The Medicaid shuffle

I’ve gotten a number of emails about Avik Roy’s post on Internists rejecting patients with Medicaid.  Here’s the meat:

The Health Tracking Study Physician Survey, sponsored by the Center for Studying Health System Change, polled more than 4,700 physicians around the country in 2008. Among the questions the surveyors asked was: “Do you accept all, most, some, or no new Medicaid patients?” It asked the same question about patients with Medicare and those with private insurance.

I put together this chart, representing the percentage of physicians who accept no new patients, segregated by specialty and insurance type. The numbers speak for themselves. Medicaid beneficiaries have a far more difficult time finding a doctor than do those with Medicare or private insurance (click to enlarge):

Let’s start with the concession that Medicaid reimburses too little. OK? Do we have that out of the way? Since we all agree, it would be nice if we could focus on improving that, and get Medicaid to reimburse more. But that, of course, would require us to actually spend more on Medicaid, not less, and the people who are usually upset about the reimbursement are also upset about spending anything on Medicaid at all. The reason that we can’t reimburse enough is that we are underspending on Medicaid. Medicaid is cheap, as I’ve discussed before.

But once we’re past that, it’s time to look at that chart. It’s also time to refocus on who Medicaid covers. Medicaid is really an insurance program for children, pregnant women, the disabled, some elderly who qualify for SSI, and some parents. The number of adults who aren’t pregnant and looking for a primary care doctor is actually a rather small part of the Medicaid population.

So, for instance, if 40% of pediatricians were refusing Medicaid patients, I’d be more concerned. If 40% of ObGyns were refusing Medicaid patients, I’d be more concerned. But 40% of internists refusing Medicaid patients in 2009? I wish it weren’t so, but I’m not as concerned.

For instance, I could have taken this chart and trumpeted that ZERO pediatricians were refusing patients with Medicare, and posted on how that signaled that private insurance is worse and horrible and should be shut down. I imagine a number of you would have pointed out to me that pediatricians aren’t the most significant group of providers for the Medicare population.

Moreover, this is how it works.  I work in an academic medical center in a county hospital system.  We see almost all Medicaid and uninsured pateints. That’s what we do; I don’t complain about it. My kids’ doctor is in the suburbs, near our house, and – I’m willing to wager – sees far less Medicaid. If she does, that’s her choice.

If you think that’s a problem, if you’re really concerned about how difficult it is for patients on Medicaid to find a doctor, then let’s figure out how to increase Medicaid reimbursement in order to make accepting those patients more attractive to private practice physicians.* I look forward to that conversation.

*The PPACA does this. I have yet to see anyone who thinks Medicaid reimbursement is too low support that.

UPDATE: I made a logical error on the chart with respect to pediatricians, and corrected it. My point is the same, though – pediatricians don’t really matter for the Medicare population.

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