Perhaps this belongs in GQ, but it’s bound to turn into a debate at some point, and there might not be any clear factual answer anyway.
A friend of mine is on Medicaid and has a raft of medical problems, possibly even including cancer, some of them possibly treatable through surgery. He’s been going from doctor to doctor for a couple of years now, sometimes getting diagnoses from the GP’s that are not confirmed by the specialists to which he is referred. He is absolutely convinced he is getting screwed because he is a Medicaid patient and the doctors, if they give him the full treatment indicated, will not make as much money off it as they would from a commercially-insured patient. In particular, he says, Medicaid won’t pay for surgery unless it is to treat an immediately life-threatening condition. Is there any truth to this? (I mean, of course, as a general rule, not in his particular case.)
Well, I can’t speak for anyone other than the practice I work for, but I’m the Medicaid billing specialist as well as handling most of the commercial insurances for the practice I work for. We’re specialists and we deal with cancer among other things.
Unless there is a problem with the patient being in a managed care Medicaid that we are not network providers for, we treat our Medicaid patients exactly the same as any other patient.
I’m sure there are doctors out there who don’t, and Og knows we don’t make enough on our Medicaid patients usually to even cover the minimum costs of what we do, but that’s not something you’ll find here.
In my networking with other practices, I have yet to meet anyone who admits to treating Medicaid patients differently, either. But I’m sure it exists. Frankly, IMO, if it does, then those doctors should be reported to the State Board or the Medicaid office.
Pediatrician here. Nearly the same. Some different paperwork required. Vaccines are through a state supplier and may be a slightly different schedule. Some problems getting to specialists- some don’t do Public Aid.
IME, Medicaid or, in this state, AHCCCS, patients, are not treated differently by doctors. Any medication that is not on the formulary or any treatments or surgeries that are recommended has to be approved by the health plan, and that’s where any differences in treatment come from. The doctors will request things to be approved, but if they aren’t, it’s ultimately the patient’s or the patient advocate’s responsibility to appeal that decision. If treatment is denied, that’s not coming from the doctor, that’s coming from the health plan.
Gonna start this one out with a big caveat, ok? The following is ONE person’s word concerning HER experiences with ONE medical facility. Don’t jump on me because you, personally, aren’t like that.
That said…A former co-worker of mine had two children of her own and was also a foster parent. While all three children received the same medical care, the attitude of the staff varied depending on which insurance card (private in the case of her own children, Medicaid/Minnesota Care for the foster child) she presented at the ER - fine for her kids, rather more cynical and rude with the foster kid. Perhaps your friend is receiving bad attitudes but good medical care and can’t quite put his finger on what he’s feeling?
At a minimum, there are a fair number of doctors who won’t even take Medicaid patients, so right there, a Medicaid patient has fewer choices. Whether this translates into worse care is arguable, and would depend, I suppose, on the nature of the condition.
It is absolutely the case that hospitals consider Medicaid patients a drag on the system, and will do everything in their power to improve what they call their payor mix – ideally, to pull in more patients covered by commercial insurers that simply pay better. Most providers, in most instances, lose money on their Medicaid patients, and everyone in the business knows this. And really, I don’t see how this wouldn’t translate into worse care for patients. If you have two customers, one who pays well and one who pays badly, who’s going to get better service?
However I began looking into this after losing my job that had private insurance and having to go on medicaid because my new job doesn’t offer benefits even though I’m full time and my hourly pay is less than half of what I previously made so I cannot afford $600-$700/month to purchase insurance on my own. Doctors definitely treat me differently. I have severe panic attacks and have been treated with xanax or klonopin taking it four times a day for the last 26 years. Due to losing my insurance, I’ve had to switch doctors a couple of times as doctors keep kicking medicaid patients to the curb. Every time I end up with a new doctor it’s like jumping through hoops to get a prescription for xanax or klonopin even though when I had private insurance there was never an issue. These doctors can see that I’ve been prescribed these drugs on a daily regimen thanks to the state run drug databases. Nevertheless, I’m now looked upon as a “junkie” trying to get high because of the prejudice towards those of us on “welfare”. It doesn’t matter that I worked for 20 years at a decent job and had private insurance and paid taxes to support Medicaid for 20 years. Because I lost that job I’m now looked at as a junkie and freeloader. Nevermind the 20 years I spent paying state and federal income tax that supports Medicaid. I’ve never felt so degraded trying to get the same prescriptions that I previously had no problem getting. On top of that, just how serious in klonopin abuse? I have yet to find a documented overdose death that was attributed solely to benzodiazepine overdose. There are plenty of sensational journalistic headlines claiming that benzodiazepines are killing people right and left but if you read the articles these cases never involve only a benzodiazepine. There is usually a combination of opiates involved or alcohol. I can’t find any cases where someone dies of a benzo overdose where there were no other drugs found in the person’s system.
Part of the problem (probably not the whole problem, but at least a good part) you’re having is I’m sure merely the result of different times. Today, patients who DO have full private insurance are reporting problems getting benzos prescribed because the government rules (both DEA and state-specific) have changed, as have regulatory attitudes towards benzo abuse, doctor-shopping, over-prescribing, and the like. It’s not just the possibility of benzo overdose, but people selling their xanax on the street that has led to some of these changes.
And, frankly, doctor-switching because of doctors leaving Medicaid on casual inspection looks an awful lot like doctor-shopping, and many physicians just really don’t want to have to explain to their state regulators why they are writing prescriptions for easily-abused medications to people who have gotten similar prescriptions from multiple other doctors in the recent past.
I thought doctor shopping is when someone went to several doctors asking for medicine for the same illness. IOW, the prior poster goes to Doctor A, tells him of his prior medical history and gets a script for Xanax. Then he goes to Doctor B, describes the same history and asks for a script for Xanax, but fails to tell Doctor B that he is already receiving the prescription from Doctor A. Rinse and repeat with Doctors C through K.
Why would it be doctor shopping if I simply change physicians but am not seeking prescriptions in excess of my normal or reasonable amount?
From the point of view of the databases that track prescriptions, you went to Doctor A and got a prescription for Xanax this month, then in two months you went to Doctor B and got a prescription for Xanax, then in another couple of months you went to Doctor C and got a prescription for Xanax. The database doesn’t know or care whether you told B and C about A; it just sees multiple prescription from multiple prescribing physicians for the same easily-abused drug.
Sure, if somebody actually starts examining the details and going through the paperwork, you can show that this ISN’T really doctor-shopping, but rather a perfectly justifiable set of actions. However, the burden would fall on Doctor C to show his/her regulators that “yes, I really did know about A & B, and I really took steps to confirm with both A & B that this patient no longer had active prescriptions with them, and here’s my documentation of those steps.” Other patients who don’t switch doctors regularly don’t pose the same administrative burdens and risks; neither do “doctor-flippers” who don’t get closely-monitored prescriptions out of Doc C. The doctor wants to avoid both any impropriety and any appearance of impropriety.
You would think that a computer database could easily tell the difference between these two:
Doctor A: 30 day prescription for Xanax, no refills
1 month later
Doctor B: 30 day prescription for Xanax, no refills
1 month later
Doctor C: 30 day prescription for Xanax, 3 refills
and
Doctor A: 30 day prescription for Xanax, 5 refills
13 days later
Doctor B: 30 day prescription for Xanax, no refills
4 days later
Doctor C: 30 day prescription for Xanax, 3 refills
It would seem like an easy mathematical computation for any computer program to see that in instance #1, the patient is not “gaming” the system or doing anything improper, but in instance #2, he clearly is.
Those are nice distinct and clearly differentiated prescriptions, though; there’s not a lot of ambiguity in a zero-refill prescription. What happens when the prescriptions overlap, though, or at least potentially could overlap? For example, Doctor A wrote a five-refill prescription in January; it’s now June. Are you absolutely sure the patient actually filled all six prescriptions at roughly 30-day intervals, and have you documented that?
If every patient was a paragon of integrity, doctors wouldn’t worry about being caught in schemes; not every patient is such a paragon.
(Also, databases spit out potential problems based on whatever criteria the person requesting the report desires: ‘show me all patients who got Xanax from three or more providers in calendar 2015’ is a broad brush that will overlook details such as numbers of refills. Is every regulator detail-oriented?)
Here in the UK, with our “free” NHS, I went to my doctor with an unpleasant pain in my arm. The doctor said she she would refer me to a clinic, but … “it would take a long time!”. After leaving her consulting room I went to the reception and enquired as to whether I could pay. Yup! If I paid £80 I could be seen within a week … at the same clinic. If treatment was required I coukd then switch back into the “free” system. I went straight to an A & E, where the doc indentified the problem as something minor, not requiring treatment. Docs here often don’t examine patients, they just refer them to clinics. They’re too busy to spend much time with their patients. Our NHS is in a mess.
I’m a nurse in a hospital and don’t pay much attention to who has what insurance, but I can say all my patients get the same care regardless of who their insurer may be. The doctors that admit patients to my unit may have many, some, or no Medicaid patients under their care, but they all provide the same or very similar care (depending on the docs personal preferences in treating any particular disorder that we see. Some docs are conservative and ‘non-interventionist’, some like technology and a lot of tests and treatment, etc.)
My state is one that did not opt to expand Medicaid and our Medicaid program is stringent already. When one qualifies, there are several program providers (different companies) from which to choose, but is still overall managed much like an HMO in that one must select a primary care provider and get referrals. My state’s Medicaid patients do have problems finding providers as reimbursements are not generous.
About the only problem I have encountered (as a nurse) is that some of my state’s Medicaid providers limit the number of prescriptions one can fill in a month to five. If I get a patient who has already used some or several of those five allowed prescriptions for the month, they may have trouble getting any new prescriptions provided upon discharge home from the hospital filled. I don’t involve myself in that other than that once I am aware of the problem, I call for a social service consult to get it sorted out.
I presume anyone involved in our Medicaid program could become jaded. I recently had a patient who paid $900 to stay in one of our suites. We require a cash payment of about $300 a night for 3 nights before one is placed in a suite, and give refunds if not all the nights are used. Generally, anyone on Medicaid is not allowed to pay cash for a suite- it’s against our company policy (which I think is base on a state law).
During their stay, the spouse of the patient was obviously a medical person. This spouse was on the phone a lot, clearly prescribing care and medications, but would take the calls into the restroom to avoid being overheard. The phone-answering spouse also asked to purchase an expensive piece of hospital equipment that costs about $1500 from a hospital employee during the stay. This unusual behaviour peaked the interest of a staff member who did note that the on-the-phone person was a physician and that the patient was also a medical person, and had a Medicaid application pending. I presume the pending application enabled the patient to get around this ‘no cash payments for suites for the Medicaid insured’ rule.
On the surface, this seems like it could be a bit of Medicaid fraud, but I’m not willing to rush to judgement about the situation. Perhaps the family has had some sort of misfortune that we don’t know about.
When I worked in retail pharmacy, I had colleagues who did that kind of thing. It didn’t matter why the person was on Medicaid, either; that’s how they treated all of them. Spouse has Alzheimer’s? So what. Special needs adoption? Who cares? I was even censured for being nice to them. Why wouldn’t I? They are PEOPLE.
I did not allow that behavior when I was present. For instance, if the prescription was ready to dispense, I would dispense it and not make them come back an hour later like some of them would do.
Karma has a way of biting people like that in the rear end, trust me on that.
Most doctor shoppers don’t just use multiple doctors, they also use multiple pharmacies, often in different cities too. That’s where the database comes in handy.
I also didn’t realize right away that this was a zombie thread.
About the only problem I have encountered (as a nurse) is that some of my state’s Medicaid providers limit the number of prescriptions one can fill in a month to five. If I get a patient who has already used some or several of those five allowed prescriptions for the month, they may have trouble getting any new prescriptions provided upon discharge home from the hospital filled. I don’t involve myself in that other than that once I am aware of the problem, I call for a social service consult to get it sorted out./QUOTE]
I’ve heard about that! That is completely insane. So many Medicaid recipients have chronic illnesses like diabetes, organ transplants, AIDS, cancer, etc. and may have 10 or 15 prescription that they NEED.
Quite a few doctors lose money on Medicare patients; Medicaid is much worse. It’s not uncommon for it to be half the reimbursement rate of commercial insurers. There’s also a disproportionate amount of subscribers that abuse the system on Medicaid, which can tax the patience of both insurance companies and doctors. Minnesota in fact has an official black list of about 2000 of the worst of them. http://mn.gov/dhs/general-public/office-of-inspector-general/minnesota-restricted-recipient-program/
The database reports don’t show how many days’ supply was intended, nor how many refills written. They only show instances of dispensing. They look like this:
Xanax 1mg #30 John Smith, MD 1/5/2016
Xanax 1mg #15 John Smith, MD 2/5/2016
Xanax 1mg #30 Frank Jones, MD 2/22/2016
etc. Those dates are the date the medicine was dispensed, not the date on the prescription.
When I worked at the grocery store, I had a customer who was on a similar list that Iowa had. IIRC, she could use any pharmacy but could only go to certain doctors or hospitals.
I later worked with a woman whose sister was an Illinois optometrist, and at the time, Illinois Public Aid paid NINE DOLLARS for an optometry exam! :eek: To give you some perspective, Medicare paid $55 and she barely broke even on that. To top it all off, IPA is often as much as a year behind in paying their bills, and that’s when the state is solvent, which it currently isn’t.