The Search for Affordable HealthcareSep 01, 2015 ● By Frisco STYLE
Al Brewster, a Frisco resident and active member of the Rotary Club of Frisco, qualifies for Medicare and has personally experienced the difficulty associated with finding a facility that offers care that will be covered by his insurance. When he first arrived in Frisco, in 2006, most practitioners accepted Medicare, but that has changed. Over the last few years, his wife’s general practitioner, as well as the emergency care center near his house, have both stopped accepting Medicare because of its lack of financial gain for healthcare providers. When Mr. Brewster recently contracted pneumonia during a trip to South America, it took much longer than necessary to receive care because of the inability to find a facility that accepted Medicare. “Fortunately, my lung problem was not an ‘immediate’ requirement,” he said. “I wonder what happens when someone is badly injured and arrives at one of these facilities.” This situation is only part of the problem that needs to be addressed in our area, considering the large number of senior citizens that reside in Frisco. While it can be difficult to find a facility among the rapidly dwindling places that accept Medicare, they do still exist.
Know the FactsTo understand your options, it helps to gain a clear understanding of what Medicare really is. The world of insurance can be complicated and confusing, but there are resources available to help you navigate your way through the information. The two main ways to get Medicare coverage are through Original Medicare and the Medicare Advantage Plan. Original Medicare involves Part A (hospital insurance, including inpatient care at a hospital, lab tests and surgery) and Part B (medical insurance, including doctor and outpatient care), and the coverage is provided directly by Medicare. Part A should automatically be paid for through Social Security with the money a working person who is 65 or older has been collecting over the years. Plan B, however, requires a monthly premium. With this original plan, you have your choice of whatever doctor or facility that accepts Medicare. With the Medicare Advantage Plan, Part C (both A and B, as well as occasional extra coverage) is included, and coverage is provided by private insurance companies that are approved by Medicare. The insureds have to choose facilities that accept this particular plan or they may end up paying more than is required. This option also costs an extra monthly premium in addition to the Part B premium. The insured usually also gets Part D with the Advantage Plan, which includes prescription drug coverage.
Reliable resources like the medicare.gov website can help you simplify the complicated process of finding healthcare that is right for you. This website has explanations of Medicare plans, as well as lists of available healthcare facilities that accept your particular plan. It also has a calculator that will determine when you are eligible to apply for Medicare and how much your premium will be. There are links to financial counselors who can sit down and explain plans in person, so there is a chance to ask questions. Once you understand how your plan works, it is time to start the search for places that will accept it. Each individual facility chooses for itself whether or not to accept Medicare. Unfortunately, several companies have changed their acceptance policies, making it more difficult for senior citizens to get the proper care that they deserve, particularly if their need is immediate or urgent.
Reasons for ChangeSo, why have so many companies stopped accepting Medicare? A major part of the problem began in 2008, when Medicare paid doctors 78 percent of what they got from private insurers. Mr. Brewster said that in a recent conversation with his doctor, he was told the doctor loses $37 every time he sees a Medicare patient. As the baby boomer generation reaches the age to enroll for Medicare, the need is quickly outweighing the resources. A survey by the Texas Medical Association found that 42 percent of all Texas physicians surveyed no longer accepted all new Medicare patients because of the lack of profit.
Doctors are growing apprehensive about accepting Medicare because of the loss of income, but there are still doctors who will accept this insurance. In a recent conversation, Marsha Niven, a PA-C advanced practice provider with Clinic 21, said that her company chooses to accept Medicare because “it gives us a bigger presence in the local neighborhood.” Cutting out Medicare coverage eliminates a large percentage of the population that could be helped by the facility’s services. She said that while she cannot speak for specific facilities that do not accept Medicare, she thinks they have stopped accepting it because “Medicare payments are substantially less than the payments a facility receives from private insurance, even when the exact same services are rendered.” She added, “Without a mix of privately insured patients and Medicare insured patients, many practices and facilities cannot keep their doors open.”
Be PreparedThere are facilities in Frisco to choose from when selecting a destination to receive care, including clinics for non-life-threatening emergencies and freestanding emergency centers. Several facilities offer both emergency care and urgent care. One of the latest, more relevant healthcare trends, according to Ms. Niven, is the differentiation between services in an actual emergency room or at your doctor compared to those at an urgent care facility. She recommends “utilizing your primary care provider when appropriate, but also utilizing a facility like Clinic 21 for urgent needs that arise, or when your primary care physician is not available.”
In a life-threatening emergency, like a stroke or heart attack, it is best to go to the emergency room. In any other everyday emergency, like a cough or muscle sprain, visiting an urgent care facility is the financially efficient option. According to one emergency room website, because of the newness of the freestanding emergency center concept, the Center for Medicare Services (CMS) does not recognize them as potential providers of healthcare. Therefore, some facilities are prohibited from billing CMS by federal law. This is an important factor to take into account when trying to find somewhere to get care. However, in the case of an emergency, it is important to find whatever is located close and to worry about insurance later. Health in an emergency comes first. As a precaution, Mr. Brewster recommends seeking out a healthcare provider that accepts your insurance earlier rather than later. He said, “You will know in advance where to go and not duplicate my waste of time and effort at hospitals.”
Learning about the best options for your future healthcare can help eliminate any panic or increased financial strain. Get the facts and do your research to ensure a stress-free approach to dealing with Medicare.