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LAFAYETTE, La. — Eight-year-old Draven Smith was expelled from school last
year for disruptive behavior, and he is being expelled again this year. But his
mother and his pediatrician cannot find a mental health specialist to treat him because he is
on Medicaid, and the program, which provides health
coverage for the poor, pays doctors so little that many refuse to take its
patients.
Dr. Rachel Chatters, right, with Ana Smith, says she begs
specialists to see Medicaid
patients.
Ms. Smith said she has tried for more than a year to find a
psychiatrist to treat her son Draven, 8, who is on Medicaid.
The problem is common here and across the country, especially as states,
scrambling to balance their budgets, look for cuts in Medicaid, which is one of
their biggest expenditures. And it presents the Obama administration with a
major challenge, since the new federal health care law relies heavily on
Medicaid to cover many people who now lack health insurance.
“Having a Medicaid card in no way assures access to care,” said Dr. James B.
Aiken, an emergency physician in New Orleans.
Nicole R. Dardeau, 46, a nurse in Opelousas, La., in the heart of Cajun
country, can attest to that. She said she could not work because of unbearable
pain in her right arm. Doctors have found three herniated discs in her neck and
recommended surgery, but cannot find a surgeon to take her as a Medicaid
patient.
From her pocketbook, she pulls an insurance card issued by the Louisiana Department
of Health and Hospitals
“My Medicaid card is useless for me right now,” Ms. Dardeau said over lunch.
“It’s a useless piece of plastic. I can’t find an orthopedic surgeon or a pain
management doctor who will accept Medicaid.”
For patients like Draven Smith, whose mother said his behavior problems
stemmed from attention-deficit hyperactivity disorder, the result is lack of access
to doctors, especially specialists. For Draven’s pediatrician, Dr. Rachel Z.
Chatters in Lake Charles, La., caring for poor children is a mission. About 80
percent of her patients are on Medicaid. It is, she said, frustrating to beg and
plead with other doctors to see Medicaid recipients.
“I devote one afternoon a week, every Wednesday afternoon, to trying to find
specialists for my patients — a pulmonologist for children with chronic
persistent asthma, a neurologist for children with seizures or developmental delays, a psychiatrist for
children with serious mental health problems, a hematologist for patients with
sickle cell disease,” Dr. Chatters said.
Draven’s mother, Ana M. Smith, said: “I have tried for more than a year to
find a child psychiatrist or psychologist to get Draven evaluated, but the
mental health professionals in this area have told me they absolutely do not
take Medicaid. If Draven could get the help he needs, I believe it would be
unbelievably beneficial to him.”
The new health law calls for a temporary two-year
increase in Medicaid payments for some primary care services, but this does not
affect specialists.
Bruce D. Greenstein, secretary of the Louisiana
Department of Health and Hospitals, said, “We have a hard time finding
specialists for Medicaid enrollees.”
About 20 states cut Medicaid payment rates for doctors last year, according
to a survey by the Kaiser Family Foundation. At least 16 governors have
proposed rate reductions this year for health care providers.
Gov. John Kitzhaber of Oregon, a Democrat, proposed cutting
Medicaid payment rates for doctors, dentists, hospitals and nursing homes by 19 percent. Christine Miles, a
spokeswoman for Mr. Kitzhaber, said his priority was to preserve eligibility.
In Illinois, Gov. Pat Quinn, a Democrat, has proposed reducing
Medicaid reimbursement rates by 6 percent for hospitals and nursing homes.
Gov. Brian Sandoval of Nevada, a Republican, has proposed cutting
Medicaid rates by 5 percent for hospitals, 15 percent for nonprimary care
doctors and 25 percent for dentists.
In South Dakota, Gov. Dennis Daugaard, a Republican, just signed a budget
bill cutting Medicaid rates for doctors, dentists, hospitals and
nursing homes — even primary care physicians and pediatricians.
States have broad discretion in setting Medicaid payment rates. Federal law
sets standards, but they are rather vague. Rates are supposed to be “consistent
with efficiency, economy and quality of care,” and sufficient to ensure that
services are available to Medicaid recipients at least to the same extent as to
the general population in the area.
In a few states, Medicaid recipients and providers have blocked cuts or
secured higher reimbursement through litigation. But in many states, the promise
of equal access remains unfulfilled.
Dr. Kim A. Hardey, an obstetrician-gynecologist in Lafayette, said he
received about $1,000 from the Louisiana Medicaid program for providing prenatal
care and delivery for a full-term pregnancy, compared with $2,400 from private
insurance.
With the expansion of Medicaid eligibility, he said, more of his patients
will be on Medicaid, and fewer will have private insurance, which helps offset
the financial losses doctors sustain on their Medicaid business.
Already, Dr. Hardey said, many of his patients have jobs with private
insurance but switch to Medicaid when they become pregnant, avoiding premiums,
deductibles and co-payments.
NEW YORK (Reuters Health) - Orthopedic surgeons are much more hesitant to see kids with broken bones than they were a decade ago, suggests new research from California.
When contacted by telephone, more than half of orthopedic practices wouldn't schedule an appointment for a kid with a recently-broken arm who had private insurance. What's more, almost all refused appointments to kids covered by Medicaid, the government-run health insurance program for the poor.
"I'm not at all surprised by what happened with Medicaid," said Dr. David Skaggs, from Children's Hospital Los Angeles, one of the study's authors.
When his team did a similar study 10 years ago, most practices also wouldn't see kids on Medicaid. But all of them scheduled appointments for those with private insurance.
"The shocking finding was that half of the people don't see children anymore," Skaggs told Reuters Health.
"They come with parents who ask lots of questions, and it just takes longer and it's more energy... and you're not paid any more," he explained.
Especially outside of big cities with specialized pediatric hospitals, that may mean it's harder for injured kids to get treatment, he said.
For the new study, a researcher called 45 orthopedic practices around Los Angeles pretending to be the parent of a 10-year-old boy with a broken arm who needed an appointment with an orthopedic surgeon. The investigator called each office on two different occasions, once saying that the son was privately insured, and once telling staff he was covered by Medicaid.
Nineteen of those 45 practices offered the "parent" an appointment for a privately-insured kid within a week. That compared to 50 out of 50 offices that offered parents an appointment when Skaggs and his colleagues made the same calls ten years ago.
Only one practice set up an appointment for a kid covered by Medicaid. And when the investigator asked each office for a referral to an orthopedic surgeon who did take Medicaid, just nine could name one.
It's no secret that kids on Medicaid have a harder time getting appointments, because public insurance often doesn't reimburse doctors as much as private insurance. In California, "the orthopedic surgeons were losing money on every visit," Skaggs said.
"The evidence in the article... is consistent with other evidence that a lot of physicians just don't accept Medicaid patients, period," said Sandra Decker, a researcher from the U.S. Centers for Disease Control and Prevention who has studied kids' access to care.
"Even though these kids are 'insured,' they really don't have access to medical care," Skaggs added.
That will only change if health care reform not only increases the number of people who are insured, but also increases reimbursement rates so practices have an incentive to see those patients, he added.
Right now, Decker told Reuters Health, reimbursements to primary care doctors are set to increase -- but not payments to specialists like orthopedic surgeons.
When orthopedic practices won't take kids -- regardless of what type of insurance they have -- more and more families have to seek out special pediatric facilities for treatment.
Finding a specialist isn't so much of an issue in Los Angeles, Skaggs said. But, "it does become a problem when you're outside of an urban setting -- there's the rub."
For some families, finding a kids-only orthopedic surgeon means more travel, money and time away from work and school, Skaggs and colleagues write in the Journal of Pediatrics.
General orthopedic practices, Kasser said, "just aren't taking care of kids the way they were before."
When contacted by telephone, more than half of orthopedic practices wouldn't schedule an appointment for a kid with a recently-broken arm who had private insurance. What's more, almost all refused appointments to kids covered by Medicaid, the government-run health insurance program for the poor.
"I'm not at all surprised by what happened with Medicaid," said Dr. David Skaggs, from Children's Hospital Los Angeles, one of the study's authors.
When his team did a similar study 10 years ago, most practices also wouldn't see kids on Medicaid. But all of them scheduled appointments for those with private insurance.
"The shocking finding was that half of the people don't see children anymore," Skaggs told Reuters Health.
"They come with parents who ask lots of questions, and it just takes longer and it's more energy... and you're not paid any more," he explained.
Especially outside of big cities with specialized pediatric hospitals, that may mean it's harder for injured kids to get treatment, he said.
For the new study, a researcher called 45 orthopedic practices around Los Angeles pretending to be the parent of a 10-year-old boy with a broken arm who needed an appointment with an orthopedic surgeon. The investigator called each office on two different occasions, once saying that the son was privately insured, and once telling staff he was covered by Medicaid.
Nineteen of those 45 practices offered the "parent" an appointment for a privately-insured kid within a week. That compared to 50 out of 50 offices that offered parents an appointment when Skaggs and his colleagues made the same calls ten years ago.
Only one practice set up an appointment for a kid covered by Medicaid. And when the investigator asked each office for a referral to an orthopedic surgeon who did take Medicaid, just nine could name one.
It's no secret that kids on Medicaid have a harder time getting appointments, because public insurance often doesn't reimburse doctors as much as private insurance. In California, "the orthopedic surgeons were losing money on every visit," Skaggs said.
"The evidence in the article... is consistent with other evidence that a lot of physicians just don't accept Medicaid patients, period," said Sandra Decker, a researcher from the U.S. Centers for Disease Control and Prevention who has studied kids' access to care.
"Even though these kids are 'insured,' they really don't have access to medical care," Skaggs added.
That will only change if health care reform not only increases the number of people who are insured, but also increases reimbursement rates so practices have an incentive to see those patients, he added.
Right now, Decker told Reuters Health, reimbursements to primary care doctors are set to increase -- but not payments to specialists like orthopedic surgeons.
When orthopedic practices won't take kids -- regardless of what type of insurance they have -- more and more families have to seek out special pediatric facilities for treatment.
Finding a specialist isn't so much of an issue in Los Angeles, Skaggs said. But, "it does become a problem when you're outside of an urban setting -- there's the rub."
For some families, finding a kids-only orthopedic surgeon means more travel, money and time away from work and school, Skaggs and colleagues write in the Journal of Pediatrics.
General orthopedic practices, Kasser said, "just aren't taking care of kids the way they were before."
Patient A is 72 and has Medicare and a broken wrist. They come into an orthopaedic office after making an appointment. They do not require a referral.
The patient is given a complete history and physical for that of a new patient, x-rays are taken, and the patient is confirmed to have a broken wrist. A cast is applied.
The patient is billed for the following:
99203 - New Patient Visit
73110 - 3 view xrays of the wrist
29075 - Application of a short arm cast
Q4010 - Cast supplies, short arm fiberglass cast, adult
The physician is paid $196.74.
In order to see this patient for this visit, the physician would have had to pay for countless things from rent, insurance, and taxes, to equipment, supplies, and staff. Staff would likely include:
Receptionist/Registration - 15 minutes
Medical Assistant or Nurse - 15 minutes
X-ray technician - 15 minutes
Insurance Biller - 10 minutes
Physician - 30 minutes
Let's take Patient B:
Patient B is 8 and has a Medicaid HMO and a broken wrist. They call the orthopaedic office for an appointment after having been seen in the emergency room, but require a referral from their primary care physician anyway. In order to see a specialist for any care, they must have a referral, or the specialist will not be paid. So, they are informed of this, make an appointment anyway because it is time-sensitive, and then come into the office two days later without the required referral. The billing and insurance coordinator for the office then has to spend several minutes to much longer (possibly hours) to get the referral or approval from the insurance company to see the patient.
The patient is given a complete history and physical for that of a new patient, x-rays are taken, and the patient is confirmed to have a broken wrist. A cast is applied.
The patient is billed for the following:
99203 - New Patient Visit
73110 - 3 view xrays of the wrist
29075 - Application of a short arm cast
Q4012 - Cast supplies, short arm fiberglass cast, pediatric
The physician is paid $142.23 which is actually higher than the normal ratio of medicaid payments.
In order to see this patient for this visit, the physician would have had to pay for countless things from rent, insurance, and taxes, to equipment, supplies, and staff. Staff would likely include:
Receptionist/Registration - 25 minutes
Medical Assistant or Nurse - 15 minutes
X-ray technician - 15 minutes
Insurance Biller - 30+ minutes
Physician - 30 minutes
As you can see, it costs more to see Medicaid patients, and physicians are reimbursed less.
If Patient A and B had required surgery, the amount of administrative time would have been even more lopsided, and the payments would have been:
25575: Open reduction internal fixation of radius and ulna shaft fractures.
Patient A: $927.92
Patient B: $569.00
Please note that this payment encompasses all preoperative planning, paperwork, the surgery iteself, and 90 days of follow-up care.
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