 is the president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large, metropolitan, single-specialty urology group in Fort Worth, Texas.

Robert A. Dowling, MD

Robert A. Dowling, MD, writes, "How you communicate with patients is critical to satisfaction, outcomes, efficiency, and your practice’s success."

Cleveland Clinic recently announced that it will begin billing patients or their insurance company for responses to portal messages that require provider “clinical time and expertise.”

 Providing patients electronic access to their health information is one of the Merit-based Incentive Payment System (MIPS) measures in the Promoting Interoperability category, and it carries the largest weight in the category score premised on the belief that electronic exchange of data between a provider and a patient is important and improves health outcomes.

 That access typically involves a portal with many features, including the ability to exchange secure messages with providers or the care team. Providers have expressed concern that patients will overwhelm them with messages that consume uncompensated time. In this article, I will explore the trends that led to this point and the pros and cons of using portals from the physician and patient perspectives—all to inform your decision about whether to charge for responding to messages.

 Americans are increasingly adopting asynchronous electronic methods for personal and business communications. More than 90% of adults use email regularly, most have a smartphone and use text messaging, and social media use is pervasive. The remote worker economy has only accelerated this trend. Almost half of young adults report they are “almost constantly online,”

 and a great deal of that involves posting, chatting, and other asynchronous communications. Live chat functionality is a routine feature of the internet presence of banks, retailers, and even some hospitals. In short, we have come to expect a standard of sending a message and getting a reply—usually for free—in all areas of our lives.

Trend 2: Changes in how physicians get paid.

 For 30 years, physicians have been paid on the principle that payments should be related to the resource costs needed to provide services—the resource-based relative value scale (RBRVS)—based on physician work, practice expenses, and malpractice expenses.

 Shortly after the introduction of RBRVS came the concept of evaluation and management (E&M) codes based upon the type and severity of patient conditions and, occasionally, the amount of time spent with the patient. Two recent developments have increased the expectation by physicians that they should be compensated primarily for time: the expansion of telehealth and reimbursement for phone calls, and the recent (2021) change in E&M coding guidelines to make it easier to base charges on the amount of time spent with the patient.

Trend 3: Changes in traditional physician “workload.”

 Reimbursement pressures and practice expense inflation have driven many physician practices to respond by seeing more patients per unit of time. The physical workload contributes to a mental workload that is demonstrably linked to physician burnout and has been exacerbated by the COVID-19 pandemic.

 The expanded office visit template may come at the expense of a contracted amount of time for non–face-to-face activities—responding to messages, for example.

 Most physicians in America have adopted an electronic health record (EHR), claimed up to $44,000 in incentives for doing so, and are compensated for Medicare professional services based in part on their continued adoption of features like providing patients access to information in the EHR through a portal. In 2020, it is estimated that 60% of patients nationwide were offered access to a portal, 60% of those accessed it at least once, and the most frequent activity reported (60%) was exchanging secure messages with their provider (up from 48% in 2017)

; review of 2020 MIPS data suggests higher rates of portal adoption in urology practices than in other specialties.

Trend 5: Expansion of telehealth during the COVID-19 pandemic.

 This trend has increased the expectation that many services previously only offered in an office setting are available remotely via technology.

Taken together, these trends suggest an increased demand by patients for messaging their providers, a decreased supply of uncompensated physician time in which to do so, and a natural response to charge for messaging. It is important to draw a distinction between a brief round of secure messaging and something closer to a clinical encounter. Medicare has paid for the latter—“e-visits”—since 2019. An e-visit applies only to established patients and is described by Medicare as a patient-initiated online digital E&M service conducted via a patient portal.

 There are 3 levels of codes for up to 7 days’ cumulative time: 5 to 10 minutes, 11 to 20 minutes, and 21 or more minutes. The 2022 Medicare allowables for e-visit levels (unadjusted for geographic factors) are $15.23, $29.76, and $48.45, respectively. Medicare deductibles and coinsurance apply, and private insurance may have different rules.

Portals are attractive to patients as an alternative (to a phone message) channel for communicating a clinical concern. They can avoid call centers, “telephone tag,” and create a written record of their interaction. Patients can communicate from their phone or computer at a time they choose. Many physicians prefer this channel for the same reasons. Some literature suggests portal use is associated with higher patient satisfaction.

 Literature on provider satisfaction is lacking, and it is not clear whether portals improve or worsen productivity and efficiency or lead to decreased phone messages.

Here’s how Cleveland Clinic is implementing billing for responding to messages1:

Proactively reaching out to patients with an easy-to-understand description of the new policy

Charging for the following if they are expected to take more than 5 minutes of provider time: changes to medications, new symptoms, changes to a long-term condition, and requests to complete medical forms

Not charging for: scheduling an appointment or asking a question that leads to an appointment, refilling prescriptions, following up on care within the past 7 days, and giving a quick update to the provider

Here are some additional things to think about before you charge for e visits:

Asynchronous messaging may be less efficient than a phone call when evaluating a new clinical problem. Patients may omit critical information in their initial outreach or be vague, leading to several rounds of back-and-forth.

Many EHRs do not have an automatic way of creating an encounter or charging from the messaging platform. You will have to create a workflow to initiate the charge/claim. Reimbursement for an e-visit is based on cumulative time over 7 days. You will have to establish a method of accounting for and documenting time in a 7-day “episode.”

Charges will generate revenue cycle management. A sudden surge of claims for e-visits may trigger an inquiry from payers. You may need documentation to show which portal messages generated charges and which did not.

A financial transaction may raise patient expectations about the quality and timeliness of your response to their message, especially if costs are largely out of pocket. There are no coding guidelines for documentation of an e-visit beyond the time parameters mentioned above.

Medicare’s definition of an e-visit explicitly communication with a practitioner. You cannot bill for responses from your nurse or medical assistant.

Established patients with chronic problems may push back on change. An example would be a female patient with chronic urinary tract infections who is accustomed to calling for an antibiotic periodically with new onset of symptoms. Depending on your market and your competitors’ policies, patients may leave.

Charging for clinical responses may discourage patients from reporting new symptoms or using the portal to view their health information.

How you communicate with patients is critical to satisfaction, outcomes, efficiency, and your practice’s success. The consumer economy demands electronic access to health care information, and portal adoption has surged in recent years. The decision whether to routinely charge for online “care” is therefore important and should be made in the context of your practice culture and style. If you decide to charge for responses to portal messages, be sure to make your policy clear on the portal before those messages are initiated by patients.

1. MyChart messaging. Cleveland Clinic. Accessed December 9, 2022. https://bit.ly/3Pcvott

2. 2018 Physician Fee Schedule final rule—Quality Payment Program final rule. 

. 2018;83(226):59789. To be codified at 83 FR 359186. https://bit.ly/3YcXKrk

3. Faverio M. Share of those 65 and older who are tech users has grown in the past decade. Pew Research Center. January 13, 2022. Accessed December 9, 2022. https://bit.ly/3FC40BU

4. McCormack LA, Burge RT. Diffusion of Medicare’s RBRVS and related physician payment policies. 

5. Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. 

2022;97(12):2248-2258. doi:10.1016/j.mayocp.2022.09.002

6. Johnson C, Richwine C, Patel V. Individuals’ access and use of patient portals and smartphone health apps, 2020. Office of the National Coordinator for Health Information Technology. September 2021. Accessed December 9, 2022. https://bit.ly/3iMkhLA

7. Doctors and clinicians datasets. Centers for Medicare & Medicaid Services. Accessed December 9, 2022. https://bit.ly/3CZ9vqY

8. Medicare telemedicine health care provider fact sheet. Centers for Medicare & Medicaid Services. March 17, 2020. Accessed December 9, 2022. https://bit.ly/3W7HmXE

9. Kinney AP, Sankaranarayanan B. Effects of patient portal use on patient satisfaction: survey and partial least squares analysis. 

10. Carini E, Villani L, Pezzullo AM, et al. The impact of digital patient portals on health outcomes, system efficiency, and patient attitudes: updated systematic literature review. 

Articles

Established patients with chronic problems may push back against charges.

Charging for portal use: Here is what urologists should know

Robert A. Dowling, MD, writes, "The traditional information asymmetry in medicine is changing."

Patient access to health care information continues to evolve and change the shape of patients’ relationships with physicians, hospitals, testing facilities, and insurers. The issue has the focused attention of the Office for Civil Rights (OCR) at the US Department of Health & Human Services (HHS), as demonstrated in recent enforcement actions of the Health Insurance Portability and Accountability Act (HIPAA) Right of Access.

 Most of the settlements or actions arising from OCR enforcement involve allegations that patients were not granted access (their right under HIPAA) to their medical records and typically are resolved for tens of thousands of dollars—most paid by dentists and physicians.

In 2020, the Office of the National Coordinator for Health Information Technology (ONC) issued a final rule implementing Section 4004 of the 21st Century Cures Act. Among other things, this rule implements interoperability requirements, defines 

, and seeks to give patients “more power in their health care.” Slowly but surely, the standard for personal access to health care information is evolving to become instant and electronic—just as individuals now expect from banks, airlines, local government, and other important third parties in their everyday lives. The transition is not without challenges, and some resistance from the health care system.

 that patients have rights to access? The key terms are electronic protected health information (ePHI), designated record set (DRS), and information blocking. Here’s how they work together. ePHI is “any information, including genetic information, whether oral or recorded in any form or medium, that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual” 

 is “transmitted or maintained in electronic media or transmitted or maintained in any other form or medium” 

 would be included in a DRS. When the Cures Act was implemented, a DRS was limited to a subset of health information until October 6, 2022. After that date, a DRS is simply defined as “a group of records maintained by or for a covered entity that is the medical records and billing records about individuals maintained by or for a covered health care provider or used, in whole or in part, by or for the covered entity to make decisions about individuals.”

 HIPAA and the Cures Act grant patients the rights to that access, and information blocking defines those practices that would interfere with that access, including but not limited to delaying the release of progress notes, laboratory results, or pathology results in order to permit clinician review.

Why is patients’ access to their information controversial? Instant and electronic access by patients to the electronic health record upends some long-established physician-centric traditions of medical practice and documentation and raises some concerns. First, physicians may no longer have the first pass at test results nor control over how and when those results are interpreted. Physicians who previously scheduled office visits solely to disclose and review results—especially if they are normal—may find patients challenging the need for that service, the timeliness, or the propriety of “paying for their results.”

One area of particular concern is pathology results and a new cancer diagnosis. In a recent article, Gabrielson et al highlighted these concerns in the context of prostate biopsy results and presented several ideas for addressing communication, including making pathology reports more patient friendly.

 Second, the primary audience for medical record documentation has grown bigger and now includes anyone who might at any point access the record: physicians in the practice, consultants outside the practice, support staff, hospitals, insurance companies, patient assistance organizations, attorneys, and patients. It is challenging to create and maintain a record that optimally serves all of these interests, but at a minimum, physician authors should document with the full expectation that the patient can and will access their record or possibly challenge its veracity. One example that could be problematic is a lengthy informed consent paragraph—documentation that was designed for an attorney audience, but a discussion remembered very differently by the patient. Another example might be a long review of systems—perhaps copied forward—where the patient “denied” symptoms but doesn’t recall being asked or in fact does have those symptoms. Finally, remember that regulations define the designated record set as information that is used to make decisions about patients. Contemporary systems include features such as alerts, sticky notes, messages, telephone notes, and appointment notes. If you are using these features to store or communicate information used to make decisions about patients, then, according to regulatory definitions, patients have the right to access those notes.

What are the penalties for interfering with patients’ access to their health information? The OCR has brought HIPAA enforcement actions in at least 41 cases that have resulted in monetary penalties and/or corrective action plans primarily involving medical and dental practices.1 The ONC receives and processes claims of possible information blocking from the public. As of September 30, 2022, ONC has received 511 such complaints, which included 391 concerning providers, 73 involving heatlh information technology (HIT) developers; most originated from patients.

 ONC triages and forwards complaints it determines to be possible information blocking to the Office of the Inspector General (OIG) for HHS, who is responsible for formally investigating and, in the case of HIT developers or health information exchanges, assessing any penalty. (ONC has dual authority to investigate complaints against HIT developers.)

In a proposed rule dated April 2020, the OIG noted that its civil monetary policy authority “does not extend to health care providers. If OIG determines that a health care provider has committed information blocking, it shall refer such health care provider to the appropriate agency for appropriate disincentives. The appropriate agency and appropriate disincentives will be established by the Secretary in future notice and comment rulemaking.”

 This rule has not been finalized as of October 2022. So at this time, it is unclear who will enforce information blocking by providers and what the “disincentives” look like.

The traditional information asymmetry in medicine is changing. Patients are empowered by federal laws and regulations to have timely and unrestricted access to their health information, including but not limited to almost everything in the electronic health record. There may be physician concerns about and unintended consequences of such access and transparency, but they can be mitigated by a new paradigm—the shared record. Take a moment to imagine how this can help you and your patients. Encouraging patients to review your/their notes may reinforce the short discussions you had in the exam room or uncover important omissions in the history. Reminding patients to review their test results can create shared responsibility and be a risk-management strategy. Setting advanced expectations about patients’ access to pathology reports, and your typical time and place to review, can prevent misunderstandings and improve communications. Portal access can eliminate time-consuming phone calls and letters to patients. These are just a few examples outlining how the new information paradigm anchored in patients’ access to their information can be leveraged to improve, not complicate, the physician-patient relationship.

1. HIPAA compliance and enforcement actions: resolution agreements. US Department of Health and Human Services. Updated September 20, 2022. Accessed November 8, 2022. http://bit.ly/3EkroRd

2. Code of Federal Regulations Title 45, §160.103. National Archives and Records Administration. Updated October 25, 2022. Accessed November 8, 2022. https://bit.ly/3O4nHFf

3. Code of Federal Regulations Title 45, §164.501. National Archives and Records Administration. Updated October 25, 2022. Accessed November 8, 2022. https://bit.ly/3hlja4N

4. Code of Federal Regulations Title 45, §171.102. National Archives and Records Administration. Updated October 25, 2022. Accessed November 8, 2022. https://bit.ly/3hqepHg

5. Information blocking. HealthIT.gov. Updated October 31, 2022. Accessed November 8, 2022. http://bit.ly/3daOuxO

6. Gabrielson AT, Choi U, Fletcher SA, Pavlovich CP. Lost in transparency: the 21st Century Cures Act (“Open Notes”) and prostate cancer care. 

. 2022;208(5):948-951. doi:10.1097/JU.0000000000002924

7. Information blocking claims: by the numbers. HealthIT.gov. Accessed November 8, 2022. http://bit.ly/3EhrOKP

8. Grants, contracts, and other agreements: fraud and abuse; information blocking; Office of Inspector General's civil money penalty rules. 

. April 24, 2020. Accessed November 8, 2022. https://bit.ly/3FWiDAA

"Instant and electronic access by patients to the electronic health record upends some long-established physician-centric traditions of medical practice and documentation and raises some concerns," writes Robert A. Dowling, MD.  

More access to records is good for your patients—and for you

Robert A. Dowling, MD, writes, "Although ostensibly a time saver, [copying and pasting] may lead to inaccuracies, scattered information and information overload, mistakes in care, and physician burnout."

As many as 90% of clinicians report using copy-and-paste functionality when documenting in the electronic health record (EHR), 81% admit to frequently copying other author’s notes, and 25% agree that the practice leads to mistakes in patient care.

 Several papers have been published documenting and quantifying the copy-and-paste problem by analyzing progress notes for redundancy.

 Professional organizations and patient safety organizations have issued statements and best practices on this behavior to prevent harm.

 Many believe that the notes generated by copying and pasting are a direct and significant source of physician burnout. In this article, I will summarize some of these findings and discuss how you—the practicing urologist—can limit your use of this behavior, improve patient safety, make your patient documentation more readable and meaningful, and perhaps even reduce burnout.

What is the problem? Some younger readers may have never known a medical record that was notelectronic or a progress note that was not mostly copied forward from a previous visit. But there was a time not long ago when charts were on paper, every visit was a separate document, and the record was organized by category and time. The progress note was just an interim recording of the patient’s progress. It was uncommon that a progress note was long, copied forward verbatim from a previous visit, or a complete summary of the patient. Physicians were adept at flipping quickly to key parts of the record to gain or regain their clinical impressions. Seeking to please their users, EHR developers attempted to replicate a paper chart in a computable format. At nearly the same time, insurance-driven documentation requirements for reimbursement became more complex and onerous. One user adaptation to meet these requirements was to bloat the progress note with information intended primarily to meet coding requirements and then copy it forward at every visit, often without editing or deleting old and outdated content. These habits have hardened and shaped the contemporary record. As new content is added, notes become increasingly long and redundant. Information overload obscures relevant information, wastes physician time during review, generates inaccurate data (in turn rendering data-driven quality efforts moot), and leads to errors.

 Copying and pasting is not a benign user adaptation.

How widespread is the problem? A recent analysis of over 100 million notes in a single health system revealed that 50% of note content was copied verbatim from a previous note.

Fifty-four percent of the copied content came from the same author, meaning 46% of the copied content came from a differentauthor. The findings were consistent across care settings (eg, inpatient and ambulatory) and author types (eg, role and specialty). In a famous anecdote,

 an emergency department physician seeing a patient with chest pain noted the EHR referenced a “PE.” The physician explained why he was ordering a CT scan to rule out pulmonary embolism, only to have the patient deny a history of this condition or taking blood thinners. Upon review, the PE referred to a physical exam but had been transcribed and perpetuated by multiple authors in the patient history as a pulmonary embolism. The potential for perpetuating incomplete or inaccurate information is clear, especially as documentation becomes collaborative and authors copy other authors. In the education setting, a patient record may have contributions from medical students, residents, fellows, and attending physicians. In the urology office, the progress note may be a compilation of documentation from scribes, advanced practice providers, and physicians. Copying and pasting saves time but comes with significant risk of creating an unwieldy, unreadable, and inaccurate record.

What are the root causes of the problem? Although coding requirements for reimbursement are a significant incentive for bloating the note, many believe the note paradigm itself is to blame. The contemporary EHR is an information management system with powerful tools for visualization, interoperability, and decision support. However, many users think of the EHR primarily as a progress note generator. A common practice is to use the note as a reservoir of the entire chart in the belief that this is an easy and efficient way to summarize the patient’s conditions and status. Other factors contributing to bloated, redundant notes could include a lack of EHR training, incomplete or failed implementation (including but not limited to underused favorites, problem lists, and macros), or even a faulty EHR design. The note paradigm incentivizes the use of copying and pasting but does not meet the contemporary needs of information storage, retrieval, and management or team care.

What can be done about the problem? New evaluation and management guidelines should reduce the incentive to include old information simply to justify coding levels. Some EHR vendors have already created tools that display content copied in a different style than original content, making it easier to see what is new and what is old. One possible solution is already included in most EHRs but, in this author’s opinion, is vastly underused: the problem list. Many problem lists allow dynamic documentation with a wiki model—information that can be edited but is stored and available independent of any individual note (much like a medication list). For example, the problem 

 may have some discrete attributes (eg, stage or grade) that can be updated as needed, but the problem list allows narrative comments that remain associated (not copied each time) with the problem until it is edited (eg, treatment dates). Reviewing the problem list is usually simpler and easier than scanning a bloated, redundant note. Many systems allow the automatic citation of the problem and its attributes in the progress note. For those married to the note paradigm, reordering the content—sometimes called the assessment, plan, subjective, objective note—may make it more efficient to review relevant information by pushing redundant information to the bottom. Finally, sharing notes with patients is now a reality and a mandate that will help providers be accountable for creating readable, accurate notes.

Copying and pasting is an understandable adaptation when using a computer primarily for sequential progress notes. Although ostensibly a time saver, it may lead to inaccuracies, scattered information and information overload, mistakes in care, and physician burnout. Until new systems are designed to extend the wiki model and reduce the primacy of the progress note to document clinical care, physicians need to use copying and pasting responsibly and consider alternate time-saving strategies for documentation.

1. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for Health IT collaboration. 

2017;8(1):12-34. doi:10.4338/ACI-2016-09-R-0150

2. Steinkamp J, Kantrowitz JJ, Airan-Javia S. Prevalence and sources of duplicate information in the electronic medical record. 

2022;5(9):e2233348. doi:10.1001/jamanetworkopen.2022.33348

3. Dean SM. EHR copy and paste and patient safety. Patient Safety Network. January 1, 2018. Accessed October 3, 2022. https://bit.ly/3ynTp9Q

4. Appropriate use of the copy and paste functionality in electronic health records. American Health Information Management Association. Accessed October 3, 2022. https://bit.ly/3T0AV72

5. Hirschtick R. Sloppy and paste. Patient Safety Network. July 1, 2012. Accessed October 3, 2022. https://bit.ly/3EpP6yl

Oft-used practice can lead to inaccuracies, mistakes in care, and burnout.

Why is copying and pasting in the EHR such a problem?

It’s “Medicare season,” the time of year when Medicare Advantage ads begin to saturate the airwaves and patients may ask their doctors for advice. Most practicing urologists participate in traditional Medicare and/or Medicare Advantage plans and have a working knowledge of coverage rules, reimbursement issues, the Merit-based Incentive Payment System, and other regulations that affect Medicare providers. Many urologists, though, may not understand the basics or the nuances of enrolling in Medicare, choosing an Advantage plan, the costs in the program, premiums and penalties, and other important aspects of the care experience as a patient in Medicare. Indeed, many Americans don’t understand these issues and there is an entire industry of “Medicare advisers” (usually insurance brokers working on sales commission) who help educate patients, inform their decisions, and navigate their enrollment. In this article, I will offer a primer on these subjects to better prepare you to understand what Medicare patients experience.

When does Medicare “kick in”? Most Americans become eligible for Medicare coverage when they turn 65, but 

; it does not happen automatically. The process involves 2 main steps: (1) signing up for Part A (hospital insurance) and Part B (medical insurance) during a specified enrollment period; and (2) choosing either Original Medicare or Medicare Advantage (Part C) as the method of coverage. The enrollment period for the first step starts 3 months before the 65th birthday and lasts 7 months. There are significant and ongoing penalties (in the form of increased premiums) for patients who fail to sign up during the initial enrollment period.

The second step involves a decision that can shape very different experiences for patients: Medicare Advantage vs Original Medicare. Enrollment in Medicare Advantage as a percentage of all eligible beneficiaries continues to grow each year and now stands at 45% nationally; in 11 states, Medicare Advantage penetration is above 50% of the market.

 Medicare Advantage enrollees tend to be older and have lower incomes and more chronic conditions than Original Medicare enrollees.

 Original Medicare offers patients the flexibility to see any participating Medicare provider in the United States without a referral. Medicare Advantage HMO and PPO plans have a provider network and may require referrals to see a specialist; in return, they usually offer additional services (vision, hearing, and dental), no Part B copayments, and a bundled drug plan. Original Medicare offers the flexibility to choose a supplemental insurance plan and a drug plan (Part D) from a wide range of options.

How much do patients pay for Medicare? Costs in each part of Medicare can be broken down into premiums, deductibles, and co-payments. Most Medicare beneficiaries receive Part A insurance “premium free” in return for contributing Medicare taxes during their or their spouse’s working years. The deductible for Part A in 2022 is $1556 for each hospital stay per benefit period and co-payments for inpatient stays are $0 for the first 60 days. Premiums for Part B are more complicated and are tied to adjusted gross income (AGI) of the beneficiary 2 years earlier. In 2022, everyone with AGI less than $91,000 (individual) or $182,000 (joint filers) in 2020 will pay $170.10/month for Part B; higher earners must pay an income-related monthly adjustment amount (IRMAA) that can be up to an additional $408.20/month. As mentioned earlier, there is a late enrollment penalty for people who do not sign up for Part B when they are first eligible—10% added to the premium for each year they were eligible but did not enroll. The annual deductible for Part B is $233 and the co-insurance is 20% of the allowed charges (original Medicare). Seniors pay the same premium for Part A (usually zero) and Part B whether they are in Original Medicare or Medicare Advantage; Advantage plans may subsidize part of the Part B premium, may have their own premium, and may have their own co-insurance for services.

Is a supplemental plan required? No, but most people (around 85%) with Original Medicare have a supplemental insurance policy that they buy themselves during initial enrollment (Medigap) or are provided through employer insurance. Medigap insurers are licensed by states but the policies (benefits) offered are standard across the country; Medigap policies are no longer allowed to cover the Part B deductible, and all cover Part A co-insurance and some or all of the Part B co-insurance.

 Some plans cover emergency services in other countries. (Original Medicare does not.) (See 

.) The only differences between a given plan offered by 1 insurer vs another are the premium and, perhaps, the customer service (website, bill payments, etc).

What about preexisting conditions? People newly eligible for Medicare cannot be denied Part A, Part B, or Medigap insurance (if they apply during the initial enrollment period) because of preexisting conditions, and Medigap renewal is guaranteed (premiums can go up). In all but 4 states, though, an insurance company can deny Medigap coverage except during the initial enrollment period. One common scenario is that a senior may have enrolled in Original Medicare with a Medigap policy, but later switched to Medicare Advantage. If they wish to return to original Medicare with a supplement, they may have to undergo underwriting for a Medigap policy and can be denied (except under special circumstances). Similarly, it is not easy to switch between Medigap plans. In practice, seniors can be “locked into” their Medigap selection for as long as they remain in Original Medicare. It’s an important decision.

The final piece of the puzzle is the most complicated: plans that cover prescription drugs. Seniors in Medicare Advantage plans typically have their drug plan bundled as part of that plan, and those in Original Medicare purchase a Part D drug plan from an insurer licensed in the state. Like Part B, there is a permanent premium surcharge if a senior doesn’t enroll in Part D when first eligible; like Part B, the monthly premium for Part D is adjusted for income (IRMAA). Unlike Medigap policies, Part D drug plans may be easily switched annually. Part D plans have a deductible (less than $480) and a standard but complex framework for co-insurance after the deductible is met. (See 

.) For all plans, there is an initial coverage period with co-insurance determined by the plan and the drug tier; once a drug cost threshold is exceeded (in 2022, this is $4430) there is a coverage gap or “donut hole” during which the beneficiary usually pays 25% of drug cost until true out-of-pocket costs exceed $7050; finally, there is a catastrophic period where the co-insurance is usually 5%. Medicare’s website can guide seniors through plan options available in their area based upon their current medications and prescriptions and estimate total out-of-pocket costs.

Here is a fictitious example that can illustrate what a senior might face with Medicare coverage. A 65-year-old attorney with a 2020 AGI of $500,000 has just retired, enrolled in original Medicare, and purchased a Medigap Plan G policy and Part D drug plan. He takes Eliquis 2.5 mg bid and tamsulosin 0.4 mg q day. Assuming no hospitalizations, outpatient procedures, or doctor visits, his costs in the first year are as follows:

Part B premium (including IRMAA): $544 monthly

Part D premium (including IRMAA): $101 monthly

Drug cost (average): $90 monthly (projected annual out-of-pocket expense through all phases/12)

If the same patient had a hip replacement as an inpatient, his costs would be as follows:

Part A deductible: $0 (covered by Medigap Plan G)

Copays for doctor visits: $0 (Covered by Medigap Plan G)

Co-insurance for surgeon fee: $0 (Covered by Medigap Plan G)

Medicare is an entitlement program enjoyed by millions of Americans but it is neither automatic nor free; many recent retirees may find they pay more out of pocket for Medicare in their first years than they did for private insurance. Medicare patients make up a significant fraction of the typical urology practice, and those in Original Medicare enjoy coverage for medically necessary services without a need for referral or, usually, prior authorization for tests and procedures. Urologists will benefit from a working knowledge of the program, the benefits, and the costs as seen through the eyes of the patient. Go to medicare.gov for more perspective on the patient side of Medicare.

1. Medicare Advantage enrollment continues to surge in an increasingly complex and competitive landscape: 2022 Medicare Advantage competitive enrollment report. The Chartis Group. February 25, 2022. Accessed August 26, 2022. https://bit.ly/3pTWuK4

2. Tarazi W, Welch WP, Nguyen N, et al. Medicare beneficiary enrollment trends and demographic characteristics. Assistant Secretary for Planning and Evaluation Office of Health Policy Issue Brief. March 2, 2022. Accessed August 26, 2022. https://bit.ly/3CEoVmE

3. What’s Medicare Supplement Insurance (Medigap)? Medicare.gov. Accessed August 26, 2022. https://bit.ly/3R0rfc1

4. Explore your Medicare coverage options. Medicare.gov. Accessed August 26, 2022. https://bit.ly/3Kt6e7m

Here is what patients experience enrolling in and participating in Medicare.

Robert A. Dowling, MD

Articles

Charging for portal use: Here is what urologists should know

More access to records is good for your patients—and for you

Why is copying and pasting in the EHR such a problem?

How to understand Medicare from the patient perspective