Elderly Alaskans know it is nearly impossible to find a primary care doctor who will accept Medicare insurance. Some legislators are grasping for solutions. One proposed legislation would offer grants to set up Medicare-only clinics or for the expansion of community health clinics to handle Medicare patients. While House Bill 335 contains zip for details, some doctors have expressed ideas on how they would implement the grants. If you are a Medicare client, these details are scary.

http://www.legis.state.ak.us/PDF/26/Bills/HB0335A.PDF

Medicare-only clinics raise many questions, in my mind, especially about quality of care, staff oversight and management:

1. One doctor proposed that a Medicare clinic might have a primary care doctor who would see up to 50 clients a day with nurse practitioners and physician assistants (PAs) handling the rest of the case load. Having one doctor handle so many cases a day is not realistic. Neither would one doctor have time to consult with staff and oversee their management to ensure quality control.

2. PAs and nurse practitioners are able to handle many things, but being able to consult with doctors who represent a range of experience, would further ensure quality care.

3. In order to benefit all Alaskan elders, Medicare clinics would be needed throughout the state, not just Anchorage.

4. Currently, doctors have to limit their Medicare caseload to about 15-20% of their total practice in order to keep the lights on--if they see those clients at all. If a Medicare clinic was established, it would likely cause doctors who ARE seeing Medicare patients, to drop them and request that they use the new clinic. This is perhaps the most serious downside of the Medicare clinic idea.

5. One news article reported that AARP supports the idea of a Medicare clinic. If this is so, one must wonder why. AARP is a for-profit insurance company with non-profit arms that lobby for legislation and products that they then sell to elders through their for-profit organization.

6. Perhaps the best use of the proposed grant funds would be to support Medicare clinics within existing neighborhood clinics, like the Anchorage Neighborhood Health Clinic. The one nice thing about Medicare is that it reimburses neighborhood clinics at a higher rate than other clinics or individual doctors. In most instances, these clinics receive a respectable rate for their services (although still less than what they would receive from private insurance). The allowable reimbursement rate for services provided by primary care doctors, however, is about 50% or less. Keep in mind that specialists get paid more than primary care doctors do (likely because of special testing they do); Medicare clients in Alaska do not generally have a problem seeing a specialist. But many specialists require a referral to get an appointment and this is where staff at a Medicare clinic could help.

Whatever the Alaska Legislature concludes in their effort to help solve the shortage of primary doctors for Medicare clients, the details need to be thought through carefully to avoid unintended side effects.

In the interim, there are other health issues that I wish they’d tackle that in the end will save money and result in a healthier population. For example, if the State provides health insurance for any of us, we should be expected to eliminate unhealthy behaviors--stop smoke, use seat belts and bike helmets, drink responsibly and make a genuine effort to maintain an appropriate weight. Without these expectations, we’re just throwing public money away.

But then all of us should be following the same no nonsense paths to better health.