Followup to the WSJ story earlier blogged today. Physicians who don’t limit Medicaid patients find themselves in binds like this:
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.
Related posts:
- How cutting Medicaid payments hurts patients
- Cutting Medicaid payments
- A PCP’s patient panel
- "Education is not part of the cost of treating a patient"
- Medicaid cancer screening
- Accepting Medicaid led to firing
- California is cutting Medicaid payments
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It is not related to this post. I have just read your post of 2005 about PFO and stroke: http://www.kevinmd.com/blog/2005/03/tedy-bruschi-update-stroke-and-now.html
Very interested and clear description the story of the commercial airplane pilot. I have posted new results about a similar problem, PFO and migrains and listed good references at http://iskanbasal.wordpress.com/
please note I got the news from the newsletter of the Primary care neurology society, a British GP with special interest association.
Thanks
What on earth does one doctor who is seeing less than 40 patients a day do with SEVEN staff?
“What on earth does one doctor who is seeing less than 40 patients a day do with SEVEN staff?”
Probably 5 of them to deal with denied reimbursement,and radiology denials.
What might seven employees do? They might be rescheduling all the no-shows (40% typical for Medicaid panel patients) and filling out the paperwork and chasing down the payment denials that inevitably result with Medicaid claims. Think receptionist, appointment, telephone, nurse intake, checkout, claims filing and payment posting, all the stuff that has to be done so you can see enough Medicaid patients to keep the light bill paid.
This doctor should be limiting his Medicaid patients to a small number
of his census. That might start by refusing new Medicaid and culling those presently in the practice that abuse services (like scheduling appointments and then not showing up.)
It is one thing to want to provide compassionate and needed care, it is another thing to be a doormat for both the state government and abusive and entitled patients.
I have been in clinical practices like this one. It is a demoralizing
practice environment and risks both burnout for the doctor and personal business failure. Neither he nor his family deserve that as the price of sating the limitless appetites of underfunded entitlement programs and their “beneficiaries.”
As long as physicians keep tightening the belt a little more, taking small paychecks, even forgoing them, and cutting staff, the government will continue cutting back. When physicians have refused to participate in sufficient numbers that access to care is impaired and patients clamor, then the cutbacks will stop – not sooner.
We all do one another a disservice by seeing how much we can absorb before drawing a line in the sand. Medicaid is already too little to work for.
Believe me, the primary care docs are not the only ones getting “killed” by the Medicaid “system.” Specialists get treated as badly or worse. It is no surprise to me that Medicaid patients can’t find specialists, because they are effectively demanding that their doctors subsidize their care on the revenues of the practice. The “system” is really a government-sponsored scam. The Medicaid agencies and the Medicaid managed-care contractors are making real money off the taxpayers and scamming the doctors. There is nothing good that comes from that.
I just can’t wait until 2008 when it’ll be Medicaid for everyone (Hillary ‘08!).
I agree with everything said and in fact I have limited my Medicare patients now to only seeing my present quota and those who ‘graduate’ into that group from among my present patients.
I have not yet put a quota on my Medicaid patients but that will come undoubtedly.
I was talking with a Canadian colleague of mine last week and telling him of our Medicaid/care woes and he told me that in B.C. the GP’s were now being paid 25% MORE for an average office visit for those over 65 and as well there were bonuses paid to physicians on certain ICD codes for chronic diseases such as diabetes, CHF, and the like. This would apply to a large portion of my Medicaid patients too.
Interesting that a single payer system should do that. It took a lot of lobbying by the CMA. Considering that Medicaid and Medicare have a single payor system too maybe the AMA isn’t putting up a very good fight fo us.
If you’re a single doctor and you see less than 40 patients a day it’s hard for me to see how you could keep seven employees busy. It’s easy enough to rattle out a bunch of tasks. But MGMA numbers I think max out at 4.5 employees for the busiest of physicians. It seems to me the problem was not only Medicaid.
Good job Evan. You’ve spotted the big lie in this doctor’s tale. The Medicaid practice CAN work with just 4.5 employees. Stupid doctors! Medicaid should be enough to pay your bills, put the kids through school, and leave a nice fat nest egg.
Please.
MGMA numbers are averages, and reflect medical groups (Hence “Medical Group Management Association”).
Just becaase a group of 3 docs can get by this 13.5 FTE does not mean a solo practice can do with 4,5
Actually, a solo practice needs about three. I’ve seen some with two.
The only thing I can say about this is, I don’t know if those seven people were full-time or part-time. But yes, seven full-time staff is way too much.
Maybe some of that staff was nurse-practitioners or PA’s, which could skew the ratio. But I don’t know.
“Actually, a solo practice needs about three. I’ve seen some with two.”
As usual, I depends.
I suppose you could do with one or even none, if you didn’t mind answering phones between patients. If you file claims in-house, you need staff. If you are generating a load of five hundred visits a month, you would be wise to bring filing in-house unless your labor costs are prohibitive. Outservice billers are generally not as thorough and definitely do not like to spend time chasing denied claims. They see more money from time spent on fresh claims. If you are booking twenty patients a day or more, you need a receptionist who can schedule. Any more than that, you will likely need a second person who can do checkout and generate receipts. If you are seeing twenty patients a day, you will probably want a nurse or medical technician to improve your patient flow.
So the staffing adds up. One doctor with seven FTEs is a bad ratio, unless you are doing extra services in-office like imaging or laboratory or EKGs.
The problem with the office in the post was the excessively large census of Medicaid patients.
The problem is only made worse by the high staffing costs.
My experience with an urban Medicaid population was that ten scheduled appointments with Medicaid-”paying” patients had the same contribution to practice revenues as a single discounted cash-paying patient.
My own experience is that the government patients are more time consuming and resource intensive. More no-shows, more staff time, more social problems that have to be addressed, more forms to fill out, more interagency interactions, interpretors not showing up, etc etc. I can easily see how the staffing can get out of control with the thinking that he can see more patients by off-loading more and more onto staff and eventually make money. Quality patient care takes a certain minimum amount of time. If in providing that time, you are losing money on the government patients, you will only lose more by seeing more of them. Ultimately in trying volume your way out of the problem, you will be reduced to slap-dash visits in which you only pretend to provide care–you are then in the profitable sector of the medicaid market –a medicaid mill.
The doctor who wants to serve that population needs either an alternative funding source or subsidy of some sort, or need to limit the numbers of those patients so he can support his medicaid/medicare mission with some paying patients.
The powers that be just look to see if there are any providers without regard to quality of service. If there are, even if they are sham mill operations, they deem the payment rates to be adequate.
In the end, providers who struggle to make inadequate payment work do a wonderful work for their particular patients, but help feed a system that is immoral in that it steadily chases out good care with bad.
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