McClatchy Washington Bureau
Posted on Mon, May. 13, 2013
Most doctors still reject Medicaid as program expansion nears
By Tony Pugh | McClatchy Newspapers
last updated: May 13, 2013 06:38:42 PM
BONIFAY, Fla.
Sandra Duck thinks shefs the victim of an undeclared Medicaid boycott. And
shefs probably right.
When her artificial right hip became infected with the superbug MRSA in late
2009, Dr. Dale Mitchum, a general surgeon, drained, cleaned and closed the
infected area. But when the infection returned in early 2010, Mitchum knew Duck
needed another hip replacement surgery, which he couldnft perform. He tried to
find an orthopedic surgeon who would operate. More than a year later, hefs still
trying.
gI cannot find a living soul that will touch her,h he said recently. gAnd
Ifve tried everywhere, from Tallahassee to Pensacola.h
Doctors in several states outside Florida also have refused to operate on
Duck, whofs covered by Medicaid, the state-federal health insurance program for
poor people and those with disabilities. Because of the programfs history of low
payments, fewer than half of U.S. doctors and other health care professionals
accept Medicaid patients, according to a recent study.
For those that do, getting an appointment sometimes can take months because
of the high demand, particularly among specialists.
The problem is worse in rural areas such as Bonifay, in the Florida
Panhandle. While 20 percent of Americans live in less-populated parts of the
country, only 10 percent of U.S. doctors practice there. Thatfs why 77 percent
of the nationfs 2,000-plus rural counties are designated as health professional
shortage areas, according to the National Conference of State Legislatures.
Nationwide, the lack of doctors is a growing problem that will only worsen as
some 27 million people get health coverage by 2016 as part of the Patient
Protection and Affordable Care Act. The Association of American Medical Colleges
projects a shortage of 29,800 primary care doctors and 33,000 specialty doctors
in 2015 alone.
If left unaddressed, the shortage of doctors and their rejection of Medicaid
patients could severely hamper the health care overhaul next year, when 5
million to 8 million Americans will gain Medicaid coverage under the law.
While the health care law also provides for steeply increasing Medicaid fees
to doctors this year and next year, some physicians worry that the payments
would drop again in 2015.
The new law allows state Medicaid programs to cover non-elderly adults who
earn up to 138 percent of the federal poverty level. Thatfs nearly $16,000 for
an individual in 2013 or about $32,500 for a family of four.
As of Monday, 26 states and the District of Columbia are slated to
participate in the Medicaid expansion, while New York is leaning that way,
according to the Advisory Board Company, a global research and consulting firm.
But as Duckfs experience shows, a Medicaid insurance card doesnft guarantee
care if there arenft enough physicians to treat the new enrollees or wide swaths
of doctors simply wonft see them.
Despite a regimen of antibiotics, Duck, a former hairdresser, said her hip
was getting worse. A bone has grown around a metal rod in the replacement hip
and she fears that the infection could make the damage irreversible if surgery
is delayed much longer.
gMedicaid doesnft pay enough, so they just donft want to fool with me,h Duck
said. gThey just want me to be quiet and sit back and just let my leg rot off.
Well, thatfs hard to do when Ifm 44 years old and Ifve got two grandkids. Ifve
still got a little bit of life left in me.h
Of more than 1 million physicians, therapists and counselors nationwide, only
43 percent accept Medicaid, according to a new study by HealthPocket, a
technology firm that compares and ranks health plans.
The situation varies by city. The study found that only 31 percent of
caregivers accept Medicaid patients in Washington and Detroit, 36 percent in San
Francisco, 42 percent in Philadelphia and San Diego, and 47 percent in
Seattle.
gIf the current Medicaid acceptance rates hold true for 2014, timely access
to care for those relying on Medicaid is likely to become more difficult as
enrollees compete for an already inadequate pool of doctors,h said Kev Coleman,
the head of research and data at HealthPocket.
The lean physician workforce has prompted some states to try to expand the
types of primary care provided by nurse practitioners, physician assistants and
other non-physician medical personnel. But the HealthPocket study found that
only 20 percent of physician assistants and nurse practitioners nationally
accept Medicaid, less than half the rate of doctors and other providers.
Last year, Medicaid paid physicians just two-thirds of what they received
from Medicare, the federal health insurance program for people 65 and older.
Medicaidfs fees for primary care averaged 41 percent less than Medicarefs,
according to the Kaiser Family Foundation, a nonpartisan health care
philanthropic organization.
To retain the doctors who take Medicaid patients and to recruit new ones, the
health care law hikes Medicaid primary care payments to the same level as
Medicarefs in 2013 and 2014. The increase varies by state, but it averages 73
percent nationwide, according to Kaiser.Doctors in a dozen states will see
average fee increases of more than 50 percent, while those in Florida,
California, New York, New Jersey, Michigan and Rhode Island will see their
Medicaid payments more than double, according to the Kaiser study.
The increases were supposed to begin this year, but the process was delayed.
The U.S. Department of Health and Human Services is now providing technical
assistance to states to expedite the payments, but the going is slow.
gI donft know of any state where the money is actually flowing to physicians
yet,h said Andrea Maresca, the director of federal policy at the National
Association of Medicaid Directors. Once implemented, the Medicaid pay hikes will
be retroactive to Jan. 1. Maresca said the delays hadnft sparked much outrage so
far.
gWefre not hearing a deluge of concern from states that because this money
isnft flowing, providers are droppingh Medicaid patients, she said.
But doctors such as Leisa Bailey, an obstetrician-gynecologist in rural
Bonifay, said the two-year pay hike could backfire if Congress didnft reinstate
it in 2015. Failure to do so might cause doctors to turn away millions of
Medicaid patients because treating them once again would be a money loser.
gYoufd be asking the physicians, basically, to kick those patients out. It is
the craziest thing I ever heard in my life,h Dr. Bailey said.
Bailey said shefd continue to see pregnant Medicaid patients, but because
Congress might kill the pay increase after two years, she wonft open up her
practice to all Medicaid recipients. If she did, she fears the wave of new
Medicaid patients would lead her Medicare patients and those with private
insurance to seek care elsewhere.
Dr. Adit Ginde, of the University of Colorado School of Medicine in Aurora,
has studied obstacles to patient care for Medicaid recipients. He said it was
unlikely that doctors would drop current Medicaid patients if the pay increase
werenft renewed, but they might stop taking new ones.
gOnce theyfre in an established practice, then typically they can stay within
that practice,h Ginde said. gBut itfs much more difficult to initiate a new
relationship.h
Just ask Sandra Duck. As she looked for a surgeon to operate on her infected
hip, Duck said she was growing weary of the struggle. The infection is spreading
down her leg, the antibiotics are becoming less effective and she needs a pillow
just to sit.
Johns Hopkins Hospital in Baltimore recently took an interest in her case,
and Duck was optimistic about her chances.
gI feel like theyfre the only people I trust,h she said after hearing the
news. gI just believe in them. I donft know why, but Ifve got a good feeling
about them.h
But Hopkins turned her down as well. Once again, Dr. Mitchum said, Medicaid
was the problem. The hospital declined to comment on the case, citing privacy
laws.