The 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.
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.
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.
Fair point—no one said “dirty” but I never mentioned ethnicity or race in my comments. That was something you read into it and which was not in my thoughts at all. I used “privilege” which is not equivalent to ethnicity. I too think it is unfair to ask doctors to take less money for the same service. Our health programs in this country need to be changed. My point also is that you expect “thanks” and gratitude from a Medicaid patient to a degree you do not expect that from all patients. Lack of courtesy and impolite and ungrateful behavior can and is be found in all different types of patients. To lable and assume a Medicaid patient is automatically ungrateful and disrespectful and to use that overgeneralization as a reason to refuse treatment to a person who happens to have Medicaid insurance is indecent and sad.
I have been reading along as well.
And I’ve missed the evidence of discrimination and calling people, as you wrote, “dirty”.
I haven’t seen anything that I can remember that referred to ethnicity.
What I’ve seen is a doctor who is willing to take a financial hit to provide Medicaid services. He doesn’t require gratitude although he wouldn’t mind an occasional “thanks”.
But he expects timeliness, or at least the courtesy of a phone call, so that he can spend that sudden opening in his tight schedule somewhere other than chained to his desk waiting on a late arrival that never shows.
I think people who sincerely need State assistance should speak out loudly about those who are gaming or abusing the system (eg buying lobster with a SNAP card, no-showing for appointments). When people who are better off complain, they get called heartless and racist. So they naturally become disgruntled about the whole system.
I find this so sad. It so reeks of overgeneralization and prejudice and an overwhelming feeling of privilege from people we trust in such a close relationship- doctors. I have medicaid insurance for the first time in my 58 years. I am educated and have worked all my life as has my husband. I am self-employed and carried private insurance with my husband’s employer. I was diagnosed with breast cancer last year. Half way into my treatment, my husband was let go from a job he had held for 30 years. He had just turned 65… coincidence? I don’t think so. He was able to go on Medicare but not me. I was unable to work for a time. Our income dropped significantly and I was able to qualify for Medicaid. I am still the same person I always was. I did not become discourteous, lazy or dirty the minute I went on Medicaid. People are on Medicaid for any number of reasons. It can take only one serious illness or accident to put people in a tight financial spot at the exact time they are in need of significant medical care. I wish Medicaid would pay doctors at the same rate as other insurances but I feel the biases and discrimination I am reading about here would still exist for those on Medicaid. There is so much wrong with our health care system in this country. It is humiliating embarrassing and hurtful to me to hear doctors complain about Medicaid patients and think that those unfair assumptions are made about me. Everyone deserves to be treated decently. I fully recognize my privilege in this country and there are those that have not been as lucky as I am. They are no less entitle d to be treated with kindness, understanding and decency. So these comments I’m reading make me sad for others as well.
I have time because I am waiting for him to get in the room ! He is still filling out paperwork! He wasted 30 mins of our office time. I was nice enough to still see him. Usually our office policy is 15 mins your done. If you are a new medicaid patient and you no show, your done, out.
My wife is a dentist and she takes care of mostly Medicaid insured patients. All of them smoke.. all of them. So just today she had a patient that had to have her upper jaw extracted because her teeth are bad. Why? Because of smoking. So in order to save her bottom teeth my wife advised to stop smoking. What did this patient do? She reported her to the office manager for degrading her. Are you freaking serious?! I feel so bad for my wife, has to work with these people who have denial of their health and get offended about their bad habits. Again, I am sure there are lots of Medicaid patients out there who need it, but I would say > 50% are abusing the system, smoke and have bad habits and this is the population that need needs to be addressed. My wife always comes home with nasal congestion, sniffling, coughing. Everyday I tell her we got to get her out of there.. I hope one day we can make that happen. let their smoking kill themselves and someone else.. not my wife.
Well my second new medicaid patient of the week was late 20 mins. First one of the week no showed, now this one put me behind schedule. Great!
Ohh and I suppose you’re always on time.. spare us 🙄
Well i would be if it weren’t for people like this.. so spare me…
Not even decency to call and let us know they are running late. I would do that. I would call the office apologize and let them know… never, never had a medicaid patient do that. They come when its convenient for them.
I’m sure you say that about all your minority patients. You sure seem to have time to post nonsense on this app..
And what I dont get is they all have iPhones!! iPhones! So spare me and dont give me any crap that they can’t call!
Whats with you and this minority statement? Are you a “minority” or something?
Wittstein,
Spare us the pitiful existential pose. Next you will portray him as a racist, then a homophobe and the creme’ de la creme’, an anti-transsexual. I am no fan of the medical profession for very good reasons; but my wife was a clinician for 25 years and if I were any physician I would opt out of Medicaid. They don’t show for appointments, they have a generally entitled attitude and Medicaid not only does not pay enough to make it worthwhile, but they audit docs almost by lottery and fine the at just the perfect level – 25k-30k – so that it would cost more to defend yourself than to pay the fine.
You know my dad used to always say “Son, when I was your age I worked so hard I had to support your mom, grandparents, and siblings. Now you have it so easy you just support yourself and your wife”. I tell him “dad, no that’s not true, I work very hard and I support tons of other family members too, difference is they just aren’t related to me”.
Charles,
I left this site once, willing to let this go for the moment; however, as I was writing on another project, I couldn’t get your comments off my mind. I will be brief: UTI’s are almost never “asymptomatic”, using your term. They may not produce classic symptoms such as fever or pain, but when a woman has a consistently high WBC, complains of “scratchy” feelings when she urinates and is confused for no obvious purpose, I suggest to you that at the very least a urinalysis is mandated. None was done. None was ever done. Moreover, people who are over the age of 60 often do not manifest fever with a UTI. In addition, when an ambulance took this patient directly from one large, teaching, hospital to Duke, a few hundred miles away, an infection was determined within an hour of her arrival. She died 6 days later from Septic Shock. You bet your life I have a problem here.
You describe a clearly symptomatic UTI, confusion being a somewhat frequent manifestation in the elderly. In someone that is truly asymptomatic treatment exposes patients to real risks like c diff which can be life-threatening. Further such patients re-colonize the bladder very frequently leading to acquisition of resistant organisms. Identifying who will develop serious problems like confusion and sepsis is a major problem. But I’d estimate I see 50 U/A’s suggestive of infection for every case of sepsis, so there is a trade-off. I wrestle with this issue and want what’s best for each patient. Asymptomatic “UTI’s” are not uncommon at all. I use quotes only because it’s not clear in the elderly that WBC’s in the urine warrant treatment.
And regarding my acquaintance, she didn’t admit to a mistake as she only learned after the fact what occurred which was entirely unrelated to treatment she rendered. She did what was considered moral and right yet was sued.
You are indeed right that failure to report or correct mistakes makes one complicit.
Regarding your loss, transfers often amount to a loss of at least 12-24 hours. The transfer itself, especially for a condition seen and effectively treated at hospitals across the country, may have delayed treatment and contributed to the outcome.
Charles,
My wife was extraordinarily bright, holding a PhD in chemistry and one in clinical psychology; a MA in Psychology and two undergraduate degrees and was working on an MFA in Studio Painting when she died. She won a competitive grant in early 2015, and spent that summer studying Cave Art in southern France, where she was using her experience in psych testing and her knowledge of art to analyze the Cave Paintings with the thesis that those paintings could reveal the origins of human consciousness. She was only 65. Her confusion was not any ordinary confusion of an elderly person. She was the lest confused person I have ever known. She was sick, undiagnosed, untreated and, effectively, killed by the negligence and incompetence of medical professionals in that original hospital setting. The only reason we found out she had Sepsis was because of the transfer to Duke. She was in that first hospital for over a week with no urinalysis ever performed.
As a physician, I can understand your perspective. My wife was really sick last year.. she almost died from sepsis and we lost our pregnancy because of negligence and medical error. Most of the physicians I interacted with were horrible, had such high egos, and low medical knowledge it was crazy. But that has nothing to do with this forum about Medicaid. A lot of physicians need to go to a course and learn how to interact with patients.
Larry, just as you made an incorrect assumption about my friend’s role prior to being sued, I made some incorrect assumptions of my own. I’m sorry for your loss and agree a thorough search for infections is virtually always standard when evaluating confusion.
Larry
Once again I fail to see why the article discusses mandatory participation and you insist on shifting the discussion to your spin
Find an article on medical ethics and go at it but this is all about Medicaid/Medicare participation
Dr Dave
Dr. Dave
Yes, this article is about Medicaid/Medicare participation, I agree. But my position consists of dual arguments. First, this website/online magazine concerns itself with healthcare and, frankly, puts its own spin on the subject with regularity. Second, the issue that I am most concerned with and have addressed in previous posts is far more important and, in fact, critical to many, many patients and one could argue to the long-term legitimacy of the medical profession itself. Therefore, I take whatever opportunity I get to place it into the light of day and make my case. I’m sorry if that bothers you, but life is precious, short and the forces against me are large, arrogant and venal.
Larry, I’m afraid I agree with Dr. Dave. I’ve been into something of a deep dive into problems in research and the scientific evidence that informs medical practice. It would be equally reasonable for me to go on at length here about those issues.
This might be a more congruent article for your concerns https://www.statnews.com/2018/03/02/surgery-centers-patient-deaths/ .
Additionally it’s far from clear that treating asymptomatic “UTI’s” is actually useful. And I’ve seen very few active attempts at covering up errors (though one truly egregious example comes to mind). I also know at least one doctor who has been sued after such a full disclosure. I know it happens but my experience obviously differs from yours.
Charles,
I left this site once, willing to let this go for the moment; however, as I was writing on another project, I couldn’t get your comments off my mind. I will be brief: UTI’s are almost never “asymptomatic”, using your term. They may not produce classic symptoms such as fever or pain, but when a woman has a consistently high WBC, complains of “scratchy” feelings when she urinates and is confused for no obvious purpose, I suggest to you that at the very least a urinalysis is mandated. None was done. None was ever done. Moreover, people who are over the age of 60 often do not manifest fever with a UTI. In addition, when an ambulance took this patient directly from one large, teaching, hospital to Duke, a few hundred miles away, an infection was determined within an hour of her arrival. She died 6 days later from Septic Shock. Yes, I have very BIG issues.
Charles,
I’m sorry, but as I was working on something else I thought about your comment and just couldn’t let it go. Toward the end of your March 14 post you said, “And I’ve seen very few active attempts at covering up errors (though one truly egregious example comes to mind). I also know at least one doctor who has been sued after such a full disclosure.” Hello! If you have seen ANY adverse events that were of any consequence and did not report it, YOU are part of the problem. And as far as your acquaintance getting sued after admitting a mistake. So what? If you have a 10 year old son who steals something from Macy’s and gets out of the store with it and you find out about it, what do you do? If you are any kind of responsible father, you make the kid take the item back into the store and admit what he had done. Maybe the store won’t press charges. Maybe they will. Regardless, it is on you as a a parent to make sure that kid is punished and understands why, so he won’t do it again. Right? If the store lets him go, the YOU have to punish him yourself. Right? You can’t just let him go, because then there’s no lesson to be learned. Physicians should not admit and apologize for making a mistake that cost a life or caused a serious disability to make themselves feel better and/or to hope the family doesn’t sue them. He does it because that is the moral, the ethical, the “right” thing to do. If he gets sued, he gets sued. Maybe then, he doesn’t make that mistake again. Maybe then, instead making an assumption – where medical errors come from – he will MAKE SURE. Taking short cuts, mental and otherwise in medicine is unacceptable. Period.
Larry Pierce
Sorry, you have had some issues with the quality of care you received but how does that relate to mandatory acceptance of Medicaid/Medicare third-party payments?
Dr. Dave
Dr. Dave; I disagree with any mandate for third-party payors, whether that be Medicaid, Medicare, Aetna, Cigna, etc. The surreptitious strategy played out by politicians and insurance executives on the medical profession in the 60’s and 70’s is a big part of what has caused the profession to be in virtual chaos today. But I have more than just “issues” with hospitals and physicians who make preventable errors of such consequence that people lose their lives and then act like adolescents about it. They lie, obfuscate and even alter the medical record in order to ameliorate their liability. Very, very few physicians report medical errors committed by themselves or their colleagues, when an early admission might have stopped an error chain that cost a life or caused a life-long disability. Yes, I have BIG issues with this.
Another Medicaid family no show. Its so rude. No showed on Oct 2017, No showed yesterday, and another no show today. They are officially discharged from our clinic. See ya. Not even a phone call even though they all have iphones!
I don’t blame you for getting aggravated at anyone, Medicaid patients included, for no-showing without a very good reason (like an ER visit), but before you vent too much over Medicaid’s inadequacies, please do the following: Report all Adverse Events by yourself or your colleagues, especially when it leads to death or severe disability; if you are hospital-affiliated, please order a urinalysis on patients at least every other day so that infections are caught early instead of being allowed to evolve to Sepsis; if you are an Oncologist, NEVER accept a pathology report diagnosing any lymphoma with an FNA or Core Needle; and if you are a ICU physician, NEVER send a patient for a brain scan because of confusion without first checking for encephalopathy due to infection or cefepime infusion. People die from these mistakes. Mistakes that are clearly preventable. I don’t blame physicians for wanting to make a living or for making mistakes. I blame them for not being adults and accepting responsibility for their actions by reporting those mistakes.
Instead of having to discharge them and going thru the requisite paperwork and documentation why accept them at all?
For a group of people who are getting something for free (in the case of Medicaid), they have NO gratitude or appreciation that other people’s hard work and effort are paying for their medical needs to be handled
Heck when I need to personally go to my own hospital for treatment (I have TOP end insurance and pay ALL copays as requested) I am still totally appreciative and thankful to the staff for excellent care but typically this group is more like entitled beings then thankful for even having care available
They are the FIRST to call a Congressman if things aren’t to their liking as if they actually contributed to society in any proportion or level
Dr. Dave