Wall Street Journal, Thursday, July 19, 2007
As Program Cuts Fees,
MDs Drop Out; Hurdle
For Expansion of Care
By VANESSA FUHRMANS
July 19, 2007; Page A1
BENTON HARBOR, Mich. — Medicaid provides health-care coverage for millions of Americans — but a growing number of doctors won’t accept it.
In February, Jada Garrett, a 16-year-old sophomore, developed what seemed at first a mild case of strep throat. Within a couple of weeks her joints ballooned. Many afternoons, her swollen ankles hurt too much to walk.
To get to the bottom of her symptoms, Jada needed to see a rheumatologist. But the local one listed in her Medicaid plan’s network wouldn’t see her in his office. The wait to get into a clinic was more than three months. By the time she found a rheumatologist in a nearby county to take her in mid-April, Jada’s debilitating pain had caused her to miss several weeks of school.
“You feel so helpless thinking, something’s wrong with this child and I can’t even get her into a doctor,” says Jada’s mother, Nicole Garrett, who enrolled her three teenage daughters in Medicaid after they lost private coverage. “When we had real insurance, we could call and come in at the drop of a hat.”
On paper, Jada’s Medicaid coverage is real insurance. Funded jointly by states and the federal government, the safety-net program is intended to provide comprehensive health-care coverage for more than 50 million Americans too poor or disabled to afford it elsewhere. Like the majority of Medicaid recipients in Michigan, Jada receives her benefits through a private health-maintenance organization contracted by Medicaid to administer the program.
But when Medicaid patients seek care, they often find themselves locked out of the medical system. In a 2006 report from the Center for Studying Health System Change, a nonprofit research group based in Washington, nearly half of all doctors polled said they had stopped accepting or limited the number of new Medicaid patients.
That’s because many Medicaid programs, straining under surging costs, are balancing their budgets by freezing or reducing payments to doctors. That in turn is driving many doctors, particularly specialists, out of the program.
The dwindling number of doctors who accept Medicaid is a large, little-discussed hurdle to some ambitious efforts to broaden health-care coverage. Expanding Medicaid eligibility or using the private Medicaid HMOs is a linchpin in universal-coverage initiatives in Massachusetts and other states — as well as some 2008 presidential candidates’ platforms.
In California, a key component of Gov. Arnold Schwarzenegger’s universal coverage proposal calls for a controversial 2% to 4% surcharge on doctors’ and hospitals’ revenues. The money would be used to pay for higher Medicaid fees so that doctors will take in more enrollees. About 51% of family physicians in California participate in Medicaid. For a number of specialties, such as orthopedic surgery, the percentage is much lower, according to the California HealthCare Foundation.
Michigan’s governor, Jennifer Granholm, is also pushing a plan to extend coverage to more than 500,000 of the state’s uninsured. Because physician groups have balked at taking more people at Medicaid-level reimbursements, policy makers hope the new program will pay doctors rates similar to Medicare — about two-thirds higher than Medicaid. But many people fear that will give doctors even less reason to accept people on Medicaid.
In Michigan, the number of doctors who will see Medicaid patients has fallen from 88% in 1999 to 64% in 2005. Many of those doctors tightly cap how many they’ll see or refuse to take on new Medicaid patients. At the same time, enrollment in the program in Michigan has risen more than 50% to nearly 1.6 million since 1999.
Paul Reinhart, the state’s Medicaid director, says he doesn’t believe difficulties finding specialists is a pervasive issue. But he acknowledges that patients can run into access problems. “That’s a problem that we’re working on and one that probably can only really be resolved with increased [fees],” he says. To safeguard against access problems, his agency requires the plans to have at least one primary-care physician for every 750 people in a given region. The program also checks a few times a year whether the specialists listed in the plans’ networks are indeed available.
“At this point, I have to pay money out of my own pocket to take care of that [Medicaid] patient, and it’s only going to get worse,” says AppaRao Mukkamala, president of the Michigan State Medical Society and a radiologist in Flint, Mich. There, auto-industry layoffs have helped push one in five people onto Medicaid or into the ranks of the uninsured.
For every chest X-ray Dr. Mukkamala performs, for instance, Medicaid pays him $20. Commercial insurers such as Blue Cross pay about $33 and Medicare pays $30. But with technicians, film and other equipment, his costs are about $29 per X-ray, he estimates. Medicaid patients he sees at Hurley Medical Center in Flint make up 28% of his work there.
Like many states, Michigan hires private Medicaid HMOs to administer benefits. The state pays HMOs a monthly fee for each patient. The HMOs then pay doctors, usually amounts close to government-set payments. As in many states, the managed-care plans win Medicaid contracts based partly on how robust their networks of doctors and hospitals are.
The HMOs’ directories of network providers in Michigan seem full, but phone calls to listed specialists in some places find big holes. The three HMOs which operate in the county around Benton Harbor — Community Choice, Great Lakes Health Plan and Health Plan of Michigan — post on their Web sites lists of local specialists participating in their network.
Of the 11 obstetrician-gynecologists that Community Choice lists for Berrien County, four doctors said they were listed in error, and another one no longer practices in the area. One took only Medicaid patients referred to her by doctors within her practice. Three others were only seeing new Medicaid patients at a nearby clinic, not in their offices. And two more were taking patients at the same clinic.
Many doctors on Health Plan of Michigan’s list, which includes many of the same names, had similar restrictions. Great Lakes’ Web site noted that none of the six on its ob-gyn list were accepting new patients.
All three HMOs’ listed gastroenterologists — another high-demand specialist area — only saw Medicaid patients at an offsite clinic where appointment waits can be three to nine months.
The health plans say they encourage members and their referring doctors to call them if they have trouble getting an appointment with a specialist. “We can’t just rely on what’s in the directory — it would be our obligation to help any member,” says Pamela Morris, president of CareSource Management Group, which manages Community Choice’s health plan. She adds that a wait of several months is “unacceptable.” The company says that all of the doctors in its directory are indeed contracted with it. It says sometimes staff at medical practices make mistakes about what plans they accept.
Health Plan of Michigan’s chief operating officer, Shery Cotton, says that in some places, it will pay doctors bonuses to encourage them to see ob-gyn patients. It also periodically checks in with primary doctors to see if their Medicaid patients are being refused by specialists. And it doesn’t require plan members to use just network doctors.
But Ms. Cotton acknowledges that low reimbursements from the state sometimes make raising participation a struggle: “We literally get on the phone with doctors and beg, ‘Will you see this patient?'”
Steve Matthews, a spokesman for AmeriChoice, the Medicaid arm of UnitedHealth Group Inc., which owns Great Lakes Health Plan, said that the plan’s customer-service records don’t show a doctor-access problem in Benton Harbor. He added that if a patient has difficulty, the company will help set up an appointment “anywhere in the state, regardless of whether they’re in the network.” Many primary-care doctors, however, say they don’t have the time or resources to call the plans for all of the patients for whom they have trouble finding referrals.
Robert Ward III, a neurologist in nearby St. Joseph, says the only new Medicaid patients his practice now sees are those who were admitted to the local hospital first. Occasionally, he will see a patient referred by a doctor he knows. But all three of the local Medicaid HMOs have Dr. Ward listed as a network provider — only Great Lakes Health Plan’s Web site notes that he isn’t accepting new patients. Dr. Ward says his office has pointed this out to the Medicaid plans.
When he started his practice in the early 1990s, Dr. Ward says he placed no limits and Medicaid patients flocked to his practice. Medicaid patients soon ballooned to 35% of his roster.
“It was a rookie mistake,” says Dr. Ward, one of only two full-time neurologists in the tri-county area.
Commercial health plans such as Blue Cross pay him between $72 and $85 for a typical neurological exam. He receives about $31 from the Medicaid plans. Now, 12% of his patients are on Medicaid.
Southwestern Medical Clinic, a multispecialty group, sees some Medicaid patients in its offices across the county because of its involvement in Christian-based medical mission work. That group now accounts for some 20% of the clinic’s patient mix. Yet the clinic limits many appointments to Medicaid patients who live in the same or surrounding ZIP codes of its various branches.
“We don’t want people driving past their community provider to come see us,” says Kenneth O’Neill, Southwestern’s medical director. “Otherwise the model of everyone doing their fair share starts to fall apart.”
Delays in getting treatment can have serious consequences. Jennifer Kinchen, 47, enrolled in Medicaid in late 2005, after Hurricane Katrina forced her to leave her home in Louisiana and move near family in Benton Harbor. Since late last year, she has suffered from tremors severe enough to cause her to drop her coffee mug or sometimes fall, liver problems and high levels of ammonia in her blood.
Her family doctor has searched and waited to get her an appointment with a neurologist or gastroenterologist. In the meantime, Ms. Kinchen has gone to the emergency room a few times because of dehydration and blacking out.
In Benton Harbor, more than 300 patients lost access to counseling services after the main provider of Medicaid mental-health services, Riverwood Center, stopped accepting payments from Medicaid HMOs. Riverwood says the reimbursements it was receiving from the Medicaid HMOs for outpatient sessions didn’t cover their costs.
Payment delays and other administrative hassles compounded the crunch, says Riverwood’s president, Allen Edlefson. The center lost $350,000 in 2003, the year before it decided to quit its Medicaid HMO contracts. “It was a painful decision, but we just couldn’t make it work financially,” he says.
The Medicaid HMOs helped slow costs by more tightly managing care, such as reducing hospital admissions and assuring that recipients are at least assigned a primary-care doctor. The state estimates HMOs have saved Medicaid more than $300 million annually in recent years.
Nestled along Lake Michigan’s southeastern shore, Benton Harbor has been hard hit by job losses. Manufacturers have steadily cut or relocated elsewhere good-paying union jobs with health benefits. About a quarter of the community of 12,000, poor and predominantly black, are unemployed.
As the city’s middle class dwindled, most doctors, along with the hospital, relocated in the late 1980s and early 1990s across the St. Joseph River to its much more affluent twin, St. Joseph, a picturesque lake-resort town. Most of those doctors are listed in HMO networks but many don’t accept Medicaid patients in their offices. Instead, many spend an afternoon every one or two weeks seeing Medicaid patients at a clinic set up in a building that once housed Benton Harbor’s hospital.
The doctors say they prefer the arrangement because the clinic — which is run by the St. Joseph hospital — pays them a flat rate for the afternoon, instead of Medicaid fees for each service. They don’t have to worry about the administrative hassle of filing claims or no-show patients — a common problem since many Medicaid recipients don’t have ready transportation. But for patients, this can mean waiting months for an appointment.
The specialist crunch means that more of the burden is falling on primary-care physicians such as Don Tynes. Dr. Tynes runs one of the few primary-care practices left in Benton Harbor. Three years ago, he left his job as a salaried physician in a local community health center to set up his own practice in a former dry-cleaning shop across from Benton Harbor high school.
“I don’t want to pull any punches taking care of people,” says Dr. Tynes. “I’m a spiritual man, not a businessman.” In his waiting room, gospel movies play round the clock on a DVD player and patients can sign up for his weight-loss coaching.
On a recent day, 22 out of the 37 patients were on Medicaid, and another 12 had Medicare or other government-sponsored insurance. Only three had commercial health coverage. Dr. Tynes tries to make ends meet with a bare-bones staff. He has also cultivated a loyal patient base by offering specialty services such as sexual-dysfunction treatment and marriage counseling. Depending on how good business is, he tries to pay himself an after-tax salary of $500 to $750 a week to support his family of five children.
But three times so far this year, he’s forgone his biweekly paycheck to keep the practice out of the red. Last year, he cut his office staff from seven to four people. “We [primary-care physicians] are the ones keeping this Medicaid system together, but we’re the ones getting killed,” he says.
Write to Vanessa Fuhrmans at email@example.com