Many doctors can't pay their rent on Medicare-allowed fees. Some Medicare patients can't find a doctor willing to see them at all, much less to provide VIP service.

Medicare is supposed to be "voluntary"--except of course for paying the tax. Jane Orient, M.D., executive director of the Association of American Physicians and Surgeons (AAPS) explores what that means, in the summer issue of the Journal of American Physicians and Surgeons. (http://www.jpands.org/vol15no2/orient.pdf)

The original Medicare law promised that the federal government would not interfere in the practice of medicine. Cost escalation, however, quickly led to price controls, "utilization review," and "quality assurance." Courts held that these were constitutional--because Medicare participation is "voluntary." By accepting money from Medicare, a doctor "volunteers" to be bound by more than 100,000 pages of rules.

Physicians are "opting out" of Medicare at an accelerating rate. Additionally, now that Medicare is requiring onerous procedures to enroll, or to "revalidate" enrollment, more physicians are asking why they should.

Medicare has apparently anticipated this exodus. Its new Provider Enrollment and Chain Ownership System (PECOS) may make it impossible for physicians to treat seniors outside the system--or at least for them to order or refer for any service that might be covered by Medicare.

Seniors can't avoid being "covered" by Medicare Part A without relinquishing all Social Security benefits. Moreover, their private insurance options were destroyed when Medicare went into effect.

Why should anyone want to pay for things that are supposed to be free? It's the only way to escape government oversight and rationing. Some patients might feel that a one-hour visit with a physician focused on their problems might be worth more than the government pays for six 10-minute encounters with a nurse practitioner devoted to a government-approved checklist.

Will government be able to keep doctors from offering--and thus patients from receiving--self-paid care? Apparently, it is trying to do so.