Why do some doctors not take medicaid?

Factual Questions
21

I’m sorry, I don’t know. I sort of keep myself intentionally ignorant about the ins and outs of the financial stuff as much as possible. I want to keep my decisions about care based on what the patients needs, and generally other people sort out the money stuff. But I will say that there are very few areas of this country where an Internist is hurting for patients. Mostly it’s the other way 'round. Do what you need to do for you; he’ll get more patients.

There are laws against “patient abandonment”. A physician who wishes to sever her relationship with a patient must give notice and generally a referral to another physician who can take over patient care except under some very usual circumstances. If she doesn’t, her license is at risk.

22

WhyNot

Thanks again!

While I don’t want to harm my providers, I am also worried that one or more of them will hand me a “referral” to the county clinic (ever see one of those places? Third World in the run-down shopping center) and cancel my remaining appointments.

I take it I should do the “establishment” thing with at least oe of every foreseeable specialist while I still have real insurance.

23

What do Phrenologists charge these days? Your spell-checker may simply be trying to make a helpful suggestion for finding accessible and affordable care. :cool:

24

It varies widely. Mayo clinic is going to get paid a lot more than the wheelbarrow line at Dr Nick Rivera’s"discount medical clinic by private insurance, but the same by Medicare. Offhand I seem to recall the rates we pay are 30-50% higher than Medicare (and double what Medicaid pays in some cases), if people are really interested I’ll look at some of the more common procedures and compare what we pay to someone like Mayo, to Dr. Nick Rivera, and what Medicare and Medicaid pay. I think I’ll be OK if I don’t disclose exact dollar amounts or the exact providers, the information is somewhat proprietary but on the other hand every time we send an EOB to a member it’s on there.

25

I’m thinking more the characteristics that go along with the Medicaid demographic, rather than needing care or being poor. Someone mentioned they have a tendency to no show, but it goes way being that.

There are a lot of decent people that are poor enough to be on Medicaid, but there are a disproportionate amount of shall we say, not model citizens. We’ve dealt with people in jail, paid to patch them up after getting in fights, I’ve read all kinds of documents about all kinds of screwed up family situations, families with 10 kids with 3 or 4 different last names, people who have become physically violent at provider’s offices, people who make repeated ER visits (sometimes several times a week) trying to get narcotics. We do have an official black list of people who repeatedly abuse the system.

Part of the problem is when everything is free it cheapens the value. If they don’t feel like showing up they don’t get charged a no-show fee like someone on commercial insurance. They don’t have a $100 ER copay, so why not try to score some Vicodin?

If a poor person needs a heart/lung transplant they’re going to get it, that’s our job, and if too many do we’ll just try to use that as a negotiating tool the next time our contract with the state is up for renewal.

26

  1. Fairly few but it happens. We certainly picked up a few families during this last recession as some were dismissed from their previous pediatricians practices due to the practice “not taking Medicaid” (which they went on after job losses) and our being willing to accept a few more (we do limit how many new families per month). That’s just wrong of those docs … and from an informed self-interest perspective, stupid. And I once had a preschool patient with congenital hypothyroidism abandoned by the Pediatric Endocrinologist due to going on Medicaid. Yes, it was patient abandonment in my mind but the legal case for that is tough – he gave notice and covered for emergency care if needed for a period of time and possbly even gave the name of the pediatric hospital that was theoretically available to them. That’s all that is required. I’m not aware of any cases in which a doctor’s license has been suspended or renewal denied based on a patient abandonment complaint. The bigger worry for the docs who do that is that if some bad outcome occurs before someone else is caring for that patient abandonment opens you up for a boatload of malpractice exposure.

  2. As mentioned already for our practice the standard was always to call the specialist doc and ask them nicely to reconsider, explaining to them that as a practice we send all our patients to the same specialists as much as possible and that if he won’t take all our patients then the result will that he won’t get any of our patients. It’s usually worked. In the case of the endo he was the only real game in town then … although our large medical group now has our own (guess who was pushing for that! :))

27

If it’s not too much trouble - how about a pure markup item:

Comprehensive metabolic panel? Just the analysis, not the draw or office charge (if any)

(one of the most common “blood tests” going)

Thanks

28

Another good on you!

Do you know of anyone who simply (as feasible - if it’s the only game in town, you don’t have lot’s of options) stopped referring anyone, anytime to someone who dumped a patient? Is this a “zero tolerance” situation? Do I, as one of a dozen possible practitioners in town know that, if I ever dump a patient, bad outcome or not, absolutely nobody will ever again refer anybody to me?

29

You want to know the scary part?
This substitution on a general-topis msg board is one thing -but my practionar’s office has a new (MyHealth) patient interface, with email.
It does the same flag/suggest - when I’m writing to a Nephrologist!

30

Nope. The biggest consequence I am aware of is losing one practice as a referral source.

It also must be noted that my practice (and this goes back to the days we were a stand-alone, not as members of a huge physician owned multi-specialty group) only had that ability because Medicaid was fairly small percent of our population … at that time a bit less than 10% I’d guess (end of recession it’s a bit more now). Without the bulk being private payor we’d have no influence whatsoever.

The comment about our being part of a huge multispeciaty group brings up another point: we currently get graded (and have comp to some degree tied to) our clinical outcomes. Less overweight/obesity rates, better asthma control, etc. in our patients gets us money … failure to achieve those quality metrics leaves us out of the pool. The Mediciad demographic is often tough in that regard. higher obesity rates associated with poverty, more likely to go to the ED for asthma and harder to get compliant with maintanence plans. More at home smoke exposure. So on. Of course the flip side is that the new NCQAA guidelines will require reaching out to at risk populations …

31

Speaking only for myself, I sure don’t. And I don’t think any doc would have such a ‘zero tolerance’ policy. Sometimes it’s necessary, for both the patient and for the doctor, to ‘fire’ a patient. That’s not the same as patient abandonment, because you give the patient the opportunity to find another doctor before you stop seeing them.

But if the relationship doesn’t work, it doesn’t work. Having a patient cling to you when you can’t help them, and when the relationship is hurting you, is not a reasonable or kind or medically indicated action.

Heck, I’ve had patients demand I treat them even as they’re in the process of suing me. And I’ve done so when it’s medically necessary. But I also begin the process of terminating the relationship.

32

I’m not talking about medically-necessitated, or even financially-necessitated parting - I’m talking about plain abandonment - whether there is enough admissible evidence to bring a complaint or not. Just “your check bounced; maybe County General will treat you, but I ain’t going to” - type dumped. No interim coverage. just block their phone number and turn the account over to collections.
Any blowback form this in the medical community?

33

I live in a pretty rural area in Indiana. I’m roughly 100 mile round trip from either Indianapollis, Bloomingtn or Terre Haute. (IOW, travel to a doctor in those locations on a regular basis is completely inaffordable)

Where I live there are only two doctors within a 40 mile radius who even take medicare, but oddly enough more doctors who will take medicaid. (I miss qualifying for medicaid by making about 30 dollars to much on my SSD.)

I’ve been told it’s because a)medicare takes to long to pay and B) they don’t pay much.

Very few people in this area (we have highest unemployed county in state) have any other type of insurance. I’ve seen doctors LEAVE the area and actually MOVE to the suburbs of Indianapolis.

It’s really fucked up all around here.

but how many patients know that? I had a doctor whom I had to travel over 100 miles once a month to get my scriptss from because of DEA law not allowing certain scripts to be phoned in. This doctor actually made a point of me having to drive down there for an appt simply for him to explain it me and sign paperwork I would not get these scripts from anyone else.

Sometime later I call and speak to his secretary/receptionist/I suspect mistress and tell her "I need a refill on my meds, what day should I come to pick them up? (this did not involve me seeing the doctor, just walking in and saying hello and having the scripts handed to me) To my shock she tells me “just have your local doctor write them, don’t bother doctor X like this.”

to which I replied “I’m sorry, but doctor X had me come in specifically for him to tell me I can’t do that, and even sign paperwork saying I wouldn’t. So I’m afraid I have no choice but to ask this of doctor X it’s his rule and requirement, so please tell me when I can get my script.”

Next thing I know I get a letter saying that I argue with his office staff (which I had never had a conversation with them where I had said anything unkind or really disagreed with them other then this one, and I was polite, and really didn’t feel like I argued. I stated what I had been told and apologized that that there was no other other option and asked her to please check with the doctor herself.) he refused to see me again or write scripts or refer me to anyone, it was a fucking nightmare. I actually wondered if the doctor was even aware of it, if the woman herself and done this and signed his name but when I called to ask what what was going on (had they confused me with someone else?) they hung up on me.

How would I have gone about reporting him had I known that this was illegal?

[QUOTE=DSeid;1612636/]

The comment about our being part of a huge multispeciaty group brings up another point: we currently get graded (and have comp to some degree tied to) our clinical outcomes. Less overweight/obesity rates, better asthma control, etc. in our patients gets us money … failure to achieve those quality metrics leaves us out of the pool. The Mediciad demographic is often tough in that regard. higher obesity rates associated with poverty, more likely to go to the ED for asthma and harder to get compliant with maintanence plans. More at home smoke exposure. So on. Of course the flip side is that the new NCQAA guidelines will require reaching out to at risk populations …
[/QUOTE]

I’m not sure I understand what you are saying here, to me it reads you somehow are penalized (what kind of penalty?) for, well, basically treating sick people. many of those conditions are not actually able to be controlled by the patients patients though society swears up and down it is. for example, the only way I am supposed to exercise is in a heated pool. there aren’t any of those for less than 100 mile trip around here, therefor, not really possible. I’m also on meds that cause extreme weight gain that I can’t drop.(unless U want to risk death or paralysis by seizure) I eat a careful diet, (In fact I have malnutrition issues and have to get shot for that because I don’t eat enough) but it is impossible to lose weight. I do not smoke or be around smokers, my asthma is from severe allergies and I unfortunately live in a state that is a bad allergy state. I take my meds and weekly allergy shots to control this, and thats all I can do to fight the asthma. I can’t change either of these things, why should I or anyone else be discriminated against in some way when i am doing all that I can but there it is only so much effective?

I honestly don’t understand why suicide is illegal. The descrimination against people with certain health issues is horrible enough that it certainly feels like that is the expectation society has for severely disabled people. You should just kill yourself.

34

The system is based on assuming that each doctor has a similar enough population of patients. (Sure each of us think that our patients are special, that we attract the sickest because we are so good … but for most of us the approximation is not so far off.) Given that it attempts to reward those doctors (or teams of health care providers more typically) that do a better job proactively keeping and getting that population healthier.

It is designed to align the incentives to outcomes we all want, and since a healthier population uses fewer resources in the long term, that includes the payors. We, as medical group, develop protocols to help people better control their asthma and develop systems to reach out to those who we identify as not optimally controlled and to figure out how best to get them there. As an individual doc I am incentivized to work as part of that team. Likewise with pediatric obesity (where prevention is key) and getting people immunized on time. These evidence based best practice protocols do not result in optimal outcomes for all individuals but they do improve the outcomes for the population as a whole.

But yes, some demographics have less capacity to utilize resources than others and a Medicaid population is statistically more likely to be obese, to have greater challenges working in exercise, less likely to have transportation to get to the office for asthma care and more likely to utilize the ED, etc. I honestly don’t think that those who currently decline to take Medicaid think about this much (and it is just baby steps as a more significant factor in comp formulas) and those who do are not yet worried that it will hurt them badly enough to alter their current decisions. But it may become a factor as these report cards become a bigger componant. Hopefully they will become more sophisticated along the way too. We’re working on it.

35

sidhechaos: Every state has a licensing board for their physicians (and other licensed professionals); that’s a good place to start. For instance, Illinois has a Department of Financial and Professional Regulation that turns up as the first hit if you Google “Illinois physician license”, and the “Consumers Quick Links” drop-down has a “File a complaint” option. YMMV in your state.

36

I decided to not name the exact services being priced, nor the providers, and to round, in order to get some data it would be interesting to compare without giving out proprietary information. The services are a non-routine office visit and a couple of extremely common labs in an office setting, these are what we paid, not some fantasy billed charge amount.

Provider A: $570
Provider B: $340
Medicare: $210
Medicaid: $150

Medicare and Medicaid payments do vary a bit, but not nearly as much as commercial payments from one provider to another. The same 4-1 ratio was true both for the office visit and the labs.

37

Thanks so much for the time and effort - How many providers are there, country wide, like A?
The difference between Medicare and “B” is at the high end of what I was suspecting.

I guess the big surprise is that anybody except charitable hospitals and saints accept Medicaid.

Could you provide the zip codes for he Provider A and Provider B?

I once had a PCP in a large practice on top of Nob Hill, San Francisco; currently it’s a UC Med School Clinic systems - wondering how close either of those would fit either profile.

Again. thanks

38

I don’t think we actually have a provider that really fits your profile (large independent clinic in nice area), our area is dominated by large players with a zillions branches. “B” is a large chain of clinics in a mid-sized metro area. They’re towards the average of what we would pay as we need them and they need us, so neither side can really bluff in negotiations.

The Medicaid payment is for a clinic in a rural area, and the Medicare I looked up the national average on their fee schedules. My hunch is being in an expensive area you would get a bit more from Medicaid and Medicare, maybe about the same as “B” from us, as though the area is more expensive even a large clinic doesn’t have the same negotiating power as hospitals and large care systems.

39

Thanks again -

Looks like the current UC clinic would most closely align with B; UC bills at the system-wide level*; as such it has to be one of the biggest mouths demanding feeding.

  • ’ make checks payable to “Regents of University of California”, whereas each clinic is operated by the local campus - UCSF got my ER business; UCD currently has PCP and specialty clinic business.