T

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.

advertisement

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.

Newsletters

Sign up for our Daily Recap newsletter

Please enter a valid email address.

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.

Leave a Comment

Please enter your name.
Please enter a comment.

  • This article seems so right for those who have the right intentions – intentions that can cover up the reality. Those who have experienced the financial situations first hand where most Americans most lack care may take time to comprehend the magnitude of the access barriers erected by the design. It took me decades of study. We no longer have decades – we have wasted too many already.

    Even worse we now have designers that have convinced our leaders and even associations, foundations, and institutions that designs and innovations are more important than delivery teams, workforce, and care delivery.

    With a review of the indicators, it is quite apparent that 40% if not 50% of Americans are suffering health access declines under designs 1978 to 2010 and worse since 2010. Even worse, blaming articles are sending us away from true solutions instead of toward them.

    What seems right for few Americans in a few places that are best supported with the most local resources, the most local health workforce, the most lines of revenue, and the highest payments in each line is not right for most Americans. This highest concentration perspective guides misguided health reforms, innovations, micromanagements, and constant chaotic change. This perspective also hides the fact of so much spent for so few in so few places – a theme that has played out in runaway biomedical health care costs with added costs due to micromanagement of cost and micromanagement of quality. Even worse is the next permutation of precision medicine – much more for even fewer at much higher cost in very few locations.

    So much for so few with so little result for most Americans is a theme to be understood across health, economic, education, and other designs. It is hard to evaluate which is worse, those who slash and burn what is most needed by most or those who focus on costly “solutions” that make matters worse.

    I believed in accepting all patients and did. I still work in a place that does so. I trusted that my rural practice services would be supported. I continued despite half of the income levels of family physicians and the accumulation of over $200,000 in accounts payable in just 4 years.

    But I learned the lesson of Triple Threat the hard way as I had to leave my beloved rural practice and a place of belonging like never before or since.

    My practice experiences led to a career involving 30 years of teaching, researching, and delivering health access where needed. I have learned that CMS, designers, and political leaders across the spectrum have forgotten the growing populations left behind that will pass 50% of Americans sometime between 2025 and 2035 – if not sooner.

    Rather than another dramatic blaming expose`, best journalism and best science should focus on understanding – especially real solutions. I told Medscape that they have their claim to representing physicians and I am telling STAT that you are losing your credibility with articles such as this.

  • Why I stopped seeing Medicaid patients.
    Someone mentioned H. Ross Perot in a comment. During the 1990’s, Mr. Perot’s EDS (electronic data systems) ran Medicaid. This is before the era of submitting claims electronically. We would mail claims on HCFA 1500’s and Medicaid would process and pay them in 2 or 3 weeks. We didn’t get paid a lot, but that was ok. Eventually we were able to file electronically and get paid in less than 2 weeks. Then Medicaid managed care came to Texas. No more filing electronically. In Harris County (Houston), all patients seeing a specialist needed referrals, and we had to staple the HCFA 1500 to the referral and mail it in. And we never got paid within (the state mandated) 45 days. Another commenter mentioned how Medicaid never pays a clean claim–I can attest to that. We would re-submit the claim at least twice before being paid.
    I hear from colleagues that they now accept electronic billing, but my billing department have all threatened to quit if we start accepting Medicaid again, from what they learn from their colleagues who bill in my same specialty.
    So to see patients of lower socio-economic means, I volunteer at our medical school and its county clinic a couple times a month. And when my patients lose their insurance (happens a lot in the volatile oil and gas market), I continue to see them here either for free or for a nominal co-pay. I hope that’s ok with you, Dr Sumit Agarwal.

  • Obviously Dr Agarwal has not run an office where he would take with him before taxes what is left over after paying for all expenses of running the office. When the reimbursement for seeing a patient on Medicaid is LESS than what it costs to see that patient one can see why many physicians are reluctant to see Medicaid patients.

  • Agarwal is no doubt we’ll-intentioned, but his argument is naive in the extreme.
    He suggests that physicians can make up for the inequities and inadequacies of our system of financing healthcare, and this from someone in a salaried position!
    Physicians in practice must maintain a viable practice in order to care for anyone. If one can do that on under-compensated rates, grotesque and baroque negotiations and delays with routine bills, more power to him/her, but it’s absurd to suggest it’s a moral imperative.

  • Well said!

    I would add another difficulty with Medicaid is the dependence on each state’s revenue and budget, whether or not the state expanded Medicaid with the ACA, and if there are any federal waivers.

    In addition, private practices face closure if they cannot pay the bills. The choice facing them is stay open and continue to treat the patients they can or accept more patients on Medicaid. They’re in a tight spot and it’s a spot the ACA didn’t consider. The issue of small, private practices sustainability in the health care system is vital to the entire health care system’s overall health.

  • ALL of you need to hear from an actual Medicaid/Medicare “beneficiary”! I’ve read all the comments here, and I find most/all of them lacking in clear, coherent understanding of the true nature of the whole problem. I live on a small Social Security Disability pension, with Medicaid/Medicare. I was rendered disabled by Iatrogenic Neurolepsis. I was grossly over-prescribed drugs that I now know I didn’t need in the first place. I have been rendered effectively unemployable in the current job market. I’m as healthy and productive as I am, through my own efforts, in spite of “gov’t healthcare”, and certainly not because of it. So-called “food stamps” can NOT be used to buy alcohol or tobacco, as somebody suggested here, although there is a small amount of fraud on individuals’ part. MOST of the fraud is at higher, corporate levels. The FedGov’s own GAO estimates ~$150BILLION in yearly American healthcare fraudulent billing. We have more folks doing paperwork and billing than we do providing hands-on patient care. This scam was created to provide more employment in an increasingly de-industrialized economy. Remember, Medicare is a U.S. Federal scheme, and Medicaid is (supposedly) funded & administered by the States. I work hard daily to maintain the general good health I enjoy, in spite of, NOT because of our pathetic “healthcare” system. As far as any alleged “breach of contract with society”, HAH!…It’s our own FedGov, and State/local governments which has breached any social contract with the PEOPLE. And yes, large HMO’s, hospitals, and insurance companies are part of the problem. There’s no accountability, too little oversight, and no mechanism for redress of legitimate grievances. I *could* be actively employed working with my many other disabled friends. But, that’s not gonna happen, I’m afraid. There are far too many doctors who throw pills at people, which both PhRMA and the financial/industrial complex LOVES! These over-drugged folks then require more “healthcare”, which keeps the crooked circle turning. I doubt any other commenter here is actively trying to create such an incompetent, broken system. One here talked about “no-shows”, and “no-pays”, and yes, that DOES occur, but most such folks have serious transportaion issues, and, NO MONEY. That’s why they’re living on Gov’t benefits in the first place. For such a supposedly well-educated group of people, I’m saddened at the glaringly ignorant ideology, and mean-spirited spitefulness I’m seeing here. Face it, this “social contract” is a delusional farce. And most often honored in the breach. Pathetic. Now, where’s my “happy pills” that YOU quack doctors promised us?….
    (c)2017, Tom Clancy, Jr., *NON-fiction

    • “Iatrogenic Neurolepsis” has made you so disabled that you can’t work? This diagnosis is usually reserved for psychiatric cases who took too many psych meds and causes a withdraw syndrome that eventually goes away. I think you must be disabled because you have underlying psychiatric issues that cause you to blame everyone for you medical, social problems instead of introspectively realizing you are equally to blame. You choose to take the meds, you clearly have psychiatric issues due to some personal experiences and took medication instead of counseling- you now want to blame doctors for you current social and work situation. I’m assuming you can still pick up the phone and work at a call center? Yet, it’s more convient to be “disabled” from a obscure ICD code clearly giving to you by a quack disability doctor. It gives you plenty of attention and do you have fibromyalgia as well?

    • Almost all physicians are “quacks” Dr. Hanson. You “quack-quack” every time someone throws you a piece of food (money), hoping you will get some more. When was the last time you “doctored” a patient’s record to ameliorate liability or a negative audit? When was the last time you witnessed a medical error of considerable consequence by a colleague or yourself and reported it through the proper reporting mechanism? When was the last time patient care came anywhere close to top tier of your priority chain? Income and liability control are at the top of that chain, I guarantee you. I do not deny you your right to make a living or defend yourself against garrulous litigators, but far too many patients die or suffer debilitating injury from physicians who operate (no pun intended) on auto-pilot, then never report it and even cover themselves in the record to prevent retribution. These facts are well-documented and it becomes increasingly difficult to swallow when I hear a physician complain about money, time or patient care. If you don’t like the realities of the job, go run a hedge fund. At least we all know what kind of person we are dealing with then.

  • I thought it was noble to take Medicaid until I processed insurance for an eye doctor who took it. Every bill our office submitted to Medicaid was returned for some mistake in our processing of the bill. Yet when we contacted the state to clarify what we did wrong, we would be told that we had submitted everything correctly and just to re-submit the bill. This would happen 3 or 4 times with each bill, and it took about a year or more for our doctors to get paid for each procedure. That’s a horrible business model.

    Then a major story came out in the newspaper that the state of California had been purposely floating these payments and bills, routinely putting off doctors for a year or more, and falsifying to the doctors’ offices that there were problems with the billing. It was a government scam against the providers. I had been lied to every time I’d call the state who always told me that they had no idea why our correct billing was being rejected time after time.

    For that reason, and many others, I will never trust the government with health care. We have friends in other countries who get put on long waiting lists for services. It’s horrible to see them suffering and in pain and unable to be treated. It’s inhumane. Our lives are cheap to government bureaucrats.

  • I don’t necessarily blame the physicians for this. I blame it on a country that is the only developed country in the world that insists on a market based healthcare system. Privatized for profit healthcare will only work if everyone can afford it. But not everyone can. All other developed countries have figured this out. France, Australia, Canada, Germany, UK, Denmark, Italy, Japan, Sweden even China. It’s a disgrace and an embarrassment (our healthcare system).

    • I’ve worked as a physician in New Zealand (public health) and can assure you nationalized healthcare is a liberal myth and leads to the following:
      1. Physician pay goes down which causes the best and brightest to move to other countries and there’s a chronic national shortage of doctors
      2. Doctors get paid less but can’t be sued- a good thing
      3. Doctors have final say in end of life care and treatment- not families
      4. Doctors can take quality life into consideration for performing surgeries like hip replacements, stroke care, cardiac intervention
      5. Non emergent surgeries are rationed- these include gallbladder surgery, knee and hip surgery etc. patients get on a wait list, often for years
      6. Doctors have zero incentive to see patients fast and wait times go up.
      7. People get frustrated with the national health system and buy private insurance
      8. Private insured people go to the private hospital and poor people go to the public hospital
      9. Radiologists refuse to do advanced testing like MRIs and CT scans

      Democrats want to push this model but fail to understand the true ramifications.

  • And what of Medicaid’s responsibility to society, Sumit? Is Medicaid free to do as it pleases, placing all of the burden on doctors who have neither the financial resources nor the power to affect change? Are you advocating that doctors should play a passive role in the $3.5 T US healthcare system–“we will do whatever needs to be done, please take care of us?” Surely you are not THIS naive. The mechanism for improvement in complex systems involves each party having responsibilities that they either meet or shirk. If one party shirks its responsibilities, there must be accountability. You get this, right?

  • The solution is not to force every doctor to take care of these patients and go bankrupt in the process. The solution is a combination of increasing the fee schedule, lowering the bureaucracy/paperwork involved in their care and lowering the overhead required to care for these patients. The last factor could involve business tax credits, malpractice insurance credits, hospital located and covered clinics where they can be seen…

Sign up for our Morning Rounds newsletter

Your daily dose of what’s new in health and medicine.

Privacy Policy