Dr. Michael R. Natalino's waiting room was eerily empty one morning last week. No one was in the reception area to greet a visitor. No one was sitting in any of the waiting room chairs.
After 27 years of caring for thousands of patients, Natalino, 65, came to the anguished conclusion that it no longer made financial sense to keep his office open. So the San Antonio pulmonologist shuttered his practice early this month.
“I don't want to quit medicine, but I know there is no choice,” Natalino said.
The unpredictability associated with Medicare reimbursements, the recurring threat of cuts in Medicare payments to physicians and mounting bureaucratic hurdles in health care are all to blame for the closing, he said.
Natalino's complaints are echoed by many doctors, some of whom have chosen not to take on new Medicare patients or have dropped out of the program. But those instances don't compare with the drastic measure of closing a practice.
“It's a gut-wrenching decision for a physician to do that,” said Dr. Susan Bailey, president of the Texas Medical Association. “Physicians don't like to leave their patients. To shut down a practice is a real tragedy.”
Respiratory & Intensive Care Associates, which operated in the shadows of Northeast Baptist Hospital, was running in the red, Natalino said, because he hadn't been paid on some $500,000 billed to Medicare in the past year.
Medicare uses “any reason to slow down, reduce or basically stop payment,” Natalino said.
It took two employees to handle Medicare billing: one to perform the actual billing and the other to deal with all the denials, he said.
Peter Askenaz, a spokesman for the Center for Medicare and Medicaid Services, responded that claims are paid within two weeks to 30 days, provided there are no billing errors. That's quicker than private insurers, which can take up to six months, he said.
“We know we're the fastest payer out there, as long as there are no problems,” he said.
Something as simple as an incorrect mailing address for a physician can cause Medicare's contractor to withhold payments until the problem is cleared up, another CMS representative wrote in an e-mail.
CMS representatives declined to speak about Natalino's situation because he didn't grant them permission. He's concerned it could affect his ability to collect what he said he's owed from Medicare.
Medicare patients accounted for 80 percent of Natalino's practice, which is not uncommon for a specialist who treats illnesses that typically affect older people.
“If you lose 80 percent of your revenue, then you don't have even enough to make your overhead,” said Antonio W. Felices, a medical business consultant who advises Natalino. Overhead runs about 60 percent of revenue at an efficient practice, Felices noted.
“I haven't taken home a paycheck in a couple of months,” Natalino added. “There's no money.”
Besides not getting paid by Medicare, Natalino has fretted over pending cuts in Medicare payments to physicians. Doctors escaped a 21 percent reduction last month after President Barack Obama signed legislation pushing it back until the end of November.
“I don't wish to continue to be angry and anxious and frustrated all the time,” Natalino said.
Neither do other doctors. Texas Medical Association members have reported more physicians are weighing whether to accept new Medicare patients or to continue treating others.
CMS counters that the number of doctors participating in the program has been on the rise. Its data show 94.6 percent of Texas doctors participate in Medicare, up from 89.4 percent in 2003.
“The conventional wisdom isn't supported by the hard data,” wrote CMS spokesman Bob Moos in an e-mail.
But Bailey, the medical association president, said that “CMS is not going to reflect doctors who are not taking new patients, (and) it's not going to reflect how doctors are trying to book fewer (Medicare) patients in a week so they don't lose as much money.”
Neither was an option for Natalino. A specialist who turns down a Medicare referral from a primary care physician risks losing from that same doctor a referral covered by private insurance, he said
“A specialist is in a difficult position,” said Dr. John Holcomb, a pulmonary- and critical-care specialist in San Antonio.
Natalino isn't optimistic that the landmark health care reform legislation passed this year will improve the outlook for medical care. He predicted the changes will lead to reductions in care and more rigid rules for doctors in how they care for patients.
“U.S. medicine is now the most regulated business in the world, and here they are going to (make) it even more so,” he said. “With each one of those (new regulations), the cost goes up. ... It takes a lot of the flexibility away of taking care of patients.”
Natalino wanted to continue to treat his patients for another five years before he retired. Now his patients have been referred to another physician.
Natalino will join Cedra Clinical Research LLC, where he will monitor subjects in clinical drug tests, among other things.
“It's OK,” he said. “But it's not what I've done, and what I feel like I was meant to do.”
