Need help finding a Medicare provider?
-Visit Medicare.gov or call 1-800-MEDICARE
-The Medicare Rights Center offers a national help line that operates Monday through Friday: 1-800-333-4114.
-The state Senior Health Insurance Benefits Assistance Program (SHIBA) has certified counselors to answer Medicare questions at 1-800-722-4134.
When Chuck Martin’s doctor of nine years moved to Salt Lake City, he was suddenly forced to find someone new. He never expected it would be as difficult as it was.
The 81-year-old Tumalo resident has Medicare Advantage. At first, his policy’s insurance carrier directed him to an in-network doctor in Redmond.
When he called to set up an appointment, he was told the doctor wasn’t accepting new patients.
A Google search turned up several primary care providers, but at least four of them also said they weren’t accepting new patients — a line he took as code for not accepting Medicare.
“I was without a doctor for quite a while,” he said.
Martin’s battle trying to find a primary care provider who accepts Medicare is not uncommon in Central Oregon. Many people simply stay with their established doctors when they turn 65 and become eligible for the health care program for seniors and people with disabilities. Others aren’t so lucky. They could be among Central Oregon’s new retirees or people whose doctors moved or retired.
Doctors say Medicare pays them less than what it costs to provide services, which forces them to limit the number of Medicare patients they can accept. That’s especially true for small practices. It’s a longstanding problem, but some feel it’s getting worse. Not only is Bend’s population growing, the number of people on Medicare nationwide continues to tick upward by roughly 2 million each year, according to the Kaiser Family Foundation.
Dr. Christine Pierson, chief medical officer for Mosaic Medical, plans to launch a campaign in the fall to determine, with the help of other providers and stakeholders, whether Medicare patients have adequate access to primary care providers. (Her hunch is no.) If not, what does the community need to fix the problem?
“I think we have a shortage of primary care providers able to provide care to the aging population across the nation,” she said. “In our community specifically, I’ve seen that that population is growing, both because people are aging into it and also because people are moving into our community to retire.”
Martin eventually did find a doctor. He called St. Charles Health System and got an appointment at its new Family Care clinic on Bend’s south side. He had to wait a while to get in, but he said his new doctor is great.
Lisa Goodman, a spokeswoman for St. Charles, said only primary care providers at the health system’s south side clinic are accepting new patients and the current wait time for new patients is about eight weeks. The other clinics are full.
St. Charles providers don’t discriminate based on which insurance program potential patients have, she said.
Medicare patients tend to have more medical conditions just by virtue of their age, so they often take more of a provider’s time than younger patients.
“You’re reimbursed less, but they tend to be higher utilizers,” said Dr. Matthew Rode, one of two primary care providers with West Bend Family Medicine, a small clinic in Bend’s NorthWest Crossing neighborhood. “Not because they want to be or because they’re taking advantage of the system, but because they’re older and older people tend to have more medical programs. It’s ironic, if you will.”
Rode’s clinic hasn’t openly accepted new Medicare patients for years. He said the clinic would not be able to do so and stay financially solvent because the program reimburses only about 60 percent of what private insurers do for the same services.
High Lakes Health Care, a primary care and specialty practice with more than 30 providers and clinics in Bend, Redmond and Sisters, opened its doors without restrictions to new Medicare patients for three years in a row, said Dr. Stephen Mann, High Lakes’ medical director. After that, its providers had to step back and evaluate whether they had enough privately insured patients to balance out the Medicare patients, he said.
“There was so much demand that it just flooded all the practices,” Mann said. “They filled up and they didn’t have room for any more patients.”
Mann couldn’t say how many High Lakes providers are accepting new Medicare patients as it’s a provider-by-provider decision. He said he personally is not because he’s leaving for a sabbatical.
When people become eligible for Medicare, they can enroll in either the basic Medicare program, often referred to as Original Medicare, or in a Medicare Advantage policy, the latter of which is offered by private insurance carriers.
People who opt for basic Medicare often buy private Medigap policies, also known as Medicare Supplements, to help cover things Medicare doesn’t, such as copayments and deductibles.
Some providers interviewed for this article said Medicare Advantage policies tend to reimburse better for services than basic Medicare or Medigap policies. At High Lakes, for example, providers “campaign” for their patients to get Medicare Advantage policies, Mann said.
Rode estimates Medicare Advantage policies reimburse an average of 20 percent more than basic Medicare.
At Bend Memorial Clinic, a large multispecialty provider, eight primary care providers are currently accepting new patients covered under Medicare Advantage policies, while only three are accepting patients with basic Medicare. BMC spokeswoman Katy Wooderson said that’s not because Medicare Advantage reimburses at a higher rate.
Rode’s clinic recently launched a membership program he thinks would be a good option for Medicare patients. Adult patients pay a flat rate of $49 per month in exchange for unlimited office visits, text messaging with their doctor, virtual visits and other services. While Rode doesn’t accept new Medicare patients, people who have Medicare can join his practice under the membership program. In those cases, he doesn’t bill Medicare.
Not a national problem
Nationally, a lack of provider access doesn’t seem to be a huge issue for Medicare patients, said Fred Riccardi, director of client services for the New York-based consumer advocacy organization Medicare Rights Center. His agency’s help line takes more than 20,000 questions per year, and provider access is not one of the more common issues it hears about, he said.
Riccardi said he generally separates Medicare Advantage policies, which have a set list of providers that are considered in a policy’s network, and basic Medicare, which allows patients to see any provider who contracts with the program. Medicare Advantage insurers give their members lists of providers who are accepting new patients. In Martin’s case, however, the provider wasn’t accepting new patients.
“I think there is great incentive for physicians to accept Medicare because there are, I think, 54 million people enrolled in the Medicare program and the program has clear guidelines around services that are covered,” Riccardi said.
While the majority of physicians who participated in a 2015 Kaiser Family Foundation survey said they accepted both Medicare and new Medicare patients, the percent that accepted new Medicare was lower. Only 72 percent said they were accepting new Medicare patients, compared with 93 percent who accepted Medicare overall.
Jeannie Uetz recently tried to make an appointment for her husband, who has a Medicare Advantage policy, with her own primary care physician. The 69-year-old Redmond resident was told the doctor was not accepting new Medicare Advantage patients. That’s after her former doctor told her she had stopped accepting new Medicare patients, but would keep seeing her.
“There is two examples right there of doctors who are trying to get away from taking Medicare,” she said. “I’ve heard it quite frequently from other people that it can be challenging finding a doctor who would take Medicare.”
Martin, a retired computer repairman who has lived in Central Oregon since 1973, is eager to find a solution for the pain in his legs. He’s seen five specialists and had three back surgeries to try to cure the pain that shoots throughout his legs and up into his glutes.
At first, doctors thought it was a back issue, but more recently an Oregon Health & Science University specialist told him it was likely due to arthritic knees. He’s trying a couple remedies, including water aerobics classes at Bend’s Juniper Swim & Fitness Center, to get his weight down.
“Just don’t get old,” he said.