Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
Medicare: What You Don't Know Might Scare You
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Medicare is nearing a breaking point that threatens healthcare access for everyone—not just seniors. In this eye-opening conversation with dermatologists Dr. Andrew Weinstein and Dr. Brad Glick, we uncover how decades of Medicare cuts have created an unsustainable situation for medical practices across America.
"Medicare reimbursement is lower now than it was in 1998," Dr. Weinstein reveals, highlighting a troubling reality that most patients don't realize. While inflation continues to drive up the cost of running a medical practice—from staff wages to supplies—Medicare payments have been steadily declining. This isn't just about physician compensation; it's about the ability to keep practices open and accessible to patients who need care.
We explore the structural differences between Medicare and Medicaid, break down Medicare's alphabet soup (Parts A, B, C, and D), and discuss why the current physician fee schedule is fundamentally flawed. Most critically, we examine why this matters to everyone—not just current Medicare beneficiaries. Dr. Glick explains, "If a doctor decides not to take Medicare, those doors are closed to patients needing specialized care.
The conversation takes an urgent turn as we discuss potential solutions and what patients can do to help preserve Medicare for current and future generations. Physicians aren't asking for excessive profits; they're fighting to maintain a system where they can afford to keep serving their communities without sacrificing the quality of care.
Whether you're currently on Medicare, paying into it through your paycheck, or simply concerned about healthcare access in America, this discussion offers essential insights into a crisis that demands immediate attention. Subscribe now to join our ongoing exploration of healthcare challenges and solutions that affect us all.
Introduction to Healthcare Concerns
Speaker 1Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
Speaker 2Welcome to the Dermot Trotter Don't Swear About Skin Care podcast. Today we're gonna maybe change that byline. I usually say don't swear about skincare, but now we're sort of shifting to this don't swear about healthcare, because we're diving in a little bit more into the issues that affect all of us across the healthcare spectrum. I have two great guests on today to actually talk about that and more particularly Medicare. A lot of you might be wondering well, what even the heck is Medicare? I'm not even on it, but maybe one day you will be, if it's still even here. But I have two guests Dr Bragg Lick. He's a board-certified dermatologist and dermatologic surgeon with clinical and academic practices in Margate and Wellington, florida. He's also a member of the board of directors of the American Academy of Dermatology, principal investigator for GSI Clinical Research and also the program director for Dermatology Residency Program located at Larkin Health System in Miami, florida.
Speaker 2I also have with me here today Dr Andrew Weinstein. He's a board certified dermatologist as well and the managing partner of Skin Care Physicians in Boynton Beach, florida. After serving on the? A board of directors, he turned his attention to the broken Medicare physician fee schedule. He's actually chair of the ad hoc task force finding common sense Medicare legislation and has mapped a clear path to stopping Medicare cuts, which we're all very excited about. But for those of you out there, our patients, you're probably wondering, well, why should this even matter to me? But things about Medicare, they might excite you, but they also might scare you. But first I'd like to open it up to my guest today to talk a little bit about well, what even is Medicare and why was it created? And how is it different from a word that might sound similar to some of you out there Medicaid. So I don't know, andy or Brad, which one of you wants to take that, but thank you for coming on and let's start off the podcast with that today.
Understanding Medicare vs. Medicaid
Speaker 3Okay, shannon, I'll tackle that one and I'll let Brad talk a little bit about Medicaid. So let me just introduce you to Medicare First of all. If you don't know about Medicare, it still knows about you. So Medicare is an important federal insurance program that's essentially for the elderly, so you become eligible for Medicare when you're at retirement age. There are some people who are eligible because of end-stage renal disease or for other reasons, but mostly you need to think about it as an insurance program that's sponsored and carried out by the federal government for the elderly in the United States. But it's got a much farther reach than that.
Speaker 3So if you have commercial insurance, if you have somebody else that pays for your healthcare in this country, the amount that is paid, the reimbursement that is given to hospitals, to pharmaceutical companies, to drugstores and, importantly, to your doctor, is set by something called the Medicare Physician Fee Schedule. And I'm very excited about Medicare because I'm about the same age as Medicare. Medicare first started in 1965, in late 1965. And then the next year I came about. So here we are. We are 59 years, 60 years into the Medicare experiment and, like you said, if we're not careful, that experiment may be over.
Speaker 2Well, that's scary, so we probably just scared everyone there. But, Brad, you mentioned the Medicaid piece. So for people that kind of confuse the two because I see this even with healthcare professionals, but obviously in the public they're like what am I on? Medicare, Medicaid, what's the difference? What is the Medicaid program system?
Speaker 4Yeah, I mean, medicaid is kind of a joint, it's federal, it's also state. Obviously, throughout the United States it's a form of health coverage that really is more for individuals of low income individuals and families. It is linked to a number of private payers as well too. We have a lot of them in Florida, the sort of called Medicaid health maintenance organizations, and it's really to help a specific population of individuals who, for instance, unlike our Medicare recipients, who in our payroll, in our checks that we're receiving throughout our lives, we're getting contributions to the Medicare program specifically. And this is really established differently both federally and also in the state to really target a specific population of individuals. It's funded by both state and federal.
Speaker 4It varies from state to state as well, and I think the idea behind Medicaid, at whatever level, whether it is straight Medicaid, like we have here in, or the Medicaid managed care plans, the so-called Medicaid HMOs it's really more for vulnerable populations, I think, is probably the best way to explain it.
Speaker 4And so you know, there's the good, which is the populations that we're reaching, and then the challenge, because the challenge is, just like Dr Weinstein said, many of these governmental programs are really based on federal funding and, at the end of the day, at least through my lenses one of the things that we see is healthcare seems to be cut at the end and the chunk of the dollars that are available to go to healthcare seem to be chiseled out at the very end.
Speaker 4And really, that's really the crux of the problem. Dr Weinstein I'll just put him on the spot here he really is an expert in this topic and explains it very well. And when we lobby on Capitol Hill, as we do every year at the Legislative Conference of American Catastrophic Dermatology and now we have this singular ask because of someone like Dr Weinstein, who believes and I do too that this is critically important for how we get paid, this is what we've been discussing on Capitol Hill and it's been a part of the challenge that we've been facing, not just this last year, not this last two years, but for 24 years, since 2001.
Speaker 3Hey, shannon, brad just said something really important. Maybe we overlooked it, but he said that when you get your paycheck, a certain amount gets taken out, and so what that means is that all of the seniors who are in Medicare right now it's not a welfare program, it's something that they paid for. So they paid for Medicare. And then in 1965, when Congress created the Medicare program, they made a promise to our seniors, and that promise was that health care was going to be there for them and our seniors paid for it. And there's a cynical game going on in Congress right now where every year, since the inception of the way we pay for Medicare, every year, we seem to get a cut, and certainly this is an amazing fact.
Speaker 3I graduated from medical school in 1998. That year, what's called the conversion factor and that is the amount that's reimbursed for Medicare was higher than it is today, and you can't sustain a system. So imagine you sold hammers. Imagine that you had to sell a hammer in 2025 for less than you did in 1998. That doesn't work out for these offices, for offices like mine that provide services for Medicare recipients, and for others, and we front the cost of that. The government is supposed to pay it back and they have just not been doing that. That's bad enough, but you know that fee schedule that they use and it's really based on the resources required to deliver a service that fee schedule that they use is used by every other insurance company. That's why, if Medicare goes down, your insurance goes down. Now, your cost of your insurance doesn't go down, the benefits go down, and that's what we've been facing. We've been facing a Congress that refuses to face its responsibility, that refuses to keep its promise to the elderly and they've already paid for that Medicare.
Speaker 2That's a great point you bring up, because I'm sure there are listeners out there like myself that's wondering well, what does this matter to me? Right now they're thinking I'm not going to be eligible for Medicare for quite a while. I might be paying into it, but again, oh yeah, it's going to be there. I think there's this false sense of security and, like you mentioned, though, the impact on kind of how that affects their benefits or my benefits, even having commercial insurance. You know where I'm at right now in life. That's where I think it's important you really highlight that for people to understand. It affects us all. It's not just you know, our grandparents that you might be thinking of, that might be on Medicare, but it affects us, you know, as a country and as a health care system. If you think about Medicare, though, for people just trying to get early and understand what it is or I've heard of ABCDEFG you know the different parts of Medicare. How would you briefly kind of explain that so people understand the different parts of the Medicare plan? If you will Sure.
Medicare Parts A, B, C, and D Explained
Speaker 4Well, I can jump in. You know there's the Medicare. Part A is more hospital-based and it's more related to, let's say, therapeutics like drugs devices that need to be performed where there needs to be covered in a different vehicle. Andy, you want to add to that?
Speaker 3Sure, I'd be delighted to expand on that. So it's interesting. Remember that Medicare was envisioned in 1965, when people would go to the doctor and they would pay their doctors and they would go to the doctor and they would pay their doctors and they would go to the hospital and they would pay the hospitals. Each of those had a different really was thought to be very different in people's minds. So, as Brad said, they made part A and there's a premium for part A. The premium is paid through your paycheck, and then there's a premium for part B, which is paid through your paycheck, and then an additional premium that you have to pay when you want to use it. So A is for hospitalization, b is for physician services. And then in 2006, they developed Medicare part D for drugs, and that's an additional premium that you pay and that's the part that this year, in 2025, they capped out at $2,000. So your maximum out-of-pocket payment is $2,000 in 2025. So that's your Part D.
Speaker 3And many of you have probably heard of Medicare Advantage. Sometimes we refer to Medicare Advantage as Part C. Medicare Advantage is a program where the Medicare system pays a certain amount to an insurance company, whether it's Aetna, humana, all of the companies do it because it's extraordinarily profitable for them. They pay them a certain amount, and for that that private company insures the lives of patients and they're entitled to bonuses above what they've been paid, and so they've been criticized for that. So they've been criticized because Medicare Part C or the Medicare Advantage programs seems to always be accused of having excess payments applied, and they have an amazing, amazing lobbying department, an amazing advocacy department that seems to always make sure that Medicare Part C gets increases, even though they're accused of being quite wasteful. So that's what you have. You have A hospitalization B for your doctor's office, d is for drugs and C is the non-traditional Medicare Advantage programs.
Why Doctors Are Frustrated with Medicare
Speaker 2So now that we have kind of a better understanding of sort of what Medicare is, so people kind of out there get an idea of the different types or you know parts of Medicare. You know one of the things I have patients come in they're like I don't understand why. You know doctors in particular are frustrated with Medicare. I think patients know I mean they get frustrated maybe with coverage issues, but how would you explain it? You know why doctors might be getting upset with the Medicare system and what's happening.
Speaker 3Yeah, I referred a little bit to this before, but let me just say my concern is not that the Medicare program will go insolvent, it's that doctors will stop taking Medicare, and that's worse than it going insolvent.
Speaker 3So the real frustration is that, that cynicism that Congress views Medicare with. So, as I said they the Medicare system is designed to be inflation sensitive, because if you take Medicare, you're not allowed to set the prices. When you go to McDonald's now, as compared to 2001, things are 20 or 30% more. When things are more in our offices, when wage inflation hits doctor's offices or when supplies increase. We had dramatic increases in our supply costs during COVID and, as a matter of fact, this year it's estimated that our supply costs are going to be up at least three and a half, if not 4%, when reimbursement goes down during those same periods of time. Doctors get frustrated and even though they want to take care of those patients, they sometimes can't. They have to do things that allow them to raise their prices, and taking Medicare is not one of those things, and it's a real conflict for a lot of doctors because we all want to take Medicare. We want to keep that promise that Congress made, but the reimbursement just has to be what the cost of delivering those services is.
Speaker 4Yeah, I couldn't agree more. And you know, I want to share a story. I think that's really the best thing to do, and I can share some patient stories too. But I want to tell you about a car ride that I was taking with a colleague of mine. You know, for the last four or five years I kind of had my head in the sand. I'm a dermatologist. I have a successful practice. Seemingly I have a successful practice.
Speaker 4I don't know, maybe I wasn't looking at my expenses just so carefully, maybe I don't look at my explanation of benefits that carefully. So I'm riding in the car with a colleague of mine who runs a practice very much like mine and as I'm talking to him he said to me Brad, my walls are kind of crumbling a little bit, I'm nervous, I'm not sure that I can keep doing it myself and my three other partners. I don't know that I can keep doing it because my expenses has exploded. The salaries of my staff members have gone up exponentially. Oh, we used to have front staff that made $12, $13, $14 an hour. Everyone makes $20 an hour now, or more, or $25 or more. It's expensive. You know, that colleague I was riding in a car with was Andrew Weinstein, and I learned a lot from that conversation, because that conversation turned me around to kind of look at what was really going on in my practice, because it looks really good, I have my own building, I see patients every day, lots of patients, but then when you start to look carefully, we're seeing patients for cut rate reimbursement.
Speaker 4The Medicare reimbursement is down if we look at it against inflation, because if you look at the graph, the graph just keeps going up on inflation. You look at that Medicare economic index, but our reimbursement is not only flat, if you look at the last four years, it's sinking down. I would ask a simple question to both of you who runs an organization, a business, this way? And I hate to use the word business because my patients don't necessarily want to hear it, but we are running a business. We have to pay for things, just like a pizza place does, a restaurant does, all the malls and the different businesses. And so I bring up this story because it opened my eyes and I thank Andy about that, because I'm concerned now too. I'm mindful about how I'm running my clinic now, and so we're feeling this pain. We really are, and so are our patients.
Business Realities of Medical Practices
Speaker 3You know, a lot of us have experienced our favorite restaurant closing and you know what happened before that restaurant closed. They were doing fine, they had customers, but the owner closed the books one day and the amount that he or she brought in was less than what it costs to run that restaurant and the next month that restaurant closed. And the same thing can happen in doctor's offices, will happen in doctor's offices. But I'll say this about dermatologists, about us. We have other options and that's one of the problems.
Speaker 3So many of our colleagues want to take care of Medicare patients, but they do other things. There's cosmetic procedures, there's cash pay, there are lots of things, and that's frustrating to patients. But the bottom line is, shannon, that the day, the month that we close our books and we have to write a check to support that office, it's likely that dermatologists that any physician won't do that anymore, and that's very much reflected in the crisis around finding a primary care physician. That's why most of them, in this area anyway, charge a very large sum thousands of dollars for a subscription to see them, this so-called concierge medicine.
Speaker 2I think that's where you know it may scare people. I think, first of all, what's important to you know, point out too, is that you know some patients and people listening might think oh well, you know Medicare cuts don't doctors already make? You know plenty of money and you know doctors do okay financially. I think they forget, like you mentioned, the reality is it is a business and you do have to pay all your employees, you have to pay the utilities, you have to do all these things and if you're not making that money to just simply afford to run a business, that's where you make tough decisions and I think, highlighting that again or pointing that out of how you said simply, you know some doctors just may choose not to take Medicare because it just can't help support, you know their practice, you know to keep up, you know from a business standpoint, that's a hard reality, emphasizing that the patients get that and it's not the doctors want to do that, it's that they're just in no other position. Or, like you said, they have options.
Speaker 2I think you know probably more popular where you're at, in Florida maybe, than other areas, but I've seen it up here to where docs have said forget Medicare, forget insurance, I'm simply going to have you pay that monthly subscription and come see me. But that's not doable for the average patient and, frankly, not that we want to get an argument of fairness. It simply just isn't fair for the people that paid into the Medicare system and expected this to be here so for patients to get an understanding of that. I think that's what I don't want them to think, because I don't want this kind of approach that people think that you know, we're not trying to necessarily get more money per se because people are trying to get wealthier. We're trying to get reimbursement that's reasonable to keep the practice or the business of medicine, you know, alive so we can continue to care for Medicare patients, because I think that's an important message that we emphasize. Would you not agree?
Speaker 4No, I completely agree. That is so well stated and this isn't really about me. Money that Brad gets or Andrew gets, it's for the practice, for our patients, number one. And in order for us to be able to care for our patients, we have to pay our bills. We have to pay our staff members. To pay our staff members, I had to make some decisions this last couple of years in terms of how we structure the number of staff members we have in the clinic. The expenses have gone up.
Speaker 4If I take away one individual because of various decision-making that I have to make within my practice, in my opinion that affects access to care, and it's all about the access to care, Shannon. I mean the example of concierge medicine, VIP practices or dermatologists just taking cash-only practices, and it's happening. It may not be 20%, it may not be even 10%, but it's rising. Dr Weinstein and I have many colleagues that are starting to do this, particularly as they're getting mid-range in their career, because they're frustrated. And here's the biggest problem in that dynamic If someone doesn't take Medicare or if they take cash only, those doors are closed. Here in South Florida, those patients who have skin cancer what is the cash paying physician going to do. They want to go and see a patient with a skin cancer who's not willing to pay cash, who really wants their coverage to be through their health plan. It's going to block the access to our seniors here in South Florida who really need the care that they deserve.
Speaker 3Yeah, there's two sides to it. Right that no physician is going to close his or her office if a bundle of money is coming in? That's not what's happening. Offices are literally closing because the cost to run that practice is more than they bring in in that month. So we're really there.
Speaker 3You know it gets to this idea. It's kind of an esoteric concept in economics and business called the margin. And as you get closer to the margin, your ability, you know you could be, your margin could be five or 10% and you could be doing fine. You're, yes, you're doing fine. You're paying all your bills, you're taking home a nice paycheck and when you get with the next month, you're so close to that margin, it's zero. So the difference between surviving, you know it's like, it's like Walmart. You know Walmart, I think I don't know what their margin is like two or 3%, but you know it's hundreds of billions of dollars. I'm probably exaggerating that, but it's okay until they cross over that margin and that's when Walmart stopped selling things and that's that's really where we are. So we're close to the margin.
Speaker 3So we do things like we try to, we try to cut services. So in my office, when you call the office, somebody answers the phone, people appreciate that it provides good continuity of care. Those are things that have to go by the wayside. We help our patients get medications. We will not be able to afford to do that because that extra employee might push us over the edge.
Speaker 3And in reality, the reason why I consider it so cynical is that Congress knows that the amount that an office is reimbursed is not physician salary not at all. It's for the real resources that are associated with delivering that health care service, and most of it is the cost of table paper and supplies and your employees and your amount for all the things you need to do. So not reimbursing you for that is cynical, because we are not permitted when you take Medicare. You're not permitted to charge what you want. The market forces don't apply.
How Medicare Cuts Affect Patient Access
Speaker 3So we need to do something right now. We need to make sure that seniors know that their Medicare benefits are in jeopardy, that it's a real threat, and I think that if they knew that, I think that they would be on the phone right away with their congressmen, their congresswomen and their senators and they would say it's time for you to stop cutting Medicare, because this year, this year alone, congress failed to intervene when Medicare was cut by 2.8%. That might not seem like a lot, but that is what accounts for essentially, us being 75% down. You know again, since 1998, costs are up by somewhere between 75 and 100% and our reimbursements down. That's not, that is not a formula for me to take care of somebody's grandmother.
Speaker 2And you just touched upon this, you know, andy, in the last, like you know, couple minutes here. What can patients do?
Speaker 4no-transcript the whole issue, because even organizations, whether it's the AMA, the AOA, even our American Academy of Dermatology, you know, we lobby on Capitol Hill. We try to do all the right things to make our voices be heard. But that's part of the problem, shannon. You just basically said it. We have to have Congress hear our patient voices. And so how do we accomplish that? You know, picking up the phone and calling the senator's office, whether it's in the state or it's federal. It was very difficult.
Speaker 4You know, one of the ways that we've done this and it's somewhat effective is, you know, qr codes, links that patients can directly write their own letter. There's crafted letters on their behalf. That's how we start. But I think there's a bigger picture here, and the bigger picture is that we need to put our patients on stage. They need to. The Congress needs to hear the voices of our patients live and in person. They need to see it from the overpasses of highways with posters that basically say I can't get into my doctor's office because there's an obstruction to care, because the walls are crumbling inside the office, because the three people that used to be at the front, dr Glick and Dr Weinstein can't really afford to keep three people, maybe two, maybe only one, because the costs to run our practices have gone up so much. So we're being a little redundant, but on the reverse side of it, we have to hear this from our patients. They have to tell the stories of how it's impacting them.
Speaker 3Andy, your thoughts yeah, I think that the answer is patience. I have a slightly different take on this, if I can share it with you, and that is if we were running a business, if we were the Better Medicare Alliance, who represents Medicare Advantage, and we came back to the Medicare Advantage programs and said guys, I'm sorry, there's an assault, you guys are going to get a 2.8% cut, that group would be fired immediately. So this is not an option, and I think that our organizations need to do better. I think that they need to accept the idea that 25 years of data points of falling Medicare reimbursement is enough to say there's something faulty with the processes that we use, and so I think that we need to change them, and it's obvious. So I think the first thing we need to do you know, I think this is a house of medicine problem, but I have not heard one organization offer up really innovative ideas to change things that match successful lobbying campaigns, which have happened. So here's what I think. We're dermatologists, we are members of the American Academy of Dermatology. I think members need to speak up. They need to let our leadership lost in the political machine. They are no longer acceptable to us. We need seniors to see this. So we need social media, we need standard television, we need to get them excited to the point where they understand that they're about to lose their Medicare. And they do make those phone calls.
Speaker 3I think the robo letters don't work very well because I think that Congress is not really concerned, but hanging signs from bridges, brad, that's a real one. So why do we have organizations? They do things that we can't do alone. They provide fellowship, they provide education, and if the three of us on this meeting today could organize all of this, we would. But large organizations can and we should demand that.
Action Steps for Patients and Providers
Speaker 3I say we start by getting rid of that idea that we are talking about physician reimbursement, because we're not. We're talking about stabilizing the Medicare program against cuts. I say that we empower, we require, we enable the staff members of all of these organizations to come up with ideas that work, not ones that are. There's will be presenting that and I hope to find a real paradigm shift and I know that's a hackneyed phrase a real paradigm shift within the American Academy of Dermatology, where we have some demonstration projects, where we have more effective political giving, where we only support candidates who understand how important this is for seniors, that we enable innovation and once we do that, I think the House of Medicine will see the example and I think that we can solve this. But it's not gonna be by doing things the same way.
Speaker 2And important thing is we're doing all this for patients.
Speaker 2You know, and I think that's the priority, keep that, you know, as our you know focus and you know, let people know out there that this is really physicians fighting for you, where I think, like you said, it gets reframed on this reimbursement piece and no, this is the ability to keep a business open to provide you with the best care possible, and this is to keep Medicare sustainable for future generations as well, where it'll hopefully be there for them in the future.
Speaker 2But thank you both for coming on the podcast today. I can't believe our time's already flown by. I think we've really probably gotten a little bit enlightened for people on what Medicare is, the impact, and then truly people understanding why Medicare is truly in crisis and how this impacts everyone, but in particularly, again, patients. And so again, thank you both for coming on the podcast. It's been a lot of fun to have you here with us today. If any of our listeners want to find you or connect with you, please feel free. Go ahead and share if you don't mind. Andy, and then Brad, if you'll share your social media or online presence, that would be great.
Speaker 3Sure, I'm at Dr Andy Weinstein on Instagram and you can, of course, visit my website.
Speaker 4It's Andy for the number for AADPrescom and mine's pretty simple, it's at Brad Peter.
Speaker 2Glick on Instagram, great. Well, thank you guys again and stay tuned for the next episode of Dermot Trotter. Don't swear about skincare, or maybe, as we've done today, don't swear about healthcare, as we really dive in a bit more into healthcare issues that affect us all.
Speaker 3Thanks, shannon, thank you.
Speaker 1Thanks for listening to Dermot Trotter. For more about skincare, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
