How This Physician Escaped Medicare
How Does a Physician Escape Medicare?
I have a confession to make. I have been planning my escape since the first day I set foot in the office as an attending physician. The writing was on the wall. It’s not that I didn’t love the idea of being a physician. It’s not that I was already burned out. The truth is, I saw the state of healthcare (at that time) untenable. Back in 2002 I recognized that the mountain of compliance, politics, and electronic hand cuffs were going to turn my once noble profession into a disaster. My choice, at the tender age of 29, was to do everything in my power to escape Medicare.
Medicare is the governmental payor for the majority of health care delivered in America. Not only does it control the purse strings, but also helps regulate the legal and administrative compliance involved in the practice of medicine.
Being a primary care physician with a bent towards geriatrics, there was no way I was going to spurn my main patient source.
So I had to get smart.
Getting to 5X
In the beginning of my career, I couldn’t afford to escape Medicare completely. The majority of my patients were elderly and used the government as their main source of insurance. I did see, however, to limit my future liability, I needed to gain a secure economic footing.
So I spent the next decade building up my W2 wages by hustling at my main hustle. My beginning salary of X quickly multiplied into 5X over the years. I did this by front loading the sacrifice, working extra hours, and leaping before I looked into new opportunities.
Taking a page from Jim Dahle’s book of living like a resident, I didn’t allow life style inflation to erode my new found savings. Instead, I invested in the stock market and bought rental properties. If I truly wanted to escape Medicare, I needed a strong financial cushion or even a perpetual money machine to buy my freedom.
Uncorrelated Revenue Streams
I like to think of Medicare as the stock market of medicine. You can rely on it for steady returns but you are a fool if it is your only game plan. For me, my plan to escape Medicare required other revenue streams within medicine that weren’t dependent on the government. Enter in the lazy side hustle.
Medical expert work, nursing home directorship, hospice and palliative care consulting. Every one of these opportunities paid a stipend from a private company. Then I started a concierge medical practice where patients paid extra fees out-of-pocket for services not covered by insurance. Therefore, I built a base of money and income related to medicine but free from this gargantuan governmental behemoth.
I also created revenue streams completely unrelated to medicine like real estate and blogging.
Financial Independence
My high W2 wages, reasonable lifestyle, and uncorrelated revenue streams jet rocketed me to financial independence. I created enough money to allow the stock market and other relatively passive ventures like real estate help me escape Medicare.
Mind you, I have not mentioned retirement anywhere. I haven’t even spurned Medicare completely. I still see patients in the nursing home and bill accordingly. My hospice work is made possible by Medicare’s rules requiring physician certification for new admissions even though my paycheck comes from the business.
Final Thoughts
I realized early in my career that I needed to escape Medicare. This colossal governmental entity is one of the main reasons practicing medicine is so unenjoyable today. Between arcane billing and coding rules, mountains of compliance, and the ever increasing risk of audits, I had enough.
I didn’t want to be another one of those burned out physicians, so I spent a decade building a plan that would ensure my freedom.
And it did.
If Medicare decides it wants to cut physician payments 50% over the next yer. So be it.
It won’t affect me in the least.
Smart business move for sure.
In anesthesia, we get reimbursed by CMS at a fraction of what we are supposed to because someone made a clerical error for Medicare reimbursement for our specialty. You can imagine how quick they were to fix that – they never did.
TPP
Yep. The farther my revenue is from Medicare the better.
I understand your point. What’s your opinion on the other side. If you were turning 65, would you opt for Medicare with a supplemental?
Yes. I would. I think there will always be good providers or university systems that will accept it. I just think it is hard on the physicians.
Medicare is definitely a love hate relationship. A lot of my practice dollars come from Medicare or from the effects of Medicare (if Medicare reduces payment for a particular service you can bet that the private insurance companies have a corresponding drop soon as well). I am not a fan of being constantly under threat of reimbursement cuts or them creating more hoops to jump through in order to keep payments the same.
The threats are what is so tiring.
I think CMS’s goal is to drive physicians out of medicine and replace them with substitute cheaper “providers”. Eventually an AI will possess the expertise. AI’s are in some respect monte carlo engines that rank order probability. If you’re able to input signal (lab values, physical exam, history) the engine with remove the noise and output a diagnosis and “standard” treatment. The algorithm will improve and become deadly in their accuracy, but treatment will be commoditized. Right now medicine is practiced like a bunch of Italian cooks, each one having their own special take on what goes into a meat ball. After AI there will be a standard outcome based meatball. The meatball won’t be based necessarily on science or utility but on politics and cost. If you have heart disease and two choices of treatment say bypass and Nitrates/ARB/Beta Block/Anti-coag they will look at “longevity” as the outcome, not quality of life. Let’s say longevity for each is 15 years. With bypass you can spend your 15 years climbing mountains since CV flow is restored. With medical management you spend your time in a rocking chair because it has not. The solution to heart disease might be a radical change in diet away from hyperinsulinemia caused by grain but we will never get there because only medical management will be funded. The government will mandate standardized generics on medicine and that will freeze in stone as well. Any competition will be eliminated with “Medicare for all”. Welcome to the VA
I think you paint a realistic picture.
gasem, the key is input physical exam, a rapidly growing lost art I’ve yet to see a nurse or nurse practiotioner even come close to and most new doctors are sadly lacking at- I spend most of my time with new residents teaching physical exam and observation skills as they have all become diagnostic test dependent for stuff, I can easlily predict the test or better predict the RIGHT test as SO many totally unnecessary tests are done as they haven’t done an exam…so that knee pain gets a knee MRI, , even though the knee is not the problem, as they treat the knee, the hip starts to hurt, it gets an MRI, but the hip is not the problem, another 6 weeks of PT and FINALLY someone notices this patient walks funny, as they had foot drop… seriously….not hard to see if they even walk into the office, yet they will have documented a normal neuro exam and gait that was never ever checked, I can attest to this as I’ve had 4 ER visits and 3 surgeries, and not 1 of my doctors has even done a partial neuro exam, documented my gait or other findings of which they are significant and vast, nor has a single nurse, not inpatient or outpatient in the last 15 years….I have had several surgeons say- hey I can replace those knees and you will walk so much better! I’m like- you are an idiot! I don’t walk bad because of my knees, try glut medius rupture 1 hip, sciatic nerve in posterior thigh was injured on other leg, spasticity -mild on same side, and L5 weakness on right, then we can move to the c6-7 weakness on down on the right, a knee replacement will not fix my gait but may fix my crooked knees. AI is totally dependent on us taking the time to enter pertinent and accurate information and obtaining the same from our patients and caregivers, and as long as patients don’t remember, lie outright etc…that will have its problems and as long as care givers fail to do an even adequate let alone thorough exam it will fail. I’ve worked with the folks that teach physical exam to nurses, its sad …totally inadequate and often wrong; hte ones who excel took time to learn it elsewhere( yes there are some good ones out there-sadly not many)
The art of the physical exam has been lost. Physical exam and common sense.
I disagree. Medicare was my best and most reliable payer. And easiest to work with and provide for my patients. If I wanted my patient to have an MRI of his knee, I would just order it. I didn’t have to get on the phone and call someone in St Louis and beg for the MRI.
And as far as pay to me, once my fees were submitted to Medicare, I got paid in two weeks.
I repeat: Medicare was best for my patients! And that is what mattered to me.
There is no question that Medicare is reliable. But is has fundamentally changed how doctor’s see patients. Our mastery of the patient interview and exam disrupted by compliance, paperwork, and forced into clunky electronic medical record systems. Thousands of dollars lost per practice on silly coding and billing that has only the function of serving medicare requirements. Medicare may pay easily, but it has fundamentally changed the practice of medicine and some of those changes are very negative and deeply dangerous to our patients.