It used to be that primary care physicians would keep patients even after they aged into Medicare. That is still the case in most instances but more and more Anchorage primary care physicians have opted out and are setting the patients loose.

The crisis is getting worse. What was once a slow leak is becoming a steady stream.

Dr. George Rhyneer, Sr. explained to me his plans for a Medicare clinic about a year ago in the Providence Alaska Medical Center physician's lounge. It was an informal conversation with a few other doctors. It was not surprising that Dr. Rhyneer was showing interest because the cardiologists in town tend to provide a lot of care to the Medicare patients including some primary care.

The model has some problems.

The idea is to hire one doctor to start assisted by physician extenders (nurse practitioners (NPs) and physician's assistants (PAs))and part time help from other physicians.

Medicare patients tend to be complicated with long problem and medication lists. It is hard to see 30 or 40 patients a day and do it well. The teaching in medical school and residency is to try and fix one problem at each visit but that tends to be wishful thinking.

Physician extenders do a fine job. That is especially true if they are trained for specific purposes. Gastroenterology practices often utilize their skills in follow up and treatment of chronic diseases such as Hepatitis C and Inflammatory Bowel Disease.

There are limitations. Complicated patients with multiple medical problems requiring cross specialty thinking are not the strength of physician extenders. It can work but every system that it works in has extensive physician back-up. Those systems also tend to pair a physician on a team with the extender.

It is hard to imagine NPs and PAs seeing a large volume of Medicare patients without significant assistance. It is hard to imagine highly trained internists handling 30, 40, or 50 patients a day.

The idea that the billing could be simplified seems a tough sell. If the clinic can qualify under laws regarding under served populations it could simplify the billing to a degree. It would get higher reimbursement. There is a catch in that greater reimbursement comes with greater expectations for other care.

At some point there will need to be a committed primary care physician to run the clinic. The idea is that the salary can be made competitive. It better be because taking care of complicated patients is rewarding but also taxing. The grass will be greener in other areas of town for most providers.

The same could be said of any employee of this clinic. It is harder work to take care of sicker patients. The employees from management to medical assistants to secretaries to billing staff would all need to be convinced to stay and not jump ship to easier and better paying alternatives.

It may be a place where retired physicians could dedicate time to fill in the need. I will admit to thinking about such a place as a way to keep me interested and give back when I retire. Internal Medicine sub specialists do tend to keep some of their primary care knowledge around.

It may also be a place where other health care workers might be willing to dedicate time.

There is another problem looming. Specialty care never used to be an issue. Now, more and more, it is starting to become a problem.

Every Alaska gastroenterologist sees Medicare patients without any restrictions. That is not the case for every sub specialist and my practice has performed a handful of surveillance colonoscopies for polyps on patients cut loose by other doctors in town performing the procedures.

My office is also turned away when they call for specific sub specialty surgical services on Medicare patients. To date there has been a way to get the patients services but the problem is growing.

Once it starts, it only gets worse. It started in primary care with a few providers. The Medicare patients were then funnelled into the fewer options left. That created greater pressure on those providers and they stopped seeing Medicare.

Falling Medicare reimbursement would precipitate a major crisis if the Medicare Sustained Growth Formula is ever allowed to go forward without Congressional modification.

Medicare has more problems beyond bankruptcy and acceptance on the horizon. The system is unsustainable and wholesale changes are needed. Simply trying to make something work under the present system is a folly.

Brainstorming is always a good thing. It is not that a Medicare clinic is a bad idea but is a Band-Aid. It has benefits but tt will not fix any long term issue.

Godspeed to any Medicare clinic that may open and let it provide the best possible service to patients. Most physicians including myself will do what we can to help as we have with Project Access and free care programs.

Unfortunately, it is unlikely to keep anybody from calling on St. Jude.