Medicare's new plan to reduce hospital overcrowding

melloworca6 said:Alright, look, it’s obvious the Secretary and his little inner circle have completely lost the plot. Honestly, if I were a GP, I’d be raising hell right now because they’re about to dump all this liability on our shoulders. We’ll be the ones making the final calls, which just means we’ll be the ones getting sued constantly. And let's not forget that primary care offices employ doctors who haven't even finished their specializations yet—you can't just shove this kind of responsibility onto people like that. It's reckless.

What a circus.

I don't see much shifting for family doctors. It feels like the real impact will hit hospital specialists. Now, their diagnostic recommendations will actually be tracked. Up until now, the system just monitored how many referrals a GP issued.

Specialists will have to think twice before ordering unnecessary tests or follow-ups. Every recommendation they make is going on the record now.

As for chronic conditions—think diabetes, hypertension, asthma, or COPD—primary care has always handled them. The standard was to have at least 80% of those patients managed by a family doctor, with only a small fraction seeing specialists. They've been adjusting blood pressure meds or insulin doses for years, and they'll keep doing it.

That’s exactly what they fought for.

For rare or complex cases, they’ll still write the referrals and leave it to the specialists. I don't expect much change there. But there will be a shift for, say, high blood pressure patients who are used to visiting "their" specialist at the hospital every few months—people who know the specialist better than their own family doctor—just to get a "continue current therapy" note or a minor dosage tweak.

What’s the deal with mental health care lately? How can some random layman be out here running the show on psychotherapy and meds?

It really depends on the specific diagnosis.

A primary care physician isn't going to call the shots when treating psychosis. That falls squarely within the domain of a psychiatrist.

Think of it this way: a family doctor handles mild to moderate depression. However, once you get into severe cases, treatment-resistant episodes, or depression involving psychotic symptoms, you're looking at a specialist's territory.

We don't expect a GP to act as a full-scale psychotherapist; patients will continue to see their own therapists for that level of care.

But given how mental health issues are surging—some even predict depression will soon be the most prevalent condition out there—it makes sense that not everyone needs a psychiatrist. It should be reserved for those facing moderate to severe struggles.

Moderate anxiety, some phobias, a bit of OCD... maybe even a personality disorder in the mix?
(No psychosis, though)

It’s hard to give a definitive answer. Even those of us working in hospitals haven't been briefed on the full scope of the upcoming changes. My sense is that there won't be some rigid, itemized checklist defining exactly which symptoms justify a specialist referral or which ones strictly prohibit it.

Ultimately, the decision will still rest on the primary care physician's clinical judgment.

If they deem a condition mild to moderate, they’ll likely attempt to manage it with whatever medications are currently in their toolkit first. If the treatment fails to yield results or if the progress is insufficient, only then will they refer the patient to a psychiatrist.

As for patients who already have established psychiatric care, psychiatrists will now be much more mindful of appointment intervals, as those visits will be tracked under the new metrics. That said, the GP will retain the authority—just as they always have—to decide whether a follow-up is clinically necessary.

Total nonsense. Even the guy at LOM told me himself he had no clue what was going on when I was asking him about the Ad, so now suddenly he’s supposed to be an expert overnight?

Whatever. I’ve still got some credit left, so I might just go private.

Brandon Lopez6 said:Total nonsense. Even the guy at LOM told me himself he had no clue what was going on when I was asking him about the Ad, so now suddenly he’s supposed to be an expert overnight?

Whatever. I’ve still got some credit left, so I might just go private.

You’re well within your rights to switch doctors.

Most antidepressants can be prescribed by a standard family practitioner; no specialized training required.

But if your primary care physician knows nothing about antidepressants, find a new one immediately.

I live in a tiny town where the doctor situation is pretty thin on the ground... but yeah, I’ll definitely give that some thought.

So, when we're talking about psychiatrists... and those mandatory checkups... do you guys honestly think they'll scrap them? I mean, there's a massive difference between managing high blood pressure and dealing with mental health issues...

I’ve gotta say... it just doesn't sit right with me that the government would run any kind of mental health program. I mean, what’s even the point of having psychiatrists then? I could go on and get pretty nasty about it, but I won't. It isn't the doctors' fault—it's the people running the show above them. They’re (thank Bog) perfectly sane, so they couldn't care less about the rest of us. Honestly, their best move would probably be to just lock us all up in some asylum or hospice and call it a day. ☕

George Allen71 said:So, when we're talking about psychiatrists... and those mandatory checkups... do you guys honestly think they'll scrap them? I mean, there's a massive difference between managing high blood pressure and dealing with mental health issues...

Of course they won't. It’s pretty clear from the paperwork—referrals for follow-up exams are already being planned out.

Brandon Lopez6 said:I’ve gotta say... it just doesn't sit right with me that the government would run any kind of mental health program. I mean, what’s even the point of having psychiatrists then? I could go on and get pretty nasty about it, but I won't. It isn't the doctors' fault—it's the people running the show above them. They’re (thank Bog) perfectly sane, so they couldn't care less about the rest of us. Honestly, their best move would probably be to just lock us all up in some asylum or hospice and call it a day. ☕

And do you really think there are enough psychiatrists to handle everyone struggling with mental health issues?

The same logic applies to patients dealing with diabetes or hypertension. If we have specialists dedicated specifically to diabetes or blood pressure, why should someone with less expertise try to treat them? Surely those patients deserve the top experts in their specific fields.

It brings up the question: what is the role of a family doctor in this setup? Wouldn't it be more efficient for patients to go straight to a specialist? At the end of the day, a specialist is an expert in a specific disease, organ, or system. They know significantly more about their niche than a general practitioner ever could.

Nicholas Myers said:Of course they won't. It’s pretty clear from the paperwork—referrals for follow-up exams are already being planned out.

And do you really think there are enough psychiatrists to handle everyone struggling with mental health issues?

The same logic applies to patients dealing with diabetes or hypertension. If we have specialists dedicated specifically to diabetes or blood pressure, why should someone with less expertise try to treat them? Surely those patients deserve the top experts in their specific fields.

It brings up the question: what is the role of a family doctor in this setup? Wouldn't it be more efficient for patients to go straight to a specialist? At the end of the day, a specialist is an expert in a specific disease, organ, or system. They know significantly more about their niche than a general practitioner ever could.

So what, we’re just supposed to sit here and take it because—what?—there aren't enough doctors available? 🤷

People could ask the exact same thing about diabetes or high blood pressure. If there are specialists specifically for diabetes or hypertension, why should they be treated by someone who knows less than those experts? They deserve the best specialists in their fields too, right?

In my book, "high blood pressure/diabetes" doesn't really fall into the same bucket as mental illness. Honestly, unless you've been through it (and I don't mean just feeling a little down), it's hard to get how much someone needs constant contact with a psychiatrist. Sure, if the local clinic handles it, problem solved, right? But can I just drop by and hang out for an hour? And what about the folks with blood pressure or sugar issues who are just waiting on a prescription?

Brandon Lopez6 said:So what, we’re just supposed to sit here and take it because—what?—there aren't enough doctors available? 🤷

People could ask the exact same thing about diabetes or high blood pressure. If there are specialists specifically for diabetes or hypertension, why should they be treated by someone who knows less than those experts? They deserve the best specialists in their fields too, right?

In my book, "high blood pressure/diabetes" doesn't really fall into the same bucket as mental illness. Honestly, unless you've been through it (and I don't mean just feeling a little down), it's hard to get how much someone needs constant contact with a psychiatrist. Sure, if the local clinic handles it, problem solved, right? But can I just drop by and hang out for an hour? And what about the folks with blood pressure or sugar issues who are just waiting on a prescription?

Of course not. Instead, there should be some actual vetting involved. We need to distinguish those who truly require psychiatric intervention from those who simply don't. For instance...

So, once LOM starts working, does that just fix everything? Is that the end of the story? Can I just swing by his place and hang out for an hour or so?

Perhaps this conversation serves a dual purpose. It might help some people resolve their issues directly with a primary care physician, potentially bypassing the need for a specialist altogether. Meanwhile, those who truly require psychiatric intervention will likely move up the queue, getting seen sooner because the caseload has been lightened. 🤷

I honestly have no clue, look...

Back in January (after my condition had finally leveled off for a bit), things took a nasty turn for the worse. I stumbled upon some info online about how even primary care doctors are doing some kind of psychotherapy now and prescribing meds for mental health stuff. Personally, I’d much rather just talk things out than pop pills, so that would be perfect. Plus, dealing with a mix of mild agoraphobia and this phobia that keeps me from going anywhere solo, being able to see a doctor right here in my hometown would be a lifesaver.
So, I went to see my doctor and explained what I'd read. He basically told me I should probably head to Washington, D.C., because my issues were "too much" for him to handle. I tried booking an appointment in a nearby city, but when they told me they weren't taking anyone new until late August or September, I just gave up. Sure, it's closer and easier to get to, but I couldn't deal with waiting that long.
Even if my doctor suddenly decided he was down to do counseling sessions with me, I’d be pretty skeptical. If he didn't get it yesterday, why would he suddenly get it today? The only real move is what you guys suggested—switching to a different doctor. But in a small town like this, nobody talks about whether someone is "crazy" (there are only two categories here: crazy or sane), so I have no idea which other doctor to pick or who might actually be more specialized than my current one.
Don't get me wrong, he's a great doctor. He does everything he can to help me out, but when it comes to this side of medicine, he either doesn't understand it or he's too afraid to "play around" with those kinds of things. 🤷

Brandon Lopez6 said:I honestly have no clue, look...

Back in January (after my condition had finally leveled off for a bit), things took a nasty turn for the worse. I stumbled upon some info online about how even primary care doctors are doing some kind of psychotherapy now and prescribing meds for mental health stuff. Personally, I’d much rather just talk things out than pop pills, so that would be perfect. Plus, dealing with a mix of mild agoraphobia and this phobia that keeps me from going anywhere solo, being able to see a doctor right here in my hometown would be a lifesaver.
So, I went to see my doctor and explained what I'd read. He basically told me I should probably head to Washington, D.C., because my issues were "too much" for him to handle. I tried booking an appointment in a nearby city, but when they told me they weren't taking anyone new until late August or September, I just gave up. Sure, it's closer and easier to get to, but I couldn't deal with waiting that long.
Even if my doctor suddenly decided he was down to do counseling sessions with me, I’d be pretty skeptical. If he didn't get it yesterday, why would he suddenly get it today? The only real move is what you guys suggested—switching to a different doctor. But in a small town like this, nobody talks about whether someone is "crazy" (there are only two categories here: crazy or sane), so I have no idea which other doctor to pick or who might actually be more specialized than my current one.
Don't get me wrong, he's a great doctor. He does everything he can to help me out, but when it comes to this side of medicine, he either doesn't understand it or he's too afraid to "play around" with those kinds of things. 🤷

I don't think the new model will change much regarding referrals in your situation; essentially, your primary care physician will likely still be sending you to a psychiatrist.

From what I understand, family practitioners aren't trained to perform psychotherapy—at most, they might handle some surface-level therapeutic interventions. There may be rare cases where a doctor has pursued extra training specifically in psychotherapy, which isn't strictly a field reserved for psychiatrists.

The only gray area is the detail about hospital access. I haven't seen any clear guidelines outlining the specific criteria for which facility a patient can be sent to. So, as for whether you'll be able to receive treatment in Washington, D.C. via a referral, I can't say for sure.

But, as I've mentioned before, under this new model, I doubt anyone is going to force a primary care doctor to stop referring patients to specialists.

So, I was wondering about this situation where you’ve been traveling to a different city to see a specific specialist for quite a while now. If I've been seeing the same doctor consistently, and they’re the ones proactively scheduling my follow-up appointments, will Medicare suddenly step in and mandate that all those check-ups have to be moved to the local clinics listed on my insurance card? Or is everything just going to stay exactly as it has been?

Nicholas Myers said:Avastin is a medication administered strictly within a clinical setting—we're talking infusion vials here, right?—and a primary care physician has nothing to do with drugs like that.

Actually, no. Avastin is a targeted therapy, and while we often think of infusions, there are smart drugs available in capsule form that are currently on hospital formularies; for instance, they’re used alongside chemotherapy for advanced colorectal cancer. Take Temodal, for example—it's a first-line treatment for glioblastoma, administered in combination with radiation during the first cycle and then as a standalone treatment for the next five cycles. That is also on the hospital formulary. We are talking about targeted biological therapies here—extremely expensive medications—even though our legal framework in the US still hasn't clearly defined what actually constitutes an "expensive" drug. Because of that ambiguity, it's completely unclear what criteria will be used to decide if something is considered overpriced or a "budget-friendly" option. It looks like generic manufacturers are going to be hitting the jackpot in America.
And based on how this works, the decision-making process is going to be a mess. An oncologist will propose a specific therapy, Medicare might withhold its blessing, and then you're left asking who is actually footing the bill and how much influence hospital review boards will truly have in the process... or if they'll even matter at all. To receive oncology treatment, a patient doesn't necessarily need to be hospitalized; they can take medications like Temodal at home and just head into the clinic for radiation sessions.

Angela Wright said:Actually, no. Avastin is a targeted therapy, and while we often think of infusions, there are smart drugs available in capsule form that are currently on hospital formularies; for instance, they’re used alongside chemotherapy for advanced colorectal cancer. Take Temodal, for example—it's a first-line treatment for glioblastoma, administered in combination with radiation during the first cycle and then as a standalone treatment for the next five cycles. That is also on the hospital formulary. We are talking about targeted biological therapies here—extremely expensive medications—even though our legal framework in the US still hasn't clearly defined what actually constitutes an "expensive" drug. Because of that ambiguity, it's completely unclear what criteria will be used to decide if something is considered overpriced or a "budget-friendly" option. It looks like generic manufacturers are going to be hitting the jackpot in America.
And based on how this works, the decision-making process is going to be a mess. An oncologist will propose a specific therapy, Medicare might withhold its blessing, and then you're left asking who is actually footing the bill and how much influence hospital review boards will truly have in the process... or if they'll even matter at all. To receive oncology treatment, a patient doesn't necessarily need to be hospitalized; they can take medications like Temodal at home and just head into the clinic for radiation sessions.

I'm not sure about Avastin in capsule form; I was thinking of this one instead. Avastin. The kind I encounter.

Aside from that, you have Temodal. It’s typically the first line of defense against glioblastoma. Usually, the initial cycle is paired with radiation therapy, followed by five solo cycles. It's also on the preferred drug list.

With this specific medication, general practitioners aren't even in the loop. As far as I understand from the briefings we've received, that rule about doctors being required to prescribe the cheapest option doesn't apply to drugs currently on the hospital formulary.

An oncology patient doesn't necessarily need to be stuck in a hospital bed to receive treatment. It’s possible to manage things from home—taking medications like Temodal, for instance—while simply heading into the clinic for radiation sessions.

Regarding Sutent Tabet, I know for a fact that patients pick up their prescription at the hospital and then just take it once they get home.

There's no connection between the litigation and that medication. Period.

What lies ahead for our hospitals? Honestly, I haven't the slightest clue.

vilenjačica As I was saying:
If you ask me, this is just going to create an even bigger mess... I honestly can't make heads or tails of these new guidelines. It’s a total disaster—nothing makes any sense!Heading out to the outpatient clinic. So, the specialist ordered more testing just because he felt like it... what am I even supposed to do with that now? What kind of referral is he going to write me to make this actually useful? Honestly, I’m starting to think even my own doctor won't have a clue how to handle this mess. Hah!

Honestly, I have no idea why you people think you need to be experts on medical prescriptions. It’s not your job to decipher the fine print!
They’re going to issue you an outpatient referral, and honestly, I don't see what the big deal is. What part of that is unclear?

Angela Wright said:Look at what’s highlighted here—it says everything you need to know. We’re talking about guidelines that are so incredibly vague that even the bureaucrats at Medicare can't make sense of them half the time. It’s all just a mess of conflicting limits. Here’s the kicker: if a Medicare auditor decides they don't like how a prescription was handled, they don't just ask questions; they go straight for the doctor's paycheck. They dock the physician's salary to cover the cost of the medication or the travel voucher, and there is zero recourse. No chance to appeal, no chance to explain the medical necessity. You prescribe Avastin for something outside of the one specific line item Medicare has authorized, and suddenly the doctor is paying for it out of pocket. It makes me wonder: what kind of cheap generic are they going to force you to prescribe just to stay in their good graces? 😍

Nicholas Myers said:As far as I can tell, those guidelines weren't even drafted by family practitioners.

Take drugs like Zyllt, Plavix, or Pigrel, for instance.

I remember one of my early days in general practice (that's long behind me now) vividly. My hands were actually shaking when a patient handed me a discharge summary from a specialist. They had been prescribed one of these medications following a heart attack, yet the patient hadn't received a stent or a bypass.

Naturally, Medicare mandates that in this specific scenario, the patient has to foot the bill themselves, and the cost is astronomical.

The encounter turned incredibly tense. The patient nearly came at me, and then the attending cardiologist stepped in, using roughly this kind of tone and logic.

But look, if you check the Medicare website, there's a public list detailing exactly which medications are covered "for free" and which ones require out-of-pocket payment.

Who actually compiled that list? No idea.

Jane—look, let’s get one thing straight. Avastin, just like all those other chemos, has absolutely nothing to do with my primary care doctor. These drugs aren't something you just pick up at a local pharmacy on a whim. They are administered in a hospital setting, fully covered by the hospital budget, specialized drug funds, or whatever specific insurance guideline is currently in play. My doctor couldn't prescribe this even if they wanted to! It’s strictly regulated. Because these medications are flagged for hospital administration only, that rule applies whether we're talking about tablets or IV infusions. Period.
What the hell am I going to say? I’ll tell you exactly what I think, and I mean this: if they have a properly signed medical history on file, then I don't give a damn about Medicare's guidelines or their ridiculous penalties. I truly do not care if they get slapped with a fine. I am prescribing medication based on professional medical standards—period. You and Medicare are the only ones treating patients this way anywhere in the world! If you follow those rigid little rules instead of actual medicine, a patient could literally die right in front of you because of it. It has this risk, it has that complication... I don't care. None of that matters to me. YOUR inspectors—you’re the ones who denied the patient their medication in the first place. Why even send it to an inspector if you're just going to block it? I CAN PROVIDE EXAMPLES.
The Cat, I’m sorry you had to deal with that (and I’m sure you weren't the only one), but I completely get why the patient reacted the way they did—not talking about any physical fighting, obviously—but you aren't giving them a drug that is CLEARLY INDICATED BY MEDICAL GUIDELINES. Once that happens, as far as I'm concerned, and 95 percent of SKZZ, the conversation ends right there. We've said our piece; from here on out, the responsibility for that patient lies squarely on your shoulders.

vividsailor7 said:

vilenjačica As I was saying:
If you ask me, this is just going to create an even bigger mess... I honestly can't make heads or tails of these new guidelines. It’s a total disaster—nothing makes any sense!Heading out to the outpatient clinic. So, the specialist ordered more testing just because he felt like it... what am I even supposed to do with that now? What kind of referral is he going to write me to make this actually useful? Honestly, I’m starting to think even my own doctor won't have a clue how to handle this mess. Hah!

Honestly, I have no idea why you people think you need to be experts on medical prescriptions. It’s not your job to decipher the fine print!
They’re going to issue you an outpatient referral, and honestly, I don't see what the big deal is. What part of that is unclear?

Jane—look, let’s get one thing straight. Avastin, just like all those other chemos, has absolutely nothing to do with my primary care doctor. These drugs aren't something you just pick up at a local pharmacy on a whim. They are administered in a hospital setting, fully covered by the hospital budget, specialized drug funds, or whatever specific insurance guideline is currently in play. My doctor couldn't prescribe this even if they wanted to! It’s strictly regulated. Because these medications are flagged for hospital administration only, that rule applies whether we're talking about tablets or IV infusions. Period.
What the hell am I going to say? I’ll tell you exactly what I think, and I mean this: if they have a properly signed medical history on file, then I don't give a damn about Medicare's guidelines or their ridiculous penalties. I truly do not care if they get slapped with a fine. I am prescribing medication based on professional medical standards—period. You and Medicare are the only ones treating patients this way anywhere in the world! If you follow those rigid little rules instead of actual medicine, a patient could literally die right in front of you because of it. It has this risk, it has that complication... I don't care. None of that matters to me. YOUR inspectors—you’re the ones who denied the patient their medication in the first place. Why even send it to an inspector if you're just going to block it? I CAN PROVIDE EXAMPLES.
The Cat, I’m sorry you had to deal with that (and I’m sure you weren't the only one), but I completely get why the patient reacted the way they did—not talking about any physical fighting, obviously—but you aren't giving them a drug that is CLEARLY INDICATED BY MEDICAL GUIDELINES. Once that happens, as far as I'm concerned, and 95 percent of SKZZ, the conversation ends right there. We've said our piece; from here on out, the responsibility for that patient lies squarely on your shoulders.

I can't weigh in much more since I'm working in a hospital now myself. 😍

That experience in primary care really helped me grasp how the entire system actually functions.

And yeah, they don't call them inspectors. They just show up at the clinics and comb through the charts. When half your paycheck gets docked because of it, it matters.

If they spot even a few instances of rule violations, the penalties can escalate significantly.

I hate to say it, but you're mistaken. Even we hospital doctors are part of the Medicare system; it's our superior, not just the family practitioners.

It's like saying, "I listen to my department head, but I couldn't care less about the hospital director!"

Every specialist knows the prescribing criteria. No one is asking them to withhold medication, but they are obligated—especially if a primary care doctor sends it back—to explain to the patient that they'll have to pay for it. They shouldn't pretend they've never heard of Medicare guidelines, or worse, lie and claim the patient doesn't have to pay.

That's just plain wrong.

The medication isn't being denied; the patient still gets a prescription, it's just a private pay script.

As for the lack of funding? To be blunt, that falls outside the scope of a family doctor's job.