The Medicaid Challenge (Part I)

In theory, Medicaid ensures that low-income families receive health care. But in practice, the program leaves much to be desired—and serves as a painful illustration that the existence of an insurance program isn’t enough to ensure access to necessary care.

On paper Medicaid offers pretty comprehensive coverage, seemingly even better than Medicare. For example, Medicaid covers long-term care for the elderly, nursing home care, and offers broader prescription drug benefits than Medicare.

But all the benefits don’t mean a thing if patients can’t find doctors to provide them. In a post last November, I noted that reimbursement rates for Medicaid are abysmally low across the nation as compared to both private insurance and Medicare: in New York, doctors receive $20 for an hour-long consultation with Medicaid patients, whereas a physician could earn almost $200—about 10 times as much—for such a consultation under Medicare. In 2007, the Wall Street Journal reported that Michigan’s Medicaid program pays $20 for a chest x-ray, where as Medicare pays $30 and private insurer Blue Cross, $33. For performing an appendectomy, a Michigan doctor can expect $784 from Blue Cross and just $336—about 42 percent as much—from Medicaid.

There’s nothing inherently easier about treating poor people—in fact, Americans stuck on the lowest rungs of our socioeconomic ladder tend to be in poorer health. Yet doctors are paid less under Medicaid and as a result are closing their doors to low-income patients: a 2006 Center for Studying Health Care System Change report found that the percentage of physicians who accepted no new Medicaid patients in 2004-2005 was “six times higher than for Medicare patients and five times higher than for privately insured patients.” Reimbursement was a major concern here: 84 percent of physicians who did not accept new Medicaid patients in 2004-2005 said reimbursements were a factor; 70 percent of physicians said billing requirements and paperwork were a factor; and two-thirds said delayed payments were a factor. (While Medicare, a federal program, has a reputation for paying providers in a timely manner, Medicaid—administered by states—is a much more haphazard affair, and can leave doctors waiting for months).

Thanks to these concerns, doctors around the country are giving Medicaid patients the boot. In states like Michigan the proportion of doctors who will see Medicaid patients has fallen from 88 percent in 1999 to 64 percent in 2005, even though enrollment in the state’s Medicaid program has risen by more than 50 percent over this period. In Texas, more than 60 percent of Texas doctors refuse to accept new Medicaid patients. Last year in Illinois, two clinics engaged in a messy legal battle with the state’s Attorney General to defend their right to refuse long-term care to Medicaid patients.

Closing doors to Medicaid patients can have some ugly consequences, such as increased use of emergency rooms for routine care, itself a major problem that I discussed last month. It also makes stories like that of Deamonte Driver more likely. Driver was a twelve-year old Maryland boy who died of a toothache last year because his family couldn’t find a dentist willing to accept Medicaid. His life could have been saved via a simple, $80 procedure—but without access to a provider, even under Medicaid, he couldn’t find someone to perform that procedure. So he died. 

Driver’s story may grow more common as the number of Medicaid doctors shrinks and the number of Medicaid enrollees nationwide swells. In a report released on Monday, the Kaiser Foundation calculated that the average growth of Medicaid enrollment across the nation was 2.1 percent in fiscal year 2008, and that it’s set to grow another 3.6 percent in FY 2009 (perhaps even more, as economic conditions worsen).

But access isn’t the only problem: even when Medicaid patients do get care, it tends to be sub-par. Last October, a study from Harvard Medical School compared the quality of care between Medicaid and commercial managed care plans and found that “Medicaid managed care enrollees receive lower-quality care than that received by commercial managed care enrollees.” The authors looked at information on 11 quality measures from 383 health plans that reported quality-of-care data to the National Committee for Quality Assurance for 2002 and 2003. Their sample included 204 commercial-only plans, 142 mixed Medicaid/commercial plans and 37 Medicaid-only plans. The 11 indicators covered areas of prevention and screening, chronic disease management and care for pregnant women. Among the findings:

• Timely prenatal care was delivered to 86.9% of patients in commercial plans versus 69.4% of patients in Medicaid plans. For postpartum care the difference was more striking, 77.2% versus 40.7%.
• Recommended breast cancer screening was completed for 52.6% of Medicaid patients versus 75.1% of commercial HMO patients.
• Blood sugar was tested in 73.4% of Medicaid patients with diabetes and glucose controlled in 47.4% of Medicaid patients—compared with 82.6% and 66.3%, respectively, for diabetic patients enrolled in commercial plans.
• The childhood immunization rate was 54% in the Medicaid plans and 68.7% for commercial plan enrollees.

Other studies confirm the troubling disparities between Medicaid patients and everyone else. A recent study in the Journal of the American College of Surgeons found that patients who undergo colon cancer surgery in hospitals where more than 40 percent of patients are on Medicaid have a higher risk of death at 30 days and 1 year after surgery than patients treated at other hospitals. Researchers believe that this association “is somehow related to resource limitation common to hospitals with heavy Medicaid payor mix”—in other words, hospitals that serve the poor are usually poor themselves, or are inadequately staffed, and are thus more likely to provide sub-par treatments.

Even kids aren’t safe. In 2002, researchers from Boston’s Children Hospital found that children with Medicaid insurance have a higher risk of dying after congenital heart surgery than those with commercial insurance because referral patterns often sent them to hospitals with less-than-stellar outcomes records. This, of course, makes sense: in-demand doctors with a high volume of patients don’t need to squeeze in sure-fire money losers like Medicaid patients—leaving low-income patients to find their way to less popular, and probably less skilled, doctors. This is a troubling dynamic, especially given the fact that Medicaid pays fully one-half of the national hospital bill for children with congenital heart defects.

Further, back in 2001, researchers from Harvard Medical School found that kids with chronic conditions don’t receive recommended care under Medicaid. These low-income children disproportionately rely on primary care physicians instead of specialists for their care, even though these kids “need both high-quality primary care and up-to-date subspecialty care for the optimal management of their chronic condition.” While we should always be wary of going over-board with specialty care, there are still complex chronic conditions (e.g. asthma, hemophilia, cerebral palsy) that demand “higher rates of relevant subspecialty utilization.” Yet the researchers found that “rates of subspecialty use rose only marginally” amongst children who were Medicaid enrollees. Many specialists just won’t take Medicaid patients.

So why is the quality of Medicaid care consistently lower? The greatest predictor of health in the U.S. is socioeconomic status, meaning that Medicaid, on the whole, deals with some of the least healthy Americans. But with reimbursement rates so low, top docs at flush institutions are less likely to see Medicaid patients (because they can make a lot more money seeing other sorts of patients)—and so you have the sickest patients going to less proven, and often less skilled, doctors. Even at academic medical centers there are often two clinics: one for patients with insurance, who are seen by the center’s top doctors, and a second clinic for patient on Medicaid and the uninsured, who are seen by residents.

State rules about eligibility and enrollment also can make it very difficult for low-income patients to qualify for Medicaid.  Many states have specific requirements for Medicaid eligibility that go beyond income, such as having children or being disabled, that make the medical equation even more complicated. (In these states adults with families are considered among the “worthy poor;” childless adults are viewed as somehow less deserving—an enormous problem for homosexual men suffering from AIDS.)

In some states, only the sickest patients can actually get Medicaid coverage when they need it.  For example, the American Cancer Society (ACS) notes that in Michigan, “adults who are not pregnant or caring for young children” must be suffering from a disabling condition expected to last [at least] one year before enrolling.  This helps explains why,  when ACS looked at 13,740  Michigan adults who suffered from 3 common forms of cancer in 2004, it found that Medicaid enrollees had a two to three times greater risk of death when compared  to non-Medicaid patients—even after controlling for site and stage of cancer: about 40 percent of Medicaid cancer patients in the study sample enrolled in Medicaid only after being diagnosed with late-stage cancer.

Until they were diagnosed, these patients couldn’t prove that they suffered from a disease that would last at least one year—and thus qualify for Medicaid. But, the ACS study points out, “if cancer is a Medicaid enrollee's qualifying disabling condition, then the cancer, by definition, has to be advanced. Treatments, even if they are state of the art, for late-stage cancers are less likely to offer prolonged survival benefits.” When you hold out health care until patients are very sick, health outcomes are likely to be worse. 

It’s hard to disagree with the fact that Medicaid leaves much to be desired—and that the program is proof that, just because you have health insurance, doesn’t mean that you have access to good health care. This fact makes blind expansion of Medicaid a less than ideal strategy for reform: sure, we can cover more people, but if they can’t find good doctors—or if the care they receive is sub-par—than we’re only fighting half the battle.

So what is a smart strategy for Medicaid reform? I’ll tackle that in Part II of this post.

Look for more on Medicaid from Health Beat in the future as well—we think this a topic that doesn’t get nearly as much attention as it deserves.

Comments

[Ms Place]

Yes our world is in much trouble.I have a bad heart, its not from eating bad, its from a nurse giving me a calss of drugs I coulnt take and sent me in to antaflactic shock and now I am on 75 mgs of mtoprol twice a day, and yes I have been ablated too!There care I get is this , last yr I had penumonia for 4 months and the Dr never put me in the hospital at all. I was seting on the side of the bed at 2am gurreling so bad it kept me up! I had three rounds of every thing I could take and guess what it was, a 4 months asmatha atack if He had done His home work I would have been better a lot faster!A little O2 and much better care but this was all on medicad ! That dosnt shock any one dose it?

[Bernard Malenfant]

yes i am a medicaid benificiary and i just got my plan. and i tell you it was hell trying to find a doctor. i havnt had a doctor in 10 years and am in need of one very badly. now there has to be a way of changing things. maybe to force doctors to accept medicaid against their will. after all they are the government. they force me ot pay money i dont want to. why cant they force them to take a loss on services they provide. or maybe an incentive like a tax break for medicaid paitents.i dont really knwo but what i do kwno is somthing has to be done about it. other wise we as americans will keep letting eachother die. or get even more sick. my problem wasnt the insurance. but finding a rovider.

[KK]

In NY, Medicaid beneficaries are moved into managed care plans within 6 months of enrollment, which puts the Medicaid patients on par with other state-supported (Family Health Plus & Child Health Plus) patients. Unfortunately for all of them, most private practice physicians do not take these plans in their offices, so low-income patients are sent to clinics with no-appointment policies or clinics in which appointments are made, but are basically meaningless. What this means is that low-income patients are forced to pay for medical care not with their money, but with their time.

If a primary-care visit meant taking a full, unpaid day off work, it's my guess that most Americans wouldn't see their PCPs very often. And if seeing a specialist meant a two- to three-month wait and a full unpaid day off work, then the number of patients receiving care just got cut even lower. This is a guaranteed formula for sicker Medicaid patients. In this case, access really could equal prevention.

[Alex]

Put them on salary.

[Barry Carol]

I think the need for medical homes might be overrated and overstated for most people. I do think it is certainly useful for children to have a regular pediatrician to make sure they get their immunizations and deal with other issues as they arise. Pregnant women should also have an OB-GYN to provide appropriate prenatal care. For the rest of us in the 18-64 population, however, I have my doubts.

It’s been pointed out before that a given individual’s health status is driven 40% by personal behavior, 30% by genetics, 20% by socioeconomic status and environmental factors, and only 10% by access to and availability of quality healthcare.

With respect to personal behavior, the vast majority of us know that we shouldn’t smoke and we should drink only in moderation. We know that fruits and vegetables are good for us while high fat foods, sweets, and too much salt are not. Even when a doctor tries to tell us to stop smoking or get more fiber in our diet, the advice often falls on deaf ears. Maybe it’s because we think we’re indestructible or we just lack the discipline to modify or eliminate bad habits. Sometimes we just need a catalyst for action. I’ve heard lots of women who smoked say they tried numerous times to quit but couldn’t until they became pregnant. Then, suddenly they were able to quit. People who have a cardiac event, a stroke, or are diagnosed with diabetes are scared enough to suddenly be able to drastically improve their diet and exercise regimen and quit smoking. They needed a wake-up call after ignoring their doctor’s advice for years.

In any given year, the vast majority of people have no significant medical issues. If they have a minor issue like a sore throat, ear infection or need a flu shot, they don’t even need a PCP, let alone a medical home. They can go to an urgent care clinic or retail clinic and access a nurse practitioner.

In my own case, my cardiologist takes care of my heart and blood pressure related issues and performs my annual corporate physical. When I needed to see a urologist, he referred me to one but did not coordinate any care. All urology related issues are dealt with by that specialist. What would be helpful, I think, would be a central database that all physicians could access to see what prescriptions a patient is taking. I think much of this information exists at places like the Ingenix Division of UnitedHealth Group.

As for preventive care, a doctor told me a year or so ago that a group called the Preventive Services Task Force has evaluated a large number of common preventive services and tests and graded them A, B, C or D for cost-effectiveness. He told me that he always tries to give his patients the services that are appropriate for them based on age and gender if they are graded A or B by the PSTF. For the C’s, he’ll use his judgment but generally won’t do them for most patients. For the D’s, he not only won’t do them but will try his best to convince a patient who asks for it that it shouldn’t be done because it’s not necessary and not cost-effective.

If a medical home model would require paying a doctor a meaningful amount of money to coordinate the care of each person in his or her panel including the large number that don’t have any medical issues in most years, it will likely cost more than it’s worth. I think we would be better off expanding the number of nurse practitioners and physician assistants to address the minor issues while freeing the PCP’s to devote more time to the patients who actually need their skill and expertise.

[NG]

I have dealt with Medicaid (MA) dental from a public health perspective for over 30 years, and right from he start few dentists would accept these patients, mostly children. This MA program is indeed a classic example of how insurance means little if there is no access to proper care!

The one thing I like to reflect on which shows how faulty our social logic has been over the years is this. Government through licensure and laws allows or creates a profession to exist with certain exclusive rights (such as only licensed dentists can treat dental disease). Also, government starts up a program for poor kids which says these kids have a right to get care at social expense. Yet that same government that creates both these laws (licensure for the profession and MA to pay for poor kids care) cannot think clearly enough to demand that the only profession allowed by law to treat dental disease must also treat poor kids who have a government payment voucher to get treated. How nuts is that??
Is Medical care now heading down this same illogical path??