Primary care before Medicare

Ernie Chaney, MD, FAAFP, practiced family medicine in Belleville, Kansas from 1957 through the early 1980s. Now 87 and retired in Texas, Chaney spoke recently with Medical Economics about what it was like practicing medicine before Medicare, and how the arrival of Medicare affected his relations with his patients.

Q: How long were you in practice?

A: I started in 1957. I practiced in Belleville, Kansas, a town that was 3,000 in population. In the early 1980s I got seduced into academic medicine at the medical school in Wichita where I was director of the family practice residency training program. I did that for about 14 years then retired, but then the dean called me and said ‘I need someone to take care of the family practice department,’ so I went back for a couple of years. I’ve been retired since then.

Q: Before the start of Medicare, how did your elderly patients pay for their care?

A: Some of them had some retirement (insurance). Most of them were agricultural people. It was a wheat-farming community. And if they were unable to pay their bill, then my partner and I just sent them a Christmas card saying "Merry Christmas," I know you’re having a tough time and just forget about the bill.

Q: What did you think of Medicare when you first heard about it?

A: I had some concerns about the third party payer between me and the patient. And that did happen, in my observation. It was easy for us to say to the patient, you need to have something done, it will cost this much and we’ll have to see how we can pay for it.

Later on, when a lot of people had the (Medicare) insurance, then the philosophy of the patient sometimes changed to, ‘I really want one of these tests. I think you owe it to me because I’m paying taxes and the government’s paying for it anyway.’ That certainly did happen to us, and I’m sure it happened to other physicians.

Q: How did Medicare change the day-to-day operations of your practice?

A: It sure interfered in the business end of the practice. You had to then make sure that the people working in your office knew about all the rules and regulations and things that had to be done to get paid. And if you wanted to get paid at all you had to follow them.

In addition, you had to be sure your office personnel filled out everything properly. You were always concerned that even with an honest mistake they may turn around and say, ‘Oh you’ve done something here, we’re going to have to review all your charts.’

Q: Did you have to hire more staff?

A: Yes, and they had to be trained. You had to make sure they understood the government rules and regulations to make sure you got paid, and that you didn’t get accused of any kind of lack of knowledge of what you had to do.

Q: What do you think your patients thought about Medicare?

A: I think most of them didn’t understand how much it was going to affect their care. We had some patients who thought, well, the government’s paying for it so I can get everything I want. I’d like to have a chest x-ray. Well, you had one two years ago, you don’t have any problems that need to have a chest x-ray, so I don’t think you need one. Well the government’s paying for it so I want to have one. It’s my philosophy, that if you pay for something out of your own pocket, or at least a portion of it, then you have more appreciation of how money is spent in medicine.

Q: Looking back, do you think Medicare was beneficial to your practice? Your patients?

A: I don’t think that’s the answer to the problems we have in the practice of medicine. I think a better way is to have a good relationship between the patient and the physician not only in healthcare needs but in payment for the healthcare. And for those who really can’t pay, then I think it’s my responsibility as a physician to give that care for free, and not rely on some third party.

I don’t think Medicare, to our situation, was a great benefit. I’m not sure it was worth anything at all.