Iam writing with regard to the article in the December 21, 2007, issue
titled "Part D Hassles Driving Treatment Decisions."
I can't argue with any of the findings in the study that was cited. I sit
shaking my head waiting for a study to tell me something I don't already live.
I don't have the luxury of administrative time of 45 to 71 minutes for every
hour of clinical care. Who does? I severely limit the number of Medicare
patients I see because I cannot actually afford to see them. As a solo
practitioner in an office with limited contract staff for help, I take the
time I need to give the patients a thorough assessment and sufficient
follow-up. I spend 25 minutes for medication management visits with the
complicated elderly patients I do see. Anyone familiar with Medicare
reimbursement knows the problem there.
Second-guessing treatment decisions is not limited to Medicare Part D. One
non-Medicare insurer makes me get preauthorization every time I change the
dose of a medication, and another wants me to explain every time I prescribe a
stimulant medication to an adult because medication for ADHD is approved only
for patients under 18. Then there are the increasingly arcane rules about
authorizing treatment at all. In some cases patients are assured of coverage
for visits, to discover later that I was expected to know that further
treatment would not be covered if the insurer did not receive a call from me
between the first and second visits. When the insurer refuses to pay, the
patient is told that the doctor "failed to obtain authorization."
The real failure is in the refusal of certain companies to initiate contact
with physicians to clarify payment policies so that patients are not caught in
I have watched the psychiatric community in my region slowly withdraw from
all insurance plans, Medicare and non-Medicare alike, in favor of a
fee-for-service practice only. I despair for the patients who are affected by
this nonparticipation. I despair for myself when I see average annual earnings
listed in the trade papers that are more than double what I take home after my
rigidly controlled overhead. I have been an APA member since entering
residency in 1988, and I am uncertain what my dues have purchased for me when
I watch earnings erode, while patient care is compromised.
I love what I do, and I am well regarded in my community. After 11 years, I
am also giving up. I have an opportunity to take a staff position at a local
hospital. If that works out, I will leave behind my office and the patients
who have come to depend on me. It has come down to survival.