Why it's so hard to find a doctor for Mom and Dad

Q: I moved my parents, age 93, from Eastern Washington to an assisted-living facility near me in Seattle.

They need a new internist, so I began a search that turned out to be amazingly difficult. I called several clinics and explained that they have Medicare Parts A, B and D and a supplemental hospital plan.

Repeatedly I was told that, because my parents are on Medicare — which doesn't reimburse enough — their doctors are limited in the number of older people they can see, and their practices are already full. I offered to pay privately but struck out there, too. What's going on?

A: There's a certain uniformity to finding a physician under Medicare these days. Rich or poor, if you're 65 or older, you're likely to have similar slim pickings (but more so if you're on Medicare and Medicaid).

What's interesting is that I answered an almost identical question four years ago. Little has changed since, and it's certain to get worse in the future.

"A confluence of many difficult and complex forces — long in the making — is assaulting our health-care system," I wrote then. "Physicians are being hit hard.

"One of the main culprits is the 'overpromise/underfund' dilemma of offering public health-care programs such as Medicaid (for the poor and disabled) and Medicare (for people 65 and over) without sufficient funding, then standing back as demand skyrockets."

As with most things in life, it gets down to dollars. Operating a physician practice is like any business that follows the economic rules of supply and demand, costs and revenues. Sometimes customers don't like the outcomes, but if you're a business trying to survive, there may be no alternative.

Supply and demand

The demand for physician care in geriatrics is obviously growing: More of us are living longer, with life expectancies soaring toward 80 — and many living well beyond. More than 80 percent of Medicare beneficiaries have at least one chronic condition, and 23 percent have five or more, accounting for 68 percent of all Medicare spending.

Advances in medical care have exploded, offering more options for fixing us — hip replacements, heart bypass surgery, cataract surgery — procedures that didn't exist a few decades ago, with more on the way.

As 78 million baby boomers reach old age, demand will fly off the charts.

The supply of geriatric physicians, on the other hand, has never been enough, but now their numbers are dropping, as are those for primary and family-care physicians. Most medical students become specialists, in part because of higher pay. According to a study by our state's medical association, students being trained in family medicine have declined by 52 percent in seven years — due to lower pay, high student-loan debt, fewer training dollars and "the challenges and complexities of caring for an aging population."

Costs and revenues

At the same time, the costs of operating an office have risen due to increases in medical malpractice insurance and personnel. Less than a decade ago, each doctor needed three support staff to keep the doors open; today the ratio is 5 to 1.

But as costs were climbing, reimbursements were going down. In 2002, Medicare cut payments to physicians by 5.4 percent nationally — the fourth cut in 10 years — and more followed. In 2004 and 2005, Congress increased physician rates by 1.5 percent, then froze them for 2006 and 2007. At the same time, overhead costs grew about 10 percent.

The upshot: Many physician practices now limit Medicare patients to 30 percent. Patients with longstanding relationships with a doctor may be able to stay when they convert to Medicare. But those who're approaching a practice for the first time may have rougher sledding (something to consider if you plan to move to another area at retirement).

To find a physician who accepts Medicare, call each doctor's office and ask. A central clearinghouse offered by Medicare is at www.medicare.gov, then go to "Find a doctor" and input your area. It worked sometimes when I tried it, sometimes not, but even Medicare advises you to call each doctor's office for the most up-to-date information.

So why don't physicians who accept Medicare charge their patients higher rates? Because it's illegal. Why couldn't my reader pay for her parents' medical care privately? Because any physician who normally accepts Medicare but decides to charge privately must "opt out" of Medicare by withdrawing from the program altogether. Little wonder a small but growing number of physicians are going "bare" by setting up practices that accept no insurance of any kind, including Medicare, only cash.

All of this is even harder for people old enough for Medicare and poor enough for Medicaid. Medicaid payments to physicians have never been generous, but they've continually declined while the numbers of beneficiaries have climbed.

On top of all of this, the federal government has been trying to cut $65 billion to $70 billion from Medicare and Medicaid for several years.

If successful, and if these cuts target physicians, you can count on having an even tougher time finding a doctor who'll serve you as you grow older.

Liz Taylor's column runs Mondays in the Northwest Life section. With 30 years experience in the aging field, she writes and conducts workshops. E-mail her at growingolder@seattletimes.com or write to P.O. Box 11601, Bainbridge Island, WA 98110. You can see all of her columns at www.seattletimes.com/growingolder.