For patients who are new to Medicare it can be difficult to find a physician. This barrier to healthcare is almost certainly stressful and may even be a source of additional morbidity and mortality.
Many physicians have entered into an agreement with Medicare whereby they agree to accept in payment no more than the allowed amount for their services; this is called accepting assignment. Based on this explanation, physicians who do not accept assignment are paid only 76 percent of the allowed amount by Medicare and are allowed to charge 115 percent of the allowed amount. Thus, patients are responsible for around 38 percent of the (somewhat larger) bill for services when they see physicians who take Medicare but have not accepted assignment (see Table 1).
We are interested in identifying those physicians who are generally unwilling to accept the Medicare allowed amount - or unwilling to accept Medicare at all - for their services. Obtaining treatment from physicians in those specialties will generally be more difficult and more expensive for seniors.
Relationship between specialties and rates of acceptance
Digging into the 2012 CMS data we find that all except 1574 of the 880,644 providers in the database accept assignment. This corresponds to an overall rate of acceptance of 99.8 percent. However, this rate does vary for some specialties.
Included in the data for every provider are both therapeutic specialty and an indicator of whether the provider accepts assignment. We can check whether the fraction of providers who accept assignment varies by therapeutic area. If there are particular types of providers who are significantly less (or more) likely to accept assignment then we can assume that the allowed payment amounts for procedures performed by those providers are lower (or higher) than the healthcare market would support.
Based on Figure 1, chiropractors in the data set will accept assignment at a rate that is close to 16 times less than the general population. There are some clinical trials demonstrating that chiropractic therapies compare favorably to muscle relaxers for the treatment of lower back pain and neck pain. However, the evidence supporting chiropractic manipulation is controversial at best. In addition, there is the potential for serious adverse events such as stroke caused by tearing of the vertebral artery.
Other specialists that are particularly unlikely (relative to baseline) to accept assignment are psychiatrists, oral and maxillofacial surgeons, optometrists and dermatologists. However, while the relative rates of accepting assignment vary, the absolute probability of accepting assignment conditional on accepting Medicare at all is still quite high – around 97.5 percent for Chiropractors. Thus it is generally true that physicians who accept any payments from Medicare are very likely to accept assignment.
However, there is no legal compulsion for physicians to work with Medicare. How many providers are not listed in the Medicare data release because they are never paid by Medicare?
Specialists who are less likely to see any Medicare patients
The physician’s specialty book published by the Association of American Medical Colleges lists physicians by specialty. Included in that census are 656,000 physicians broken into 36 different specialties. For comparison, there are 560,000 unique physicians (healthcare workers with either an MD or DO) in the CMS data set. If there are particular specialties in which physicians are systematically avoiding (or seeking out) Medicare patients then the proportion of physicians in those specialties relative to the group will be different between Medicare and the overall physician census. For example, the census data list 7,706 physicians who specialize in Child Psychiatry. Considering the age restriction associated with enrolling for Medicare, it shouldn’t be a surprise to learn that there are no Child Psychiatrists listed in the CMS data.
Figure 2 shows how estimates of the number of physicians in each specialty differs when conducted with these two disparate data sets. Notice that there are some elements of this figure that suggest that the analysis makes some sense. For example, because Medicare patients are older one would expect there to be far more pediatricians in the census population – an assumption that is clearly born out in the data. In the opposite direction, emergency physicians are not allowed to turn away any patient with a medical emergency. As a result one would expect almost every emergency physician to take Medicare – the alternative would be to bill elderly patients for the full cost of emergency care (this result is also validated in our original analysis on rates of acceptance, see Figure 1).
Based on this analysis we see that ophthalmologists are more heavily represented in the Medicare physician population than they are in the general census. This may indicate that diseases of the eye are more prevalent in the elderly. On the other hand, a report in the New York Times in April of 2014 on a physician in south Florida who was paid $21 million by Medicare in 2012 would suggest that there may be a strong financial incentive for ophthalmologists to accept Medicare patients.
Based on both this analysis and on the analysis of acceptance rates (Figure 1), the Medicare fee schedule does not appear to be attractive to psychiatrists. It is clear that psychiatric illness places a financial burden on our healthcare system. What is somewhat more controversial is deciding what can be done about it. Despite tremendous ongoing effort to study the efficacy of psychiatry and psychiatric medications, there is a baseline mistrust of the field and a social stigma associated with receiving psychiatric care. Perhaps this also influences payment decisions made by CMS.
Results
The decisions that Medicare makes have a tremendous effect on the types of therapies that are made available to seniors. By choosing to put financial pressures on procedures that are most typically performed by certain physician specialists Medicare is decreasing the availability of those procedures. For the specialties in question, it may be that further proof that they benefit patient health is required for increased acceptance.
Many physicians have entered into an agreement with Medicare whereby they agree to accept in payment no more than the allowed amount for their services; this is called accepting assignment. Based on this explanation, physicians who do not accept assignment are paid only 76 percent of the allowed amount by Medicare and are allowed to charge 115 percent of the allowed amount. Thus, patients are responsible for around 38 percent of the (somewhat larger) bill for services when they see physicians who take Medicare but have not accepted assignment (see Table 1).
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| Table 1. Comparison of costs between physicians who accept assignment and those who do not. |
We are interested in identifying those physicians who are generally unwilling to accept the Medicare allowed amount - or unwilling to accept Medicare at all - for their services. Obtaining treatment from physicians in those specialties will generally be more difficult and more expensive for seniors.
Relationship between specialties and rates of acceptance
Digging into the 2012 CMS data we find that all except 1574 of the 880,644 providers in the database accept assignment. This corresponds to an overall rate of acceptance of 99.8 percent. However, this rate does vary for some specialties.
Included in the data for every provider are both therapeutic specialty and an indicator of whether the provider accepts assignment. We can check whether the fraction of providers who accept assignment varies by therapeutic area. If there are particular types of providers who are significantly less (or more) likely to accept assignment then we can assume that the allowed payment amounts for procedures performed by those providers are lower (or higher) than the healthcare market would support.
 |
| Figure 1. Probability of accepting assignment by specialty. The graph shows a subset of specialties that are statistically different from the baseline acceptance rate. |
Based on Figure 1, chiropractors in the data set will accept assignment at a rate that is close to 16 times less than the general population. There are some clinical trials demonstrating that chiropractic therapies compare favorably to muscle relaxers for the treatment of lower back pain and neck pain. However, the evidence supporting chiropractic manipulation is controversial at best. In addition, there is the potential for serious adverse events such as stroke caused by tearing of the vertebral artery.
Other specialists that are particularly unlikely (relative to baseline) to accept assignment are psychiatrists, oral and maxillofacial surgeons, optometrists and dermatologists. However, while the relative rates of accepting assignment vary, the absolute probability of accepting assignment conditional on accepting Medicare at all is still quite high – around 97.5 percent for Chiropractors. Thus it is generally true that physicians who accept any payments from Medicare are very likely to accept assignment.
However, there is no legal compulsion for physicians to work with Medicare. How many providers are not listed in the Medicare data release because they are never paid by Medicare?
Specialists who are less likely to see any Medicare patients
The physician’s specialty book published by the Association of American Medical Colleges lists physicians by specialty. Included in that census are 656,000 physicians broken into 36 different specialties. For comparison, there are 560,000 unique physicians (healthcare workers with either an MD or DO) in the CMS data set. If there are particular specialties in which physicians are systematically avoiding (or seeking out) Medicare patients then the proportion of physicians in those specialties relative to the group will be different between Medicare and the overall physician census. For example, the census data list 7,706 physicians who specialize in Child Psychiatry. Considering the age restriction associated with enrolling for Medicare, it shouldn’t be a surprise to learn that there are no Child Psychiatrists listed in the CMS data.
 |
| Figure 2. Number of physicians who take payments from Medicare compared to a general census of physicians conducted by the Association of American Medical Colleges. Physicians specializing in pediatrics or preventive medicine are under-represented among those taking payments from Medicare. Specialists in ophthalmology and emergency medicine are over-represented. Chiropractors are not included in this graph because they are not included in the census data. |
Figure 2 shows how estimates of the number of physicians in each specialty differs when conducted with these two disparate data sets. Notice that there are some elements of this figure that suggest that the analysis makes some sense. For example, because Medicare patients are older one would expect there to be far more pediatricians in the census population – an assumption that is clearly born out in the data. In the opposite direction, emergency physicians are not allowed to turn away any patient with a medical emergency. As a result one would expect almost every emergency physician to take Medicare – the alternative would be to bill elderly patients for the full cost of emergency care (this result is also validated in our original analysis on rates of acceptance, see Figure 1).
Based on this analysis we see that ophthalmologists are more heavily represented in the Medicare physician population than they are in the general census. This may indicate that diseases of the eye are more prevalent in the elderly. On the other hand, a report in the New York Times in April of 2014 on a physician in south Florida who was paid $21 million by Medicare in 2012 would suggest that there may be a strong financial incentive for ophthalmologists to accept Medicare patients.
Based on both this analysis and on the analysis of acceptance rates (Figure 1), the Medicare fee schedule does not appear to be attractive to psychiatrists. It is clear that psychiatric illness places a financial burden on our healthcare system. What is somewhat more controversial is deciding what can be done about it. Despite tremendous ongoing effort to study the efficacy of psychiatry and psychiatric medications, there is a baseline mistrust of the field and a social stigma associated with receiving psychiatric care. Perhaps this also influences payment decisions made by CMS.
Results
The decisions that Medicare makes have a tremendous effect on the types of therapies that are made available to seniors. By choosing to put financial pressures on procedures that are most typically performed by certain physician specialists Medicare is decreasing the availability of those procedures. For the specialties in question, it may be that further proof that they benefit patient health is required for increased acceptance.
