Theproposed changes might make it a bit simpler to find a doctor whotakes new Medicare patients, but it could lead to higher costs forseniors. (Photo: Shutterstock)

Vowing to protect Medicare with "every ounce of strength,"President Donald Trump last week spoke to a cheering crowd inFlorida. But his executive order released shortly afterward includes provisionsthat could significantly alter key pillars of the program by makingit easier for beneficiaries and doctors to opt out.

The bottom line: The proposed changes might make it a bitsimpler to find a doctor who takes new Medicare patients, but itcould lead to higher costs for seniors and potentially expose someto surprise medical bills, a problem from which Medicare hastraditionally protected consumers.

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"Unless these policies are thought through very carefully, thepotential for really bad unintended consequences is front andcenter," said economist Stephen Zuckerman, vice president forhealth policy at the Urban Institute.

While the executive order spells out few details, it calls forthe removal of "unnecessary barriers" to private contracting, whichallows patients and doctors to negotiate their own deals outside ofMedicare. It's an approach long supported by some conservatives,but critics fear it would lead to higher costs for patients. Theorder also seeks to ease rules that affect beneficiaries who wantto opt out of the hospital portion of Medicare, known as PartA.

Both ideas have a long history, with proponents and opponentsduking it out since at least 1997, even spawning a tongue-in-cheeklegislative proposal that year titled, in part, the "Buck NakedAct." More on that later.

"For a long time, people who don't want or don't like the ideaof social insurance have been trying to find ways to opt out ofMedicare and doctors have been trying to find a way to opt out ofMedicare payment," said Timothy Jost, emeritus professor atWashington and Lee University School of Law in Virginia.

The specifics will not emerge until the Department of Health andHuman Services writes the rules to implement the executive order,which could take six months or longer. In the meantime, here are afew things you should know about the possible Medicare changes.

What are the current rules about what doctors can charge inMedicare?

Right now, the vast majority of physicians agree to accept whatMedicare pays them and not charge patients for the rest of thebill, a practice known as balance billing. Physicians (andhospitals) have complained that Medicare doesn't pay enough, butmost participate anyway. Still, there is wiggle room.

Medicare limits balance billing. Physicians can charge patientsthe difference between their bill and what Medicare allows, butthose charges are limited to 9.25% above Medicare's regular rates.But partly because of the paperwork hassles for all involved, onlya small percentage of doctors choose this option.

Alternatively, physicians can "opt out" of Medicare and charge whatever theywant. But they can't change their mind and try to get Medicarepayments again for at least two years. Fewer than 1%of the nation'sphysicians have currently opted out.

What would the executive order change?

That's hard to know.

"It could mean a lot of things," said Joseph Antos at theAmerican Enterprise Institute, including possibly letting seniorsmake a contract with an individual doctor or buy into somethingthat isn't traditional Medicare or the current private MedicareAdvantage program. "Exactly what that looks like is not soobvious."

Others said eventual rules might result in lifting the 9.25% capon the amount doctors can balance-bill some patients. Or the rulesaround fully "opting out" of Medicare might ease so physicianswould not have to divorce themselves from the program or could stayin for some patients, but not others. That could leave somepatients liable for the entire bill, which might lead to confusionamong Medicare beneficiaries, critics of such a plan suggest.

The result may be that "it opens the door to surprise medicalbilling if people sign a contract with a doctor without realizingwhat they're doing," said Jost.

Would patients get a bigger choice in physicians?

Proponents say allowing for more private contracts betweenpatients and doctors would encourage doctors to accept moreMedicare patients, partly because they could get higher payments.That was one argument made by supporters of several House andSenate bills in 2015 that included direct-contracting provisions.All failed, as did an earlier effort in the late 1990s backed bythen-Sen. Jon Kyl (R-Ariz.), who argued such contracting would giveseniors more freedom to select doctors.

Then-Rep. Pete Stark (D-Calif.) opposed such direct contracting,arguing that patients had less power in negotiations than doctors.To make that point, he introduced the "No Private Contracts To Be Negotiated When thePatient Is Buck Naked Act of 1997."

The bill was designed to illustrate how uneven the playing fieldis by prohibiting the discussion of or signing of private contractsat any time when "the patient is buck naked and the doctor is fullyclothed (and conversely, to protect the rights of doctors, when thepatient is fully clothed and the doctor is naked)." It, too, failedto pass.

Still, the current executive order might help counter a trendthat "more physicians today are not taking new Medicare patients,"said Robert Moffit, a senior fellow at the Heritage Foundation, aconservative think tank based in Washington, D.C.

It also might encourage boutique practices that operate outsideof Medicare and are accessible primarily to the wealthy, said DavidLipschutz, associate director of the Center for MedicareAdvocacy.

"It is both a gift to the industry and to those beneficiarieswho are well off," he said. "It has questionable utility to therest of us."

KaiserHealth News is a nonprofit news service coveringhealth issues. It is an editorially independent program of theKaiser Family Foundation, which is not affiliated with KaiserPermanente.

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