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he notice on the clinic’s website, “We do not accept Medicaid,” might as well say, “Poor people aren’t welcome here.” It’s an unfortunate practice that is sadly all too common and affects the lives of millions of Americans. My patient, Gerald, is one of them.

A retired school bus driver, Gerald and his wife make do on a meager income. For health insurance, he relies on Medicaid — insurer of the aged and disabled, pregnant women and children, and the poor. Gerald drives 50 miles into the city to see me for his diabetes. There are clinics closer to his home, of course, but he makes the long journey to see me because the clinics in his area won’t see patients with his insurance. In our health care system, beggars can’t be choosers.

The blanket refusal of many physicians to see patients with Medicaid is unjust. It contributes to a health care system of separate but equal based on social class. The medical profession must fix this glaring breach in our contract with society — all physicians should accept Medicaid.

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An oft-cited study showed that 31 percent of physicians nationwide were not willing to accept new Medicaid patients. The rate was even higher for orthopedic surgeons and dermatologists, two of the highest-paying specialties in medicine. The Affordable Care Act led to some modest improvements, particularly in access to primary care, but the acceptance rate of patients covered by Medicaid remains dismally low.

Yet these patients need us. One in 10 have cancer; 1 in 5 have diabetes; 1 in 3 have mental illness. As Paul Farmer has written, disease has a “preferential option for the poor.”

To explain why some physicians do not accept Medicaid patients, physicians and administrators frequently blame the bureaucratic hassles of Medicaid, particularly its subpar reimbursements. Nationally, Medicaid reimburses providers for their services at 66 percent the rate of Medicare and at even lower than that compared to private insurance. So the business argument goes like this: To maximize revenue and margins, prioritize patients with private insurance and turn away those with Medicaid.

Patients with Medicaid are also often psychosocially complex, requiring more attention and resources than the average patient. Gerald, for example, can’t read, which complicates and frustrates his care. So the job satisfaction argument goes like this: To minimize encounters with difficult patients, prioritize those with private insurance and turn away those with Medicaid.

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What this means for patients with Medicaid is what Seema Verma, administrator for the Centers for Medicare and Medicaid Services, decries as a “card without care.” In truth, that’s a bit misleading. Gerald does have access to care — he sees me. A survey of Medicaid enrollees found that 84 percent were able to get the care they needed. Yet to do that Gerald must drive past dozens of other clinics that will not accept Medicaid and get to a safety-net clinic that will.

Although Medicaid helps bridge the gap between those who have private insurance and those who have no insurance, physicians drive a wedge into the health care system and propagate the structural inequities of separate but equal when they turn away those with Medicaid.

A modern version of the Hippocratic oath, called “Medical Professionalism in the New Millennium: A Physician Charter,” demands that we work to “eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.” That’s only fair. In recognition of the integral role that physicians play in society, the U.S. government invests $15 billion each year in the training of doctors, or $150,000 per year on each and every resident physician. No other profession enjoys this level of public support.

To rebuff Medicaid, the insurer of society’s most underprivileged and vulnerable, is to reject our moral responsibility as physicians and to worsen the very disparities in health care we have been charged with eliminating.

While policymakers continue to work towards improving Medicaid, physicians can and must do their part to live by our collective professional ethics and help those most in need of our services. Doing so would not bankrupt our practices. Each physician can decide what level his or her practice can sustain — the answer is not zero.

Over the last few years, Medicaid and health care have become increasingly politicized. But physicians must remember that behind all the double-speak, pretense, and charades are real people like Gerald who need care. Refusing to see them is nothing less than discrimination by another name.

Sumit Agarwal, M.D., is a fellow in internal medicine at Brigham and Women’s Hospital and is pursuing a master’s degree in public health from the Harvard T.H. Chan School of Public Health.

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  • Saddened by the way doctors speak about the sick and vulnerable. First, we all end up in a disgraceful place with our health, we are all vulnerable to doctors and would hope they are compassionate to our suffering, but I learned fast when they decide not to care you will suffer in a way you never could imagine and judgements are harsh. Mo, did it ever occur to you that your patient could not reach you to state they could not make it. I can give you a prime example, I recently was in multiple ER’s due to patient neglect and abandonment from three of my care providers. They ignored several calls to their answering service for help. My family had to call an ambulance after several days of pain caused me to collapse. I was then rudely screamed at by the parametics for not being able to respond to constant questions that seemed like a total blur, then screamed at by ER staff for not being able to comprehend conversation. My pain increased further as they left me in a chair which seemed like an eternity, I struggled to walk with demands I go here, do that, no one even asked or noticed that maybe I could use some help. Instead I was screamed at for taking too long. I’m told that they needed to do a CT scan, then they tell me if I stay overnight for observation which they highly recommended I do that they will meet with surgeons and do surgery that morning or transport me to another hospital who has surgeons for me. I didn’t want to stay, I had been in twenty ER’s over the last eight months where they had continuously given me pain meds that sent me into severe cramping, vomiting and shaking (had they of cared they would have administered benadryl but instead they kept me suffering for hours). I was scared, I cried but agreed to stay since I knew my last surgeon had told me I needed surgery and not to wait too long. By morning I was greeted by a different ER doctor who I was under the impression never spoke to anyone and certainly not my surgeons, no one showed up, I was discharged in the same horrible condition I had arrived in. I had been transported by parametics so I was barefoot and in pajamas, the front desk acted like they had called me a cab, but an hour later I was awoken by a police officer and told I could not sleep on the bench just outside the hospital doors. By late that night the pain became overwhelming again, I lost control of my emotional state after again my PCP, gyn, and hernia surgeon staff refused to place me in direct contact with my doctors. I waited for days for one person to call to see me. So then my hernia surgeon sets up appt., it just so happens that on this day they had three areas of construction that left me stuck in grid lock traffic for over three hours, I did call doctor twenty minutes before appointment to let them know that I wasn’t even close to their office yet, so what do they do? They punish me by telling me they can’t see me for two more weeks. As I sat stuck in traffic with my pain getting worse, I panicked and called gyn to explain my situation, so they agree to see me the next day, but I didn’t know about the change in clocks, just after I spend hours in traffic and drive into the lot I turned on my phone and notice it is an hour after my scheduled appointment, I look at my car clock and it’s fine so called doctor and to my shock they couldn’t care less. My pain load was so bad I passed out in my car after speaking to them, so I admitted myself to ER when I came to and asked for my surgeons, again they ran CT scans, I was told again they would consult surgeon to have surgery either that night or if not than in the morning, they demanded I allow them to give me moraphine for the pain, I asked them to only give half the dose as it turned out I got no relief the entire time I was there, I asked for a heat pad they had none so I laid there suffering. Then ER doc comes in and says we are discharging you with a big grin on her face like the cat ate the mouse, I was livid at how my issues were ignored for over a year as my health continued to decline. So you understand, I was a competitive gymnast my whole life, I went on to teach years of kids gymnastics and dance as well as teach fitness. I also was a song writer, photographer/videographer. Extremely active my whole life. But then something went very wrong, when I found out doctors had severely neglected to recognize things going wrong, then try to manipulate my health records to cover it up, how long do we say nothing? I never asked to be placed on CAID as you so belittling describe it, I always made my own way in life somehow, some way, but after my life’s work and accounts became emptied by doctors who did nothing as I deteriorated in six years; they collected thousands while they simply stared at me across a room and wrote falsified statements so no doctor would begin to take me seriously; here I am stuck in CAID about to be put on the streets because not one surgeon will admit to the damages I suffered from years of misdiagnosing. By the way I had money to pay, it’s just that after they told me I needed surgery, they delayed me from doctor to doctor to doctor until they wiped me out knowing surgery was the only way to correct my situation. I now can barely empty my wastes, I am bedridden in pain and I need a highly skilled surgeon Caid won’t pay for. My surgeon’s they sent me certified letters after I missed my appointments for situations I had no control over. The ER’s have made what a surgery would’ve cost and I could have been back on my feet months ago, but now I will remain trapped in the system, eventually I will lose control of my organs and doctors will talk about Disney and laugh at their horrible freebie CAID patients they don’t want. However, had you of cared for your patients before they got so sick they were forced to accept CAID, you wouldn’t have so many of us to talk about. I had a good doctor in my teens, he was on the Mayo Clinic board, he never doubted me or made fun of me as his patient and he always looked into my issues even if my own family disbelieved and he always found the problem, I wish he was here now.

  • So Mo let me see if I have this right
    You are keeping the contract out of personal guilt that if no one else is treating them you need to be there for them BUT you have no respect for them and their lifestyle?
    So as I suggested that is hypocritical no?
    Why no drop the contract pick out the few who you DO like and respect and treat them for free? Same income on a given monthly basis.
    Trust me you don’t recognize who I am but there aren’t 10 surgeons in the ENTIRE USA that do what I do and yet I treat the patients I want to and do them ALL for free
    Without the mandatory contract requirements you can pick and choose the ones you like and the rest can kiss your 6 (as we used to say in the Navy)
    Isn’t it easier to pick and choose the ones you want rather than being forced to treat all of them based on a contract?
    Sure you will lose a few dollars in income by not participating BUT the money you save by not having holes in your schedule will more than be offset by the cash and InsCo patients so fill in the few openings with Caid patients and be happy emotionally and financially.
    I bet your staff would kiss your ring if you did this and what is THAT worth in terms of productivity and staff support?
    Decades ago we shifted to a team approach to care with all staff members having a say in the way the practice runs. Now if you are a phone answerer or a PA or even a Fellowship student as long as you are on my team you have a say.
    With that, it has been universally accepted for almost 40 years that we do NOT accept Caid patients and that we not PARTICIPATE with Medicare (but we treat lots of them of course heck we are cancer surgeons)
    The point is 4 dogs 12 parrots and a partridge in a pear tree I care less BUT you are treated at the honor of the team and any dishonor you are GONE.
    You blow us off Bye Bye, you don’t follow our rules of pre and post op care you are Bye Bye. You disrespect ANY of my team Hasta Liuego Bye Bye
    On the flip side, you will never in your life find a more customer service oriented practice. We are Disney Trained we are all routinely evaluated by the guest relations team at Disney (we are 3 miles from Disney World in Orlando) and we look and feel like a 5 star hotel, not a medical facility complete with pick up and delivery and even hotel arrangements for our MANY out of town patients who fly in to have us take their face and neck apart and try to repair things
    ALL of this free (except for the hospital side of things only I am free the rest is charged for along with any of my partners and the like I am the only goofball who works pro-bono)
    Dump your mindset of “if I don’t do it then …” and shift to “we will treat everyone with equal dignity and passion bilaterally”
    Dr Dave

    • Dr. Dave,
      Nice to hear from someone whose specialty and practice allow for a Disney-induced customer service donation of 100k a week. This may be a primary revelation for you, but oh, say, 98% of physicians, let alone average people walking the street, are not in that position. Since you do so many surgeries, how many of your Disney-indoctrinated patients have sued you? Have you “doctored” any medical records lately to make that possibility less likely? Yes, I have lots of issues with the medical profession that I have aired on this site many times, so I’ll pass on that this time. I will just remind you of this unalterable fact:
      Most physician who take Medicaid live in fear – and that fear grows yearly – of a contrived and manufactured audit by government entities who develop and engender an expanding means for making their mediocre, but safe, paychecks keep coming into their bank account. They could not care less if a doc is guilty or innocent of the charges. If they can get hold of a given clinicians billing software and patient notes, they will find a way to fine that physician. The fine is almost always in the range of 25k to 30k, + or -, per offense. Just enough so that it is less expensive to pay the fine than to hire an attorney and fight it. So, my advice to all physicians – every single one – is drop out of Medicaid. They are far worse than Medicare in terms of abuse of physicians.

      And here is a suggestion for you: If you are giving away 100k a week to patients who may, or may not, truly be in a position not to pay for services, why don’t you bypass one or two of them for a few weeks and pay the tuition for a young, talented med student – preferably a woman, since my research has indicated that female physicians are far better at their jobs than men – through med school, instead of forcing them to take on untenable loans, which then make it necessary for them to choose a residency program far shorter in length so that they can start eking away at the interest payments that will take ten years before principle payments kick in. If you do that, you might see more physicians willing to forego medicaid and the resentment that accompanies it, and more willing to see pro bono patients and spend their weekends at Disneyland (or World). While you’re at it, please give them a few moments of your time to advise them that adults – as opposed to ten-year old children – report their mistakes, instead of lying to get out of trouble, and stand up AS ADULTS and accept any punishment that is due the degree of mistake that is committed. When you kill someone, they are dead forever. The punishment a physician may receive last for only a short amount of time and is generally paid for by – imagine the irony – an insurance company.

  • A medicaid patient called us 2 weeks ago to get in because she was desperate. So I opened up a slot for her to come in today. Did she even show up?! No! Ridiculous. No phone call, no decency to let us know that she changed her mind. Nothing. She is banned. I will not do this for any medicaid patient every again.

    • Mo
      If you hate them so much why not drop out of participation and if there are some you really like treat them pro-bono?
      I get it they are a hassle but publicly bad-mouthing each and every one who isn’t acting in accord while you continue to participate is a bit hypocritical no?
      I never accepted them and actually never participated with Medicare either but I did it with full openness as to why and the reasons along with a philosophy that if I wanted to treat someone I would and not worry about compensation. Trust me when I gift a service it is FAR greater than when you do. Since 1999 we GIFT about $100K per WEEK in surgeries!
      My services are tens of thousands of dollars EACH and we do several per week and all are free (now) back then we ONLY charged the insurance and some cash patients no public assistance or other participation agreements that didn’t at least pay the bills and a bit more.
      I disagree that if someone is on Medicaid they should live like a dog with no pets and no personal amenities BUT I agree they should not be allowed to add insult to injury with smoking, excess alcohol, and the like
      We need to implement mandatory across the board compliance in order to gain access to social networks be they InsCos supported by large swaths of public revenues or even employer-based programs the bottom-line is that if you want anyone to pay any portion of your bills then you need to cooperate with lifestyle alterations or pay your own way
      Dr. Dave

    • Dr Dave, I would have removed medicaid patients out a long time ago, but I cant because I’m one of the only providers in my specialty in this area that actually takes Medicaid. The rest of the physicians in my specialty were smart enough to not see them, but someone has to. I’m not saying they cant have dogs or cats, but 4 dogs?! 4 cats!? thats absurd! and they dont know how to manage their money at all. And who is paying for all that crap, we are! Its dumb! Anyways, I have a few more medicaid patients on the schedule tomm.. . let see what happens.

  • Ok today I had two new medicaid families come in. They both showed up on time! The first family has 4 dogs. Yes 4 ! Not 1, not 2, not 3,.. 4 dogs! According to online resources thats nearly 4000.00/year expense! The second family has “dogs and cats” and the family smokes. Im glad my taxes are going for cat , dog food and smokes. Gotta keep those pet food makers in business.

  • “Physicians who refuse to accept Medicaid patients breach their contract with society”

    What contract?

    Because I for one missed that part. No one named “society” asked for my signature on anything.

    So, please enlighten us.

    What is this “social contract” you reference?

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