You are asking me some excellent questions. The fact that this troubles you encourages me. The fact that we tolerate so much of this from fellow physicians makes me feel less respect for physicians.
Let me lay the background by saying that doctors did not appreciate medicare or medicaid and fought it when it came. Clearly however, these have improved access to care, particularly in rural areas. There are also frequent conflicts between government and physicians. In my distant past in rural practice, I was in the first group of physicians that got out into practice and got paid less from Medicare as a new physician in 1983. I testified in federal district court in this matter (a not so good introduction into the judicial system, picture yourself being sworn in over the phone with attorneys laughing and talking in the background). Apparently the case was made mute because the feds already figured out what they were doing was discriminatory. More recent regulations, investigations, and audits have not made doctors more trusting of Medicare.
On the Family L list serve we recently discussed the relatively new practice of doctors doing exclusive care of rich patrons.
You are indeed correct that rural doctors do feel a responsibility to take all kinds of patients. As a group they do so, but there are exceptions. There are many ways to exclude or discourage those who might not be a good fit, or those who might take more time, or those who might be more complex.
Later addition to this posting (note that the midwest physicians are among the highest in accepting Medicare patients, this is likely due to having more primary care and rural practitioners).
This is an important area to explore when looking at your future practice site. You should be compatible in this area with the doctors in your town and area.
The current funding mechanisms make it relatively easy to exclude the poor, the elderly etc., since they are in categorical programs. The higher percentage of elderly, especially in some rural Nebraska towns, makes it a challenge too because older patients take more time. In a given unit of time (lost to memory banks) a PC doc can see about 2000 patients in a usual mixed age mix, but only 800 if the patients are all geriatric. Physicians must learn to bill for the more complex patients and manage time well.
A classic example of cherry picking was the often repeated story of the HMO in Florida offering a party on the second floor for potential new clients, but not having any access for those unable to get there because there was no elevator for those with chronic disease or disability.
In the past, new rural doctors took on all patients and as doctors left or retired or died, then new patients came into their practice. Now with more employed and group situations, it is a bit more up to the physicians who are usually all employed to come up with the arrangements.
In the long term we must continue to choose students who ask these kind of questions, because it is difficult to train these issues into anyone, much less a developing physician with little interest in these areas.
In the long term we need to look at funding mechanisms that reduce the potential for cherry-picking, but doctors or by insurance companies.
I am encouraged by recent moves to reduce inequities in reimbursement. Critical Access hospitals have been a godsend to rural Nebraska. Fee scales have been compressed to increase reimbursement to rural areas and decrease to the most urban. We now have some excellent studies on public health showing the inequities of rural vs urban and remedies are now being put in place. It takes time to build documentation and work on such areas, but these areas are being addressed. Also when we were in DC at the rural policy meeting, I was very impressed with the changes at the top in federal health programs. The top people were very open and conduct public meetings to get feedback. They work with good people who have been beat down for years in overworked jobs with a lot of bosses to deal with. You can imagine it takes time for them to open up to constructive feedback and critique. One of the top health aides at the White House has asked us for feedback and we plan to do so.
If you would like to address your question to the rural list serve, I can post it to the group and add your name so that you can see the responses.
Dr. Bowman,
You mentioned the list serve before and I would like to read what others like yourself have to say about all of these topics. Thanks for taking the time to answer my questions. I truly appreciate your effort.
Sincerely,
Michael Borunda