Private Contracts Between Doctors and Medicare Patients: Key Questions and Implications of Proposed Policy Changes
| Appendix Table 1: Less than 1% of physicians have “opted out” of Medicare, with psychiatrists making up the largest share | |||||
| Specialty | Number of physicians in patient care, 20151 | Percent of all physicians in patient care, 2015 | Number of Medicare opt-out providers, 20162 | Percent of Medicare opt-out providers, 2016 | Percent of all opt-out providers, 2016 |
| PHYSICIANS | |||||
| Addiction Medicine | NA | — | 30 | — | 0.6% |
| Allergy/Immunology | 4,019 | 0.5% | 37 | 0.9% | 0.7% |
| Anesthesiology | 38,749 | 5.1% | 14 | 0.0% | 0.3% |
| Cardiovascular Disease/Cardiology | 23,242 | 3.1% | 31 | 0.1% | 0.6% |
| Critical Care | 8849 | 1.2% | 4 | 0.0% | 0.1% |
| Dermatology | 11,062 | 1.5% | 101 | 0.9% | 1.9% |
| Emergency Medicine | 36,607 | 4.8% | 37 | 0.1% | 0.7% |
| Endocrinology | 5,682 | 0.7% | 84 | 1.5% | 1.5% |
| Family Medicine/General Practice | 103,235 | 13.6% | 859 | 0.8% | 15.8% |
| Gastroenterology | 13,014 | 1.7% | 20 | 0.2% | 0.4% |
| General Surgery | 22,043 | 2.9% | 61 | 0.3% | 1.1% |
| Geriatric Medicine | 4,422 | 0.6% | 20 | 0.5% | 0.4% |
| Hand Surgery | NA | — | 8 | — | 0.1% |
| Hematology/Oncology | 12,234 | 1.6% | 12 | 0.1% | 0.2% |
| Infectious Disease | 6,548 | 0.9% | 12 | 0.2% | 0.2% |
| Internal Medicine | 101,281 | 13.3% | 537 | 0.5% | 9.9% |
| Oral/Maxillofacial Surgery | NA | — | 87 | — | 1.6% |
| Nephrology | 8,885 | 1.2% | 5 | 0.1% | 0.1% |
| Neurological Surgery | 4,920 | 0.6% | 32 | 0.7% | 0.6% |
| Neurology | 11,501 | 1.5% | 60 | 0.5% | 1.1% |
| Neuromusculoskel, Osteo Manip, Sports Medicine | NA | — | 127 | — | 2.3% |
| Obstetrics/Gynecology | 38,690 | 5.1% | 328 | 0.8% | 6.0% |
| Ophthalmology | 17,413 | 2.3% | 38 | 0.2% | 0.7% |
| Orthopedic Surgery | 18,292 | 2.4% | 121 | 0.7% | 2.2% |
| Otolaryngology | 8,894 | 1.2% | 19 | 0.2% | 0.3% |
| Pain Mgt/Interventional Pain Mgt | 4,328 | 0.6% | 65 | 1.5% | 1.2% |
| Pathology | 9,688 | 1.3% | 5 | 0.1% | 0.1% |
| Pediatric specialties | 72,667 | 9.6% | 304 | 0.4% | 5.6% |
| Physical Medicine and Rehabilitation | 8,352 | 1.1% | 53 | 0.6% | 1.0% |
| Plastic and Reconstructive Surgery | 6,727 | 0.9% | 113 | 1.7% | 2.1% |
| Preventative Medicine | 4,091 | 0.5% | 45 | 1.1% | 0.8% |
| Psychiatry, Geriatric Psychiatry, Neuropsychiatry | 33,051 | 4.4% | 2076 | 6.3% | 38.1% |
| Pulmonary Disease | 4,830 | 0.6% | 15 | 0.3% | 0.3% |
| Radiation Oncology | 4,499 | 0.6% | 1 | 0.0% | 0.0% |
| Radiology, Nuclear Medicine | 30,263 | 4.0% | 26 | 0.1% | 0.5% |
| Rheumatology | 4,831 | 0.6% | 20 | 0.4% | 0.4% |
| Thoracic Surgery | 4,153 | 0.5% | 1 | 0.0% | 0.0% |
| Urology | 9,325 | 1.2% | 24 | 0.3% | 0.4% |
| Vascular Surgery | 3,086 | 0.4% | 5 | 0.2% | 0.1% |
| Other* | 59,948 | 7.9% | 10 | 0.0% | 0.2% |
| Total, all physician specialties | 759,421 | 100% | 5,447 | 0.7% | 100% |
| OTHER PRACTITIONERS | |||||
| Behavioral Health, Counseling, Social Work | — | — | 3,257 | — | 27.9% |
| Optometry, Eye/Vision services | — | — | 83 | — | 0.7% |
| Dentistry, dental-oral surgery, oral health | — | — | 7,252 | — | 62.2% |
| Podiatry | — | — | 37 | — | 0.3% |
| Other | — | — | 1,037 | — | 8.9% |
| Total, Other Practitioners | 11,666 | 100% | |||
| NOTES: Physician counts include active allopathic and osteopathic medicine physicians. NA (not available) indicates that the specialty category is not supplied in the applicable data source. *Physicians in specialties with fewer than 2,500 total physicians are not categorized by specialty in AAMC analysis of AMA data; included as “Other.” SOURCES: Kaiser Family Foundation analysis of: 1Physician counts from Association of American Medical Colleges (AAMC) 2015 Physician Specialty Data Book, using American Medical Association (AMA) Physician Masterfile (December 2015); 2 CMS, Opt Out Affidavits https://data.cms.gov/dataset/Opt-Out-Affidavits/7yuw-754z/data (January 2016). |
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| Appendix Table 2: Examples of Medicare reimbursement and beneficiary cost-sharing for a $500 service on Medicare’s fee-schedule | ||||
| Provider’s arrangement with Medicare | Payment arrangement | Medicare’s usual reimbursement | Beneficiaries’ usual liability* | Total net payment to provider |
| Participating provider | Assigned claim: Medicare pays its portion directly to provider; patient is liable for applicable cost-sharing | 80% of fee-schedule amount = 0.8 x $500 = $400 |
20% of fee-schedule amount = 0.2 x $500 = $100 |
100% of fee-schedule amount = $500 |
| Non-participating provider | Assigned claim: Medicare pays its portion directly to provider; patient is liable for applicable cost-sharing | 80% of reduced (by 5%) fee-schedule amount = 0.8 x (0.95 x $500) = $380 |
20% of reduced (by 5%) fee-schedule amount = 0.2 x (0.95 x $500) = $95 |
Reduced (by 5%) fee-schedule amount = 0.95 x $500 = $475 |
| Unassigned claim: Patient pays provider’s full charge and seeks reimbursement from Medicare for its portion. On net, patient is liable for applicable cost-sharing PLUS the amount the provider charged above Medicare’s fee-schedule rate | 80% of reduced (by 5%) fee-schedule amount = 0.8 x (0.95 x $500) = $380 |
20% of reduced (by 5%) fee-schedule amount plus balance-billed amount = $95 + (≤ $71.25) = up to $166.25 |
Up to 115% of reduced (by 5%) fee-schedule amount, known as the “limiting charge” = up to 1.15 x (0.95 x $500) = up to $546.25 |
|
| Opt-out provider | Private contract: Provider sets fee with Medicare patient; Medicare does not reimburse provider or patient for any portion of the service | = $0 | Unlimited | Unlimited |
| NOTES: *These calculations are for traditional Medicare and assume that the beneficiary has already met the annual Medicare deductible. Beneficiaries with supplemental insurance may have coverage for out-of-pocket liabilities. | ||||