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<<   作成日時 : 2009/04/02 20:15   >>

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 メディケアから脱退する医師たち
 多くの人は、メディケア(高齢者公的医療保険)として適格になると、保険の援助を急に止められていると気づく。しかし、医師の中には、メディケアから脱退したり、新たな患者受け入れをしない人がいる。
 理由として、返還率があまりに低く、事務手続きが多いことが上げられる。医師にかかるときにはメディケアが利用できるか確認が必要で、65才に達する前にメディケア受け入れ医師を見つけておく必要がある。内科医、特にプライマリケア医を探すのは容易でない。
 例として、ニューヨークのNew York-Presbyterian Hospitalと提携した93人の内科医の内37人がメディケアを受け入れているのみである。
 米国内科学会の推計では、2025年に35,000-45,000人の内科医が不足する。メディケアの受け入れはますます困難となるだろう。2008年6月の報告では、メディケア受給者の29%が医師を見つけるのに問題があったとしている。テキサス医師会の2008年の調査では、州医師の58%が新たなメディケア患者を受け入れたが、プライマリー・ケア医師ではわずか38%にすぎなかったと。
 予約なしでも簡単な外科処置や処方も受けられる米国内の18,000の緊急医療センター“urgent care centers”ではほとんどがメディケアを扱っている。
 年間1,600-1,800ドルを払うと、「コンシェルジェ」または「ブティック」医療が、メディケアで受けられる。
 メディケアなしで「コンシェルジェ医療」を受けるには、年間料金は15,000ドル程度となる。全国の約500人の登録医師はwww.conciergemedicinemd.comで見られる。
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Doctors Are Opting Out of Medicare
http://www.nytimes.com/2009/04/02/business/retirementspecial/02health.html

By JULIE CONNELLY
Published: April 1, 2009

EARLY this year, Barbara Plumb, a freelance editor and writer in New York who is on Medicare, received a disturbing letter. Her gynecologist informed her that she was opting out of Medicare. When Ms. Plumb asked her primary-care doctor to recommend another gynecologist who took Medicare, the doctor responded that she didn’t know any ― and that if Ms. Plumb found one she liked, could she call and tell her the name?

画像Chris Richards for The New York Times
RX Harold and Margret Thomas, with Dr. Steven Knope, a concierge doctor in Tucson who charges a yearly retainer.

Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them. Some doctors ― often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists ― are no longer accepting Medicare, either because they have opted out of the insurance system or they are not accepting new patients with Medicare coverage. The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.

When shopping for a doctor, ask if he or she is enrolled with Medicare. If the answer is no, that doctor has opted out of the system. Those who are enrolled fall into two categories, participating and nonparticipating. The latter receive a lower reimbursement from Medicare, and the patient has to pick up more of the bill.

Doctors who have opted out of Medicare can charge whatever they want, but they cannot bill Medicare for reimbursement, nor may their patients. Medigap, or supplemental insurance, policies usually do not provide coverage when Medicare doesn’t, so the entire bill is the patient’s responsibility.

The solution to this problem is to find doctors who accept Medicare insurance ― and to do it well before reaching age 65. But that is not always easy, especially if you are looking for an internist, a primary care doctor who deals with adults. Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare, according to the hospital’s Web site.

Two trends are converging: there is a shortage of internists nationally ― the American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs ― and internists are increasingly unwilling to accept new Medicare patients.

In a June 2008 report, the Medicare Payment Advisory Commission, an independent federal panel that advises Congress on Medicare, said that 29 percent of the Medicare beneficiaries it surveyed had a problem finding a primary care doctor or specialist to treat them, up from 24 percent the year before. Those looking for a primary care doctor had more difficulty. A 2008 survey by the Texas Medical Association found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.

Currently, about 40 million Americans have Medicare insurance, according to medicare.gov. Coverage is provided to those 65 or older, some younger disabled people and people of all ages with end-stage renal disease.

Those approaching Medicare eligibility should talk to their doctors. Even doctors who won’t take new Medicare patients may be willing to allow their existing ones to remain in their care. If they are not, it’s advisable to start looking around. But the search will be easier for people who start early.

“If you have just moved into town and are 64,” said Dr. Jeffrey P. Harris, an internist and the president of the American College of Physicians, “it is easier for you to see a doctor than if you had just moved into town and are 65.”

Before giving up on a doctor who will not accept Medicare, a patient should ask about signing a private contract that stipulates the patient will be responsible for paying the doctor’s fees and lists exactly what those fees are and what they cover. Some doctors may be willing to negotiate and tailor prices to what patients can afford.

For example, a doctor who charges younger patients with employer health coverage $250 for an office visit might be willing to accept $175 from an older patient who pays cash and requires no insurance claims.

“I have a lady of 93 who pays me $5 a visit, and for her that’s real money,” said Dr. Steven D. Knope, an internist and private contract doctor in Tucson. “I charge her because then she listens to what I say.”

How do you find a doctor who accepts Medicare? The Web site www.medicare.gov provides a list of enrolled doctors. Other sources are state medical societies and local hospitals, most of which have online directories of doctors. But that’s no guarantee they will see new patients.

Other options are also available. Roughly 18,000 walk-in, stand-alone urgent care centers in the United States are staffed with doctors who set simple fractures, take X-rays, do minor surgery, diagnose ailments and write prescriptions. By far the majority of these centers take Medicare.

Although they were never intended to provide continuing care, “our primary care practice is growing more than anything else,” said Dr. Franz Ritucci, who is medical director of the American Academy of Urgent Care Medicine and practices at America’s Urgent Care in Orlando, Fla., a chain of walk-in centers that also has clinics in Columbus, Ohio.

The centers are open 12 to 18 hours a day and patients do not need an appointment, though they may have to wait. Some centers allow appointments to see a specific doctor for follow-up.

“If you can hook up with a primary care provider in an urgent care center who is willing” to provide continuing care, said Dr. J. James Rohack, a cardiologist who is president-elect of the American Medical Association, “then yes, it’s an option.”

Type “urgent care centers” into a search engine and thousands come up. In June, the Academy of Urgent Care Medicine plans to add a list of centers it has accredited to its Web site, www.aaucm.org.

Another, more expensive option is concierge or “boutique” care, which comes in two forms. In the most popular kind, doctors accept Medicare and other insurance, but charge patients an annual retainer of $1,600 to $1,800 to get in the door and receive services not covered by Medicare, like annual physicals. Before signing up and paying the retainer, patients should get a written agreement spelling out which services the doctor will bill Medicare for and which the retainer covers. And always check carefully for double-billing.

The other form of concierge medicine ― doctors who have opted out of Medicare ― is more expensive still. Fees range as high as $15,000 a year and cover office visits, access to the doctor when care is needed, referrals to specialists and thorough annual physicals.

Dr. Knope, the author of “Concierge Medicine: A New System to Get the Best Healthcare,” has this kind of practice in Tucson. His patients sign a contract agreeing to pay $6,000 a year for individuals and $10,000 a year for couples. The fee covers office visits, physical exams and phone consultations, and Dr. Knope will meet patients in the emergency room, see them in the hospital and occasionally make house calls.

A list of about 500 concierge doctors throughout the country is available on Dr. Knope’s Web site, www.conciergemedicinemd.com.

Is the care worth the money? Harold and Margret Thomas, who are in their mid-70s and live in Cincinnati, spend the winter in Tucson. After many phone calls, the couple were unable to find an internist in Tucson who took new Medicare patients, so they signed with Dr. Knope in 1996. Five years ago, when Mrs. Thomas developed a blinding headache, her husband called the doctor at 8 o’clock one night, and he, suspecting an aneurysm, insisted they get to the emergency room immediately.

The doctor met them and ordered an M.R.I. and a CT scan. The tests revealed an aneurysm, and Dr. Knope found a surgeon who quickly operated. Medicare paid for the emergency room, the surgery and the hospital stay.

“If there were a concierge practice in Cincinnati, I’d be part of it there, too,” Harold Thomas said.

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