niko karvounis, health beat blog report: medicaid challenge (part i) (984)
The Medicaid Challenge (Part I)
niko karvounis, October 01, 2008
, , , 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). . . .
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.
. . . 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. [mybolding ---rk])