• Doctors would rather have something than nothing

    When I was testifying yesterday, one of the questions asked of me relayed a feeling that most doctors and hospitals would oppose the Medicaid expansion. Um, no.

    Look, I don’t doubt there are individual doctors who do. I know some. But pretty much all of them see few Medicaid patients, have lucrative practices, and are more politically opposed to the ACA than the average person. But they don’t speak for the health care system as a whole.

    Take Indiana, for instance. The Indiana Hospital Association supports the expansion, for pretty much the same reasons I do. As do many (if not all) of the physician groups that represent people more often covered by Medicaid.

    There’s a reason for that, and it’s not necessarily altruism.

    What many seem to miss, over and over, is that we’re not debating between giving the uninsured Medicaid or private insurance. We’re debating between giving them Medicaid or nothing.

    Many of the doctors who hate Medicaid don’t like that it under-reimburses. They get much more money from private insurance. So they preferentially choose privately insured patients, and they avoid Medicaid patients. That’s their right.

    But some types of physicians don’t have that option. About one third of kids are covered by Medicaid, as are one third of births. So pediatricians see a disproportionately large number of Medicaid patients, as do OB-gyns. Medicaid generally doesn’t cover non-elderly adults well. So general internists and family physicians see a large proportion of the uninsured.

    Ask these groups if they’d like to see Medicaid expanded, and they will say yes.

    Why? Well, a GP who sees an uninsured patient, and likely receives nothing for caring for them, would rather get a Medicaid payment, even if it’s not as much as it would be from private insurance. Something is better than nothing. The same goes for hospitals that care for the uninsured or under-insured. They would all rather get “measly” Medicaid dollars than get nothing at all.

    Most of the physicians who oppose the Medicaid expansion would rather see privately insured patients than Medicaid patients. That’s their right. But lots of physicians, and most hospitals, don’t have that luxury. They’re choosing between uninsured patients and Medicaid patients. Some payment is better than none.*

    *Let’s not forget that all of this ignores the health benefits of the Medicaid expansion, the economic benefits of the expansion, and the fact that the ACA is significantly increasing Medicaid reimbursement for a while.


    • A slow horse always beats no horse…

    • Any reimbursement that exceeds the marginal direct cost of seeing a patient results in a contribution margin to the practice, so a Medicaid patient is “better” than leaving an appointment slot unfilled. There is an opportunity cost if an appointment filled by Medicaid patient could have been filled by a Workers Comp>auto>commercial>Medicare patient.

      Private practices are concerned that if they become known as a provider for Medicaid, they will get flooded with appointment requests that can crowd out the better reimbursing patients (in Michigan, ‘caid pays @$22/rvu, BCBS @$42) Under PPACA this year of course, Caid should be par with Care for primary care

    • This 2006 issue brief by Peter Cunningham and Jessica May describes the situation pretty well:

      :Despite increases in Medicaid payment rates and enrollment, the proportion of U.S. physicians accepting Medicaid patients has decreased slightly over the past decade, according to a national study by the Center for Studying Health System Change (HSC). In 2004-05, 14.6 percent of physicians reported that they received no revenue from Medicaid, an increase from 12.9 percent in 1996-97. There were also small increases in the percentage of physicians who were not accepting new Medicaid patients. A more striking trend is that care of Medicaid patients is becoming increasingly concentrated among a smaller proportion of physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. Relatively low payment rates and high administrative costs are likely contributing to decreased involvement with Medicaid among physicians in solo and small group practices.”

      “Medicaid Patients Increasingly Concentrated Among Physicians”

    • “We’re debating between giving them Medicaid or nothing.”

      A lot of the arguments regarding Medicaid, Medicare, and just anything to do with health care, seem to miss this important detail.
      It’s like either they don’t know how many people are uninsured, or they just don’t care?

      But doctors, and anyone in the health care field, would have to care in some capacity.

      In Pennsylvania, my governor (Corbett) is refusing Medicaid expansion.
      It’s not those of us uninsured that are making the biggest stink, but a plethora of hospital organizations, doctors, health care workers, etc, are criticizing & rallying against Corbett’s decision.

      With good reason:


      ” For uninsured and underinsured patients, Pennsylvania’s hospitals absorb nearly $1 billion a year in unreimbursed costs.

      As a way to help pay for expanded insurance coverage and reduce these extraordinary levels of uncompensated care, Pennsylvania’s hospitals agreed to more than $7.5 billion in Medicare and Medicaid payment cuts through 2021 to be used for uninsured individuals’ health insurance coverage through Medicaid expansion and federal subsidies to help individuals purchase private insurance.

      The net impact on hospitals would be that the higher rates of insurance coverage would simultaneously reduce hospital losses and improve patient care — a truly win-win scenario.

      If Medicaid expansion is implemented by the state as envisioned by the ACA, hospitals’ financial stability will improve and access to care will be preserved for all patients, whether covered by Medicaid, Medicare or by a private insurer.

      If the commonwealth does not expand Medicaid, this could lead to peril for Pennsylvania’s hospitals, as the number of insured patients will not increase, but the $7.5 billion in shared sacrifice that hospitals accepted as part of the ACA will.

      As a result, not expanding Medicaid would be a lose-lose proposition. “

    • Medicaid is pretty clever about what they do. Take OB. In our area, they reimburse hospitals at close to private rates. They pay providers much less.


    • Carroll states that doctors have a “right” not to see Medicaid patients. But that “right” is going away.

      There’s a bill under consideration in Massachusetts that would force all doctors to see every patient who walks in the door, regardless of insurance coverage.

      Many doctors who refuse Medicaid would be OK with seeing a certain percentage of patients on it. However, state Medicaid insurance contracts state that if you accept Medicaid, you have to open the books to EVERYONE with Medicaid.

      So the choice is not “should I accept patients with Medicaid” the choice is “should I see NOTHING BUT Medicaid.” This is the real question doctors face.

    • I would like to share your comments from yesterday and today with OB-GYN RNs in Indiana via our professional organization’s newsletter. Do you mind of I copy and paste your comments, with credit to yu and TIE, of course.

    • Why would a governor be against Medicaid?

      Part of it is the ‘woodwork effect.’

      Right now there are millions of individuals who could qualify for Medicaid even now but do not sign up. If they do sign up, they would be at least in part a state responsbility.

      Jeff Goldsmith has published the numbers on this. For some states, mainly southern ones, the numbers are scary. States like Texas and Floride might actually have to start an income tax.

      There is a second reason, crassly political.

      There may be more votes to gain from opposing Medicaid than from supporting it.

      The poor and uninsured do not vote in any bloc at all.

      Whereas anti-tax voters do make a bloc, as the Tea Party has shown.

      Therefore the desire to just not tallk about Medicaid very much.

      • “Right now there are millions of individuals who could qualify for Medicaid even now but do not sign up. If they do sign up, they would be at least in part a state responsbility.”

        I have heard of this. But I have a question.

        People say that there are loads of people who DO qualify for Medicaid, but don’t sign-up. They say if Medicaid is expanded, the newly eligible will sign up, AND everyone (or mostly everyone) who qualified before but just didn’t know it or didn’t sign up, will now sign-up – but not be covered federally.

        Won’t the change in the situation, brought by the ACA, encourage those people eligible to sign-up regardless of whether it’s expanded?

        • I say that all the time. The woodwork problem won’t be fixed by denying the expansion. It will happen because of the mandate and the publicity of the ACA.