The Folly of Medicare’s One-Ailment-per-Visit Rule

The problem in medicine is not merely that all the prices are wrong. A lot  of very important things doctors can do for patients are not even on the list of tasks that Medicare compensates.

In addition, Medicare has strict rules about how tasks can be combined. For example, special-needs patients typically have five or more comorbidities—a fancy way of saying that a lot of things are going wrong at once. These patients typically cost Medicare about $60,000 a year, and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.

Under Medicare’s payment system, however, a specialist can bill Medicare the full fee only for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They will generally get no payment for treating four additional problems. Since doctors don’t like to work for free or see their income cut in half, most have a one-visit-one-condition policy. Patients with five morbidities are asked to schedule additional visits for the remaining four problems with the same doctor or with other doctors. The type of medicine that would be best for the patient and that would probably save the taxpayers money in the long run is the type of medicine that is penalized under Medicare’s payment system.

Take Dr. Richard Young, a Fort Worth family physician who is an adviser for the federal government’s new medical Innovation Center. Here’s how Jim Landers of the Dallas Morning News explained it:

[When Young] sees Medicare or Medicaid patients at Tarrant County’s JPS Physicians Group, he can only deal with one ailment at a time. Even if a patient has several chronic diseases—diabetes, congestive heart failure, high blood pressure—the government’s payment rules allow him to only charge for one.

“You could spend the extra time and deal with everything, but you are completely giving away your services to do that,” he said. Patients are told to schedule another appointment or see a specialist.

Young calls the payment rules “ridiculously complicated.”[1]

For more on the folly of the government-shaped third-party payment system, please see my Independent Institute book, Priceless: Curing the Healthcare Crisis.

Note:

1. Jim Landers, “Trust your doctor to save?” Dallas Morning News, January 9, 2012, http://www.dallasnews.com/business/columnists/jim-landers/20120109-trust-your-doctor-to-save.ece.