• Medicaid. Again.

    Yet another piece on how doctors won’t accept new patients with Medicaid. More specifically, another piece where doctors say they won’t take new patients with Medicaid:

    About one in three doctors across the country doesn’t accept new patients who are covered by Medicaid, the federal-state insurance program that is supposed to enroll millions more low-income Americans as part of the Obama administration’s health overhaul, according to a new government study.

    Some 31% of physicians in a sample of 4,326 said they wouldn’t accept Medicaid beneficiaries, economist Sandra Decker of the National Center for Health Statistics reported in an article in the journal Health Affairs published Monday. Most of the doctors cited the low reimbursement from Medicaid.

    By contrast, 18% of the doctors said they weren’t taking new patients with private insurance, and 17% said they weren’t taking new patients who had coverage through Medicare, the federal program for the elderly.

    I’ve said all this before, so I’m not going into too much detail. Here are the high notes. This is a report of what doctors say they are going to do in the future. Take that with a grain of salt. Doctors have a very good reason to say this. This is also due to low reimbursement which (1) the ACA starts to improve and (2) we could absolutely improve if we wanted to by allocating more to Medicaid, which is a cheap form of insurance. The “wait time” issue is caused by a too-small supply of doctors, which could also be fixed if we wanted. It has nothing to do with “Medicaid” in and of itself.

    But the bottom line is that people are complaining that giving uninsured people Medicaid is a bad idea. Fine. Many of those same people didn’t want to give uninsured people private insurance in the exchanges, though, because that cost more. So now, when they argue against giving them Medicaid, they are essentially arguing for giving them nothing. At least for today. Sure, they’ll wave their hands at vague plans for somehow insuring the poorest among us, but I have not yet seen any comprehensive plan put forward in Congress with any real level of support that allows people in this socio-economic spectrum to be privately insured to the level that Medicaid covers.

    And don’t be fooled into thinking that if we somehow took less money and handed it over to states in the form of “block grants” that they could somehow magically cover the same number of people and increase reimbursement to physicians.

    Bottom line – YES, Medicaid needs to be reformed. YES, Medicaid could reimburse more. YES, Medicaid could be better. Almost everyone I know who supports Medicaid believes that. They want to do those things. They cost money, though. Somehow, those who don’t like Medicaid believe that it should be as good as private insurance, reimburse just as much, and somehow cost less.

    P.S. More physicians reported in this article that they would take new Medicare patients than new privately insured patients. Remember that the next time everyone starts screaming that Medicare reimbursement is too low, no one will take it, and we need to get rid of that program, too.



    • Dr Carroll: In some of your past arguments regarding this issue, you cite the fact that Medicaid providers are primarily OB/GYNs and pediatricians, so they’re the docs that matter most. However, wouldn’t Medicaid expansion put most of the burden of accepting new patients on GPs, since the majority of the newly eligible will be adults who aren’t pregnant or with kids?

      • Yep. That’s why I don’t make the same arguments when I’m talking about the expansion. Those studies (the ones where I make that observation) are looking at the current conditions and the past.

        It’s very different when we look towards the future. Lots of people say they will do one thing and then do another. If people could accurately predict what they will do in the future, then today’s poll would be a perfect predictor of the November election. Things change.

    • Sometimes payers can push down on costs in one place only to see that pressure cause them to rise in another. Many states have seen the number of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) and their use as settings for primary care for the Medicaid population, dramatically increase, while care from solo practitioner or small group physician have decreased. Even Medicaid managed care health plans contract with the FQHCs and RHCs. In 2009, 56 percent of Medicaid patients at FQHCs were covered by a Medicaid managed care organization (Health Resources and
      Services Administration 2010).

      So instead of paying the miserable Fee-For-Service (FFS) rates to physicians, which they continue to lower in order to save money, the states are increasingly paying the much higher Prospective Payment System (PPS) rate set by the Federal government. The states must even pay a FFS “wrap-around” payment to the clinics for visits by Medicaid managed care patients. These payments are to bring reimbursement up to the full PPS rate, and are in addition to the capitation payments that States they are paying the plans to pass through to the clinics.

      Peter Cunningham and Jessica May wrote a nice paper in 2006 looking at the variables that influence the likelihood that a physician will see 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.”
      See “Medicaid Patients Increasingly Concentrated Among Physicians.” http://www.hschange.com/CONTENT/866/

    • Okay, so we pay Medicaid docs more. Then the hospitals want more. Then the pharmas want more. Then the nurses. then the …you see where I am going. The Medicare docs and and other health care providers see that Medicaid docs got more so they want more…. If everybody in the system gets more, who gets less to save costs?

      Or is all this talk about ‘saving’ money just hobgoblin nonsense?

      At some point (assuming we never go to the simplest and most cost effective way, single payer), somebody somewhere is going to have to get a haircut. Unless, of course, we let the system implode/explode.

      Who and what gets a haircut?

    • The numerical majority of Medicaid beneficiaries are moms and kids, but it’s worth considering that while the minority of Medicaid beneficiaries are seniors and the disabled, they account for most of Medicaid’s spending. Most of that is long term care or behavioral health services. For non-duals (mostly the younger disabled), Medicaid must pick up the tab for their health care as well.

      These folks will require coverage for nursing home stays, for community-based long-term care, for psychosocial behavioral health interventions like assertive community treatment, for substance abuse interventions, for counseling. These services are all really freaking expensive. And they’re really freaking critical for seniors and the disabled.

      This does not directly relate to the author’s comment about access to PCPs. But it does relate to the folks who say we should not put more people on Medicaid as the entire program is a failure. I would respond that the program is also not a failure for seniors and the disabled. They get coverage where they otherwise would not. Commercial insurance companies are only just starting to get interested in covering these individuals in Medicaid or Medicare managed care, because they’re very complex populations.

    • Ironically, I jumped right from your post to this opinion piece in the LAT today, written by among others, a dean of a law school. Catch his math on the last two paragraphs.


      I wish life was that easy, and its an example of how teachers are failing the pupils.


      • Yes, it was stunning to read a former Dean of a Business School suggests that people who qualify for Medicaid on the basis of either very low income or very great medical need are appropriate candidates for high deductible health insurance coverage. By the way, California already has Medicaid coverage for people with just enough income to pay for some of their health care expenses. It’s called Share of Cost. Unlike traditional or no-cost Medi-Cal coverage, SOC beneficiaries must contribute to their coverage by paying their medical expenses up to a predetermined threshold each month. Unlike other forms of cost-sharing (i.e., copayments or deductibles), it is only after beneficiaries meet their monthly SOC obligation that they qualify for Medi-Cal benefits.

    • Besides low reimbursement, I believe there is at least one other factor that makes many doctors reluctant to see Medicaid patients; that is, fear of being sued for malpractice. Some doctors believe Medicaid patients are more litigious and more “demanding”. But a quick Google search showed me an opposite result: Medicaid patients actually sued for malpractice less frequently compared to patients with conventional insurance.

    • This is a trend monitored by the National Center for Health Statistics since 1999, more pronounced in the last 2 years as part of the National Ambulatory Medical Care Survey managed by the CDC. Since the level of reimursement is worse for private pay patients, I can only conclude that the decreased acceptance of “Medicaid” new patients is a reflection of their health care needs. The low reimbursement is one factor, but it is outweighed by the complex character of their health care needs given the capacity of a standard Primary Health Care clinic’s capacity to manage them, especially the compliance issues.

      The ACA of 2010 will eventually overwhelm our nation’s current Primary Health Care with its improved accessibility through universal health insurance. Also, the ACA does not create any means to assess patterns of accessibility community by community, let alone any means to promote local solutions to any identified deficits. One is left to assume that Primary Health Care will continue to be under-capitalized, unjustly efficient and unpredictably effective. Thus, the ACA of 2010 will do nothing to the over-all health of our country but add an extra $100 Billion to our nation’s debt, annually!