calculations to be too irregular relative to the activities of my local peers to be valuable.

Please allow me to explain a few frequently unknown details of how payment for medical care works.

At this juncture, Medicare’s permitted reimbursement rate for a standard medical home visit in the local area is $139.  Reimbursement for a standard office visit is $144.  Medical home visits not only take more time and resources on account of driving, navigating entry procedures at living facilities and so forth, but also are performed generally on patients that are highly medically complex, amping up the effort relative to a typical office patient, and often resulting in a high volume of “post-visit” work such as generating orders for testing/treatment through a variety of auxiliary services and channels, communicating with specialists or other service providers such as nurses, case managers, pharmacies, therapists, etc.  None of the “post-visit” work is considered “billable activity” by Medicare.  All of that labor is assumed to be “covered” under the visit reimbursement.

Whereas it is also worthwhile to note that Medicare only covers on average 79% of the billed amount, meaning that of a $139 billing claim sent to Medicare, ThriveAPC only receives $111 *from* Medicare when the bill is fully processed and approved.  There is a 20% cost-sharing assumption for most Medicare patients.  Supplemental health insurance plans sometimes pay for this 20% co-insurance fee.  Sometimes, but not always.

Whatever labor is performed by ThriveAPC that remains unpaid by Medicare or supplemental health plans, to date we have simply written off, on account of a strict code to avoid sending “surprise bills” to patients.  Our objective is not to “make money”, but to serve the community as effectively as possible.

However, unless we are solvent as an entity, we will be unable to serve the community.  In order to provide the top-notch medical care we take pride in, we have to *exist*.  And we unfortunately cannot exist if we cannot cover operational costs.

We have taken pride in our commitment to writing off co-pay and co-insurance charges typically charged to patients in association with standard Medicare claims.  Unfortunately, due to these decreases in Medicare reimbursement, we are no longer able to sustain operations while doing this.

Unfortunately, even “patient care” is becoming increasingly encumbered for Primary Care Physicians.  Government forms to be manually filled out in order to justify reasonable care through ancillary providers or alternative coverage for such care such as through Veterans benefits or Social Security/Disability (which is separate from Medicare as an entity), Prior Authorizations with endless clinical questions and requiring documentation that would be obviously archived. 

It is all understandable when it breaks down.  There has been too much fraud committed in the past, and all these ancillary providers are trying to protect themselves from fraudulent activity.  But those of us seeking to follow all the rules are the ones who are handcuffed and morally harmed with the logistical beatdown, then blamed by patients for sluggish response.

Advice from so many angles insists that I drop the fight and adhere to convention.  Get a billing service.  Contract with the insurance companies (BCBS, Aetna, United, Anthem, etc).

But I have a firm policy:  Never accept support from someone who has the power to break you by disappearing.

The following changes will be made in our billing/pricing scheme, effective September 1, 2022, details to be published in the near future:

  1. Membership Fees, Pay-As-You-Go Office Visit Fees and Home Visit Distance Fees will increase across the board, although patients who have maintained loyal membership for a certain number of years will be protected from any increases in recurring (monthly or annual) membership rates.
  2. Co-insurance charges for non-member Medicare patients will be payable at the time of a visit.  Supplemental insurance plans will likely cover/reimburse this cost to the patient.
  3. Medical Marijuana certification and renewal will be more readily available but will incur separate charges even for member patients.  Discounts will apply for member patients and Medicare beneficiaries.

I have faith that there are enough individuals and families out there who are open-minded enough to understand why I run Thrive Adult Primary Care the way I do, and to continue using our services in spite of these changes. Certainly, those who are not in alignment are always welcome to seek services among my amazing colleagues in the local area, albeit those who are struggling with different elements of a system that disables our hard-earned professional liberties. The population of responsible, well-educated medical professionals available to take on patients is dwindling rapidly, and what I describe here is only a small percentage of the reasons as to why.

Please accept my best wishes to all. My sincerest hopes for a brighter future extend profusely.

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