Should the AMA Be Giving Members Advice on How to Opt Out of Medicare?

CHICAGO — Should the American Medical Association (AMA) be advising its members on how they can stop accepting Medicare insurance and still stay in business? Members of the AMA House of Delegates seemed divided on that question here Sunday.

“I opted out of Medicare 9 years ago, and I’ve never been happier as a private-practice physician,” said Rebekah Bernard, MD, of Fort Myers, Florida, speaking on behalf of the Florida delegation. “AMA has made Medicare payment reform our top priority, and yet … there is very little political will to increase physician payment. Physicians need to be aware that we have the option of leaving this broken payment system, and perhaps if enough of us take that step, our legislators will hear our pleas to fix the Medicare payment model.”

Bernard was speaking during an AMA reference committee hearing at the association’s annual meeting, in favor of a resolution authored by her delegation that asks for the AMA to develop an educational resource for physicians who want to opt out of Medicare. The resolution has the support of the reference committee holding the hearing, but not everyone agreed that having the AMA do so would be a good idea.

“While we recognize and support physicians’ right to participate or decline participation in a particular insurance plan, we do not feel it is the role of an AMA to instruct or encourage physicians to opt out of any specific program or payment modality,” said Earl Stewart Jr., MD, of Marietta, Georgia, speaking for the American College of Physicians. “As we all know, interactions with insurance plans vary by geography, specialty, and patient demographic, and we are concerned that proactively encouraging opting out of the plan will lead to decreased access to care … This is an equity issue and a rural healthcare access and parity issue. We also believe it is counterproductive to the business and the doing of medicine, and to other potential solutions such as increasing Medicare reimbursement and expanding to include a public option.”

It’s also not a good look for the AMA, argued Pino Colone, MD, a delegate from Howell, Michigan, who was speaking for himself. “It will be played in Washington that ‘Look, on one side, the American Medical Association is pushing for the benefits in Medicare … and on the other side, look at this in the background, they are teaching their physicians to get out of Medicare,’ so it will not be a positive impact on the [AMA],” he said.

Not so, said John Corker, MD, a delegate from Cincinnati, Ohio who was speaking for himself. “I think we can trust our AMA and our advocacy team to provide tools for our physician practices that are on the brink of failure that decide that their last resort is to stop taking Medicare … without necessarily encouraging them to do so,” he said. “I think we can trust our organization to do this in a way that the optics aren’t encouraging doctors not to see Medicare patients, but to reinforce our point and give teeth to our point that our physician practices are on the brink of failure” and may have to do this as a last resort.

Other Medicare-Related Issues

Delegates also discussed another Medicare-related resolution — one from the Society for Cardiovascular Angiography & Interventions (SCAI), along with several other groups, to have the AMA work with the federal government to address a flaw in the Medicare Physician Fee Schedule (PFS) that results in physicians being reimbursed less than their cost for certain high-priced disposable items. “Performance of office-based procedures for diagnosis and treatment are highly effective, cost-effective, high-quality, and convenient for our patients,” said Jeffrey Marshall, MD, of Atlanta, who spoke for SCAI. “Unfortunately, many of these procedures use disposables that are expensive — often upwards of $500.”

“These direct equipment costs for office-based procedures are so expensive they exceed the PFS reimbursement, so patients don’t have an opportunity to get those treatments close to home,” said Marshall. “In essence, the only way that the patients can get those treatments is to travel some distance to a hospital.” The resolution’s suggestion — to have Medicare remove the items from the PFS and reimburse for them separately — “would provide payment for the care delivered. This change is needed to allow for less expensive treatments in office-based setting.”

Several delegates really liked that idea. “The physician fee schedule simply does not accommodate the high price of disposable items that we need to use to treat these patients,” said Eric Dippel, MD, of Davenport, Iowa, who spoke on behalf of the Outpatient Endovascular and Interventional Society in favor of the resolution. “Since 2019, there’s been a 40% reduction in the payments for the practice-expense side of the Physician Fee Schedule; this is in addition to the conversion factor reductions.”

“It is essential to ensure that physicians are adequately paid for their work as well as for supplies and equipment,” said Alain Chaoui, MD, of Peabody, Massachusetts, speaking on behalf of the AMA Council on Medical Service. He noted that the AMA, its Current Procedural Terminology (CPT) editorial panel, and its RBRVS Update Committee (RUC) “have been working tirelessly to address this issue.”

But AMA past president Barbara McAneny, MD, an oncologist in Albuquerque, New Mexico and delegate for the Association for Clinical Oncology , supported referral of the resolution to the Council on Medical Service.

“We can’t figure out whether this will help us or hurt us,” said McAneny, speaking for the association. For example, she said, “In an oncology practice, one has to have a USP-800 compliant pharmacy to mix the drugs. That cost me about half a million dollars to put into my pharmacy and resulted in what we are paid for an infusion to be about $300 less than the cost … We don’t know whether or not pulling that infusion pharmacy requirements [from the fee schedule] will help us or hurt us. So we think that this needs some very significant study.”