Mayo Clinic Family Medicine in Arrowhead Arizona Will No Longer Take Medicare Patients
by Maggie Mahar
The total annual costs for the physical and three office visits would be about $1500, according to the letter that Mayo sent to the 3,000 patients who receive care at the clinic. The letter also informs those patients that they will not be able to transfer their primary care to another Mayo facility.
Michael Yardley, chairman of public affairs of the Mayo Clinic in Arizona, said the changes are necessary because Medicare’s reimbursement rates for primary care are so low. "It has been difficult for us to be able to sustain our own medical practice in a way to provide the best care to patients and for us," he told a local news outlet, youwestvalley.com. “For some the $1500 annual fee- will be cost-prohibitive, and that’s why it’s so painful," Yardley acknowledged. "We have a list of physicians for them that are accepting new Medicare patients. We have done homework in that area, and we have customer service representatives for folks who we are encouraging them to talk to about it."
Keep in mind that the median income for U.S. seniors is $20,000—and that includes Social Security, investment income, pensions, income from part-time work—every penny that comes into the house. This means that half of all seniors rely on less than $20,000 a year—in some cases, far less. This is why $1500 for primary care, in addition to whatever Medicare co-pays and deductibles they face for drugs and other services, could easily be more than many can afford.
In the letter, Mayo said it will continue to accept Medicare for critical care and specialty services as well as lab services and physical therapy—but not routine primary care. (So much for the idea of a “medical home.”)
Mayo warned earlier this year that its operations were struggling. In a March statement, hospital administrators said income from patient care dropped to $205 million in 2008, down from $293 million in 2007. The hospital also estimated unpaid portions of Medicare and other senior programs at $765 million for the year.
Under health care reform, primary care physicians are likely to receive higher fees. The House bill promises increases of 5 to 10 percent (depending on whether there is a shortage of primary care physicians in a given area), plus bonuses for physicians who deliver higher quality care.
But this Mayo Clinic isn’t going to wait for reform. According to hospital officials “this is a two-year-pilot program.”
It’s not entirely clear what the program is piloting.
When I called Mayo headquarters in Rochester Minnesota a source told me that Mayo CEO Denis Cortese is “not available this week.” I’m still waiting for a Mayo official from Arizona to return my call, as promised. When he does, I’ll update this story.
In the meantime, I can only wonder: if one of the Mayo Clinics family practices is going to dump its Medicare patients will other physicians around the country soon follow its example?
Postscript: Mayo in Arizona Returns My Call
A Postscript: Michael Yardley, Mayo’s chairman of Public Affairs in Arizona did get back to me. When I asked what exactly this pilot program was piloting, he replied. “We’re essentially trying to look at a different way of delivering health care.”
I’m afraid I interrupted him: “a new way of delivering care—by not delivering care?” No, he explained, the clinic would continue to deliver care as long as patients could pay $175 to $400 out of pocket. He quickly admitted that this would not be possible for everyone. “This was a very painful decision for us to make.”
“But,” he explained, “over 50% of our practice is taking care of Medicare patients. Primary care is a small component of our practice,” and so apparently that is why Mayo decided to pull back on primary care, while continuing to provide critical care.
Yet, if primary care is such a small component of the business, why couldn’t Mayo absorb the losses associated with being underpaid for primary care?
Medicare pays only about 50 percent of what it costs us to provide the service, Yardley explains.
And what does it cost Mayo to see a primary care patient? An office visit costs us $175 to $400, says Yardley—“the range that we are asking patients to pay.”
Wait a minute. It actually costs Mayo $175 to see the simplest cases? Of course that $175 to $400 includes not just the doctor’s time, but overhead. Still, begin with the doctor’s time: how long does the average routine visit with a primary care physician last?
“One hour,” Yardley replied.
“In other words,” I asked, “If I went to a primary care doctor at your clinic with a sore throat, and said that it hurt so much that I was afraid it was Strep (the only reason I would go to a doctor if I had a sore throat), the doctor would spend sixty minutes swabbing my throat, and explaining that if it was Strep, I would need antibiotics? Otherwise, he might explain, I should drink plenty of liquids . . .
Of course, the doctor might also ask if I had had Strep in the past, or other ear, nose and throat infections. No doubt there are other questions that a good clinician might ask. But how could he possibly fill an hour seeing a patient with no complaints other than a sore throat?
It makes sense that he might spend an hour with a new patient on an initial work-up—but 60 minutes, as the average, for all primary care visits with patients who use this clinic for their regular care?
Yardley, who is after, a spokesperson, not the head of medicine at the clinic, really couldn’t explain. “The average visit is an hour,” he repeated.
I couldn’t fault Yardley. This is his job, and this is all that Mayo had given him to say. I expressed my sympathy that he, as an individual, has been put in an impossible position. He thanked me (without, in any way, faulting Mayo.)
Finally, we talked about the fact that Mayo has been in the forefront of arguing that we need to make structural reforms in the way we deliver and pay for care in order to get better value for our health care dollars.
“Value” equals better outcomes at a lower cost. That is what the Mayo Clinic is all about. At least, that is what I have told HealthBeat readers in the past.
“But,” I asked Yardley,” if it costs Mayo $175 to $400 to see a primary care patient, is that really good value for our health care dollars? Would you really expect taxpayers to pay that much?”
Understandably, Yardley can’t say how much taxpayers should be expected to pay.
A final question: if Medicare is paying only 50% of what it costs Mayo to see primary care patients, does this mean that Mayo believes that Medicare reimbursements for primary care should be increased by 100%?
Yardley indicates that an increase at that level wouldn’t be “sustainable.” Medicare would go broke.
In the end, all that Yardley can tell me is this: “We are experimenting to see whether we can sustain our primary care practice with this new model of payment.” In other words, it seems that they are trying to find out how many seniors in their area can afford the $1500 for a physical plus three office visits. (Of course if a patient has the misfortune to need more than three office visits in the year, he will need to ante up more than $1500.)
If patients have the money, the clinic will continue to take them. Isn’t this rationing by ability to pay? “We can’t provide primary care to everyone who wants care,” Yardley replies.
This reminds me of something Rick Scott, the former head of HCA/Columbia once said, explaining why hospitals just can’t throw their doors open to one and all. In Money-Driven Medicine, I quote him: “Do we have an obligation to provide health care for everybody? Where do we draw the line? Is any fast-food restaurant obligated to feed everyone who shows up?” (HCA/Columbia is the hospital chain that bilked Medicare, paid kickbacks to doctors, and wound up pleading guilty to no fewer than 14 felonies, while paying $1.7 billion in criminal and civil fines. Scott walked away, “Scott-free” and now runs “Conservatives for Patients Rights,” a group dedicated to blocking healthcare reform. (I wrote about Scott on HealthBeat earlier this year--March 3, 2009
Clearly, this is not what Yardley meant to say. He is hardly Rick Scott. He is the spokesperson for Mayo in Arizona, and Mayo has failed to give him a good explanation of why they are doing what they are doing there.. I truly am sorry that he has the misfortune to be the subject of this post. To his credit, throughout the interview, he was polite and patient. He did not make the policy. No one should blame him for being the messenger.
I wish I could direct my questions to Dr. Denis Cortese, Mayo’s CEO. I know that both physicians and some at the higher administrative levels at Mayo read HealthBeat. I’m hopeful that Cortese may see these queries---questions that anyone might ask-- and somehow, explain what is going on here.The responses I’m hearing just don’t square with Mayo’s philosophy that “the patient always come first.”
I still believe that Mayo’s Rochester, Minnesota medical center acts on that motto. I have spoken to doctors who have worked there for years. I have spoken to patients. I have seen research data.
But what on earth are they doing in Arizona? My guess is that, in the midst of the debate over health care reform, someone at Mayo decided to use an outlier clinic to make a strong political statement: “Medicare payments to family practitioners are far too low.” Agreed.
But for a Mayo clinic to ask doctors to abandon 3,000 elderly patients hardly seems the most professional way to make that statement. I wonder how primary care physicians working at that clinic feel about this. I’d like to hear from doctors and patients in Arizona. You can reach me at maggiemhar@yahoo.com.
Keep in mind that the median income for U.S. seniors is $20,000—and that includes Social Security, investment income, pensions, income from part-time work—every penny that comes into the house. This means that half of all seniors rely on less than $20,000 a year—in some cases, far less. This is why $1500 for primary care, in addition to whatever Medicare co-pays and deductibles they face for drugs and other services, could easily be more than many can afford.
In the letter, Mayo said it will continue to accept Medicare for critical care and specialty services as well as lab services and physical therapy—but not routine primary care. (So much for the idea of a “medical home.”)
Mayo warned earlier this year that its operations were struggling. In a March statement, hospital administrators said income from patient care dropped to $205 million in 2008, down from $293 million in 2007. The hospital also estimated unpaid portions of Medicare and other senior programs at $765 million for the year.
Under health care reform, primary care physicians are likely to receive higher fees. The House bill promises increases of 5 to 10 percent (depending on whether there is a shortage of primary care physicians in a given area), plus bonuses for physicians who deliver higher quality care.
But this Mayo Clinic isn’t going to wait for reform. According to hospital officials “this is a two-year-pilot program.”
It’s not entirely clear what the program is piloting.
When I called Mayo headquarters in Rochester Minnesota a source told me that Mayo CEO Denis Cortese is “not available this week.” I’m still waiting for a Mayo official from Arizona to return my call, as promised. When he does, I’ll update this story.
In the meantime, I can only wonder: if one of the Mayo Clinics family practices is going to dump its Medicare patients will other physicians around the country soon follow its example?
Postscript: Mayo in Arizona Returns My Call
A Postscript: Michael Yardley, Mayo’s chairman of Public Affairs in Arizona did get back to me. When I asked what exactly this pilot program was piloting, he replied. “We’re essentially trying to look at a different way of delivering health care.”
I’m afraid I interrupted him: “a new way of delivering care—by not delivering care?” No, he explained, the clinic would continue to deliver care as long as patients could pay $175 to $400 out of pocket. He quickly admitted that this would not be possible for everyone. “This was a very painful decision for us to make.”
“But,” he explained, “over 50% of our practice is taking care of Medicare patients. Primary care is a small component of our practice,” and so apparently that is why Mayo decided to pull back on primary care, while continuing to provide critical care.
Yet, if primary care is such a small component of the business, why couldn’t Mayo absorb the losses associated with being underpaid for primary care?
Medicare pays only about 50 percent of what it costs us to provide the service, Yardley explains.
And what does it cost Mayo to see a primary care patient? An office visit costs us $175 to $400, says Yardley—“the range that we are asking patients to pay.”
Wait a minute. It actually costs Mayo $175 to see the simplest cases? Of course that $175 to $400 includes not just the doctor’s time, but overhead. Still, begin with the doctor’s time: how long does the average routine visit with a primary care physician last?
“One hour,” Yardley replied.
“In other words,” I asked, “If I went to a primary care doctor at your clinic with a sore throat, and said that it hurt so much that I was afraid it was Strep (the only reason I would go to a doctor if I had a sore throat), the doctor would spend sixty minutes swabbing my throat, and explaining that if it was Strep, I would need antibiotics? Otherwise, he might explain, I should drink plenty of liquids . . .
Of course, the doctor might also ask if I had had Strep in the past, or other ear, nose and throat infections. No doubt there are other questions that a good clinician might ask. But how could he possibly fill an hour seeing a patient with no complaints other than a sore throat?
It makes sense that he might spend an hour with a new patient on an initial work-up—but 60 minutes, as the average, for all primary care visits with patients who use this clinic for their regular care?
Yardley, who is after, a spokesperson, not the head of medicine at the clinic, really couldn’t explain. “The average visit is an hour,” he repeated.
I couldn’t fault Yardley. This is his job, and this is all that Mayo had given him to say. I expressed my sympathy that he, as an individual, has been put in an impossible position. He thanked me (without, in any way, faulting Mayo.)
Finally, we talked about the fact that Mayo has been in the forefront of arguing that we need to make structural reforms in the way we deliver and pay for care in order to get better value for our health care dollars.
“Value” equals better outcomes at a lower cost. That is what the Mayo Clinic is all about. At least, that is what I have told HealthBeat readers in the past.
“But,” I asked Yardley,” if it costs Mayo $175 to $400 to see a primary care patient, is that really good value for our health care dollars? Would you really expect taxpayers to pay that much?”
Understandably, Yardley can’t say how much taxpayers should be expected to pay.
A final question: if Medicare is paying only 50% of what it costs Mayo to see primary care patients, does this mean that Mayo believes that Medicare reimbursements for primary care should be increased by 100%?
Yardley indicates that an increase at that level wouldn’t be “sustainable.” Medicare would go broke.
In the end, all that Yardley can tell me is this: “We are experimenting to see whether we can sustain our primary care practice with this new model of payment.” In other words, it seems that they are trying to find out how many seniors in their area can afford the $1500 for a physical plus three office visits. (Of course if a patient has the misfortune to need more than three office visits in the year, he will need to ante up more than $1500.)
If patients have the money, the clinic will continue to take them. Isn’t this rationing by ability to pay? “We can’t provide primary care to everyone who wants care,” Yardley replies.
This reminds me of something Rick Scott, the former head of HCA/Columbia once said, explaining why hospitals just can’t throw their doors open to one and all. In Money-Driven Medicine, I quote him: “Do we have an obligation to provide health care for everybody? Where do we draw the line? Is any fast-food restaurant obligated to feed everyone who shows up?” (HCA/Columbia is the hospital chain that bilked Medicare, paid kickbacks to doctors, and wound up pleading guilty to no fewer than 14 felonies, while paying $1.7 billion in criminal and civil fines. Scott walked away, “Scott-free” and now runs “Conservatives for Patients Rights,” a group dedicated to blocking healthcare reform. (I wrote about Scott on HealthBeat earlier this year--March 3, 2009
Clearly, this is not what Yardley meant to say. He is hardly Rick Scott. He is the spokesperson for Mayo in Arizona, and Mayo has failed to give him a good explanation of why they are doing what they are doing there.. I truly am sorry that he has the misfortune to be the subject of this post. To his credit, throughout the interview, he was polite and patient. He did not make the policy. No one should blame him for being the messenger.
I wish I could direct my questions to Dr. Denis Cortese, Mayo’s CEO. I know that both physicians and some at the higher administrative levels at Mayo read HealthBeat. I’m hopeful that Cortese may see these queries---questions that anyone might ask-- and somehow, explain what is going on here.The responses I’m hearing just don’t square with Mayo’s philosophy that “the patient always come first.”
I still believe that Mayo’s Rochester, Minnesota medical center acts on that motto. I have spoken to doctors who have worked there for years. I have spoken to patients. I have seen research data.
But what on earth are they doing in Arizona? My guess is that, in the midst of the debate over health care reform, someone at Mayo decided to use an outlier clinic to make a strong political statement: “Medicare payments to family practitioners are far too low.” Agreed.
But for a Mayo clinic to ask doctors to abandon 3,000 elderly patients hardly seems the most professional way to make that statement. I wonder how primary care physicians working at that clinic feel about this. I’d like to hear from doctors and patients in Arizona. You can reach me at maggiemhar@yahoo.com.
Mayo Clinic attacked for Pro-Reform Stance (daily kos)
Wed Oct 14, 2009 at 08:22:03 PM CST
In an article yesterday in the Washington Post, Mayo Clinic was attacked for cutting off access to Medicaid and Medicare patients. In fact, these cutbacks were extremely limited. The story is the second in the Post by Alec MacGillis that reflects the position of an organization known as the AAMC. Mayo's response:
Mayo Clinic feels that this story is a distraction from the true issue at hand—that of getting Congress to pay for value. As we have stated on this blog numerous times before, the only way to raise the bar for care while at the same time bending the cost curve, is to reward the best outcomes—Pay for Value, not volume.
Mayo continues to see Medicare patients from its region (MN, IL, WI, IA, SD and ND or 99% of Mayo’s Medicare patients). The change affected only a small number of patients coming from Montana and Nebraska. The change in Arizona involved a single primary care clinic, at which Mayo continues to see Medicare patients for specialty services. This has been conflated in the conservative blogosphere into the meme that 'Mayo is no longer accepting any Medicare or Medicaid patients.' This is an outrage.
Like an earlier article in the Washington Post by the same reporter, Alec MacGillis, titled "Is the Mayo Clinic a Model Or a Mirage? Jury Is Still Out", it is an unabashed attempt to discredit Mayo as an appropriate ideal for reforming US health care. Behind the stories appears to be the AAMC, the Association of Academic Medical Centers, which represents the country’s teaching hospitals and lobbies for the continuation of special extra payments to these hospitals. The official of the AAMC quoted in the article is in fact "AAMC's 'voice' on advocacy issues," Dr. Atul Grover, head of its Advisory Panel on Health Care. Dr. Grover, recently of The Lewin Group (a subsidiary of for-profit United Health Care) took on the advocacy position in March. His assignment: to be, according to AAMC President Daryll Kirsch, MD, "the main architect and strategist of the AAMC's advocacy agenda, effectively mobilizing the association's government relations and communications teams and resources to accomplish the legislative goals of the academic medicine community." The AAMC is best known in the industry as lobbying for the continuation special extra payments to these hospitals.
Mayo’s position has been that US health care would benefit from a health care system that is more like "Mayo-care for all." For this it has endured a series of attacks by the AAMC and several specialty societies, including the ACC, the American College of Cardiology. It is no accident that the AAMC-influenced article appeared in the Washington Post appeared on the day of the vote in the Finance Committee on the Baucus bill.
The gist of the attacks has been to question Mayo's quality, its low costs, how sick its patients are, and whether its practice is "transferrable." I hope to settle these questions by providing the facts as they have been well established and that are surely well known by the AAMC and other organizations.
The data in the tables below shows that the attacks on Mayo’s patient mix, quality, costs and outcomes are unsubstantiated. For this data, I accessed the publicly available American Hospital Directory (ahd.com) which compiles data from HHS's Center for Medicare and Medicaid Services, the Agency for Healthcare Quality and Research, and other public sources.
oThe Dartmouth Atlas (showing regional differences in surgery and costs
o The Commonwealth Fund State Scorecard (new)
o The Kaiser Family Foundation StateHealthFacts (newly updated)
Mayo's Credentials as High Quality, Low Cost Provider
For the analysis below, there are two sets of medical centers provided for comparison. The first is the complete list of hospitals in the Top Ten of the annual US News and World Report rankings (in which Mayo has scored second place every year just after Johns Hopkins since the ranking was introduced in the early 1990s. All data is for Medicare.
# US News Top 11 Sev CMI adj Cost COL Adjusted
1 Johns Hopkins 1.82 $12,484 0.96 $11,985
2 Mayo/Saint Marys 1.97 $8,926 1.00 $8,926
3 Reagan UCLA 2.16 $11,625 1.03 $11,974
4 Cleveland Clinic 2.33 $6,987 0.97 $6,777
5 Mass General 1.85 $9,774 1.25 $12,218
6 Columbia Presb 1.89 $10,525 1.24 $13,051
7 UCSF 2.07 $14,803 1.13 $16,727
8 U Penn 2.27 $9,032 0.97 $8,761
9 Barnes-Jewish 1.86 $7,800 0.93 $7,254
10 Brigham & Women's 2.02 $9,937 1.25 $12,421
10 Duke 2.00 $7,920 1.02 $8,078
US AVERAGE 0.89 ahd.com CNNMoney
The second list includes nearby health systems or similarly organized practices (in addition to Cleveland Clinic in the first list these include Intermountain Health and Geisinger Clinic). Gunderson/Lutheran is a somewhat smaller integrated group practice. HealthPartners (Regions Hospital) is a successful co-op.
Other Major Centers Sev CMI adj Cost COL Adjusted
Geisinger 1.87 $7,157 0.84 $6,012
Gunderson-Lutheran 1.70 $7,941 0.95 $7,544
Intermountain 2.03 $8,287 0.95 $7,873
Mayo/Saint Marys 1.97 $8,926 1.00 $8,926
Olmsted Medical Group 1.23 $8,620 1.00 $8,620
Regions Mpls/StP 1.63 $8,128 1.00 $8,128
U of Minnesota 1.85 $11,432 1.00 $11,432
U Wisconsin Madison 0.98 $10,529 0.93 $10,968
US AVERAGE ahd.com CNNMoney
In brief, Mayo sees a mix (severity) of patients commensurate with that of its peer hospitals. It does this while achieving lower costs and high quality (see ahd.com).
The Commonwealth data [pdf]shows that Minnesota in which the Mayo system is the primary provider has low instances of unnecessary deaths; Mayo's region is typical of Minnesota as a whole (Dartmouth).
The Dartmouth studies have shown that in addition, Mayo does very well in terms of avoiding unnecessary procedures, manages end-of-life care well, and saves money as well. A specific study of patients with chronic conditions by the Dartmouth Institute for Health Policy and Clinical Practice and the Robert Wood Johnson Foundation, which accompanied its 2008 Atlas, reported:
Consider this comparison between the Mayo Clinic’s flagship St. Mary’s Hospital and
UCLA Medical Center.
• Spending: UCLA spent more than $93,000 per patient over the last two years of
life. The Mayo Clinic, by contrast, spent $53,432—a little more than half the
amount of UCLA on similar patients over the same period of time.
• Utilization: Chronically ill patients in their last six months of life had more than
twice as many physician visits at UCLA compared with Mayo, and they spent
almost 50 percent more days in the hospital.
• Resource Use: Compared to the Mayo Clinic, UCLA uses one-and-a-half times
the number of beds, almost twice as many physician FTEs in managing similar
patients.
This study concludes "If the U.S. health care system mirrored the practice patterns of gold-standard health care systems such as the Mayo Clinic in Minnesota, Medicare could save tens of billions of dollars annually. Those savings would come just when Medicare needs that money most, as baby boomers prepare to retire in droves, putting unprecedented pressure on the health-care system."
IN THESE STATISTICS it should be noted that in addition to Mayo, the other centers which also achieve these goals are also centers which practice in the tradition of the "integrated group practice." These include the Cleveland Clinic (which is the most similar to Mayo but sees a high percentage of Medicaid patients), Geisinger Clinic (Pennsylvania), and Intermountain Health (Utah).
This analysis should settle the question as to whether Mayo provides excellent care to a challenging set of patients, does this at lower cost, and achieves excellent results in terms of measures of quality and patient satisfaction, avoiding both unnecessary surgeries and unnecessary deaths, by well established criteria.
If others have data that contradicts this, it would be better for us all if they would produce it rather than mislead the country at this critical time with blatantly false and intentionally misleading information and insinuations.
Posted by: Auriandra | October 15, 2009 at 12:06 AM
An hour??????????? How about ten minutes tops!!for a routine visit. Next time I will time it.
Posted by: Mayo Arrowhead Patient | November 29, 2009 at 01:38 PM
This is just sad...
Posted by: George Shirley | May 26, 2010 at 04:28 PM