Why physicians are hesitant to take Medicaid patients

In an earlier post, I presented some data on which kind of physicians in the United States are most and least likely to see new patients who receive Medicaid, the state/federal program to pay healthcare costs for low income people. Now a recent study lays out some reasons why many physicians are so reluctant to see such patients.

Not surprisingly, it starts with low reimbursement rates. Medicaid pays about 61% of what Medicare pays, nationally, for outpatient physician services. The payment rate varies from state to state, of course. But if 61% is average, you can imagine how terrible the situation is in some locations. Physicians interviewed in the study explained that they felt it was their duty to see some amount of Medicaid patients in their practice. They recognized the moral need to provide care for this population. But they did not want to commit career suicide — they did not want good deeds to bankrupt their clinical practices.

But reimbursement rates were not the only story. Many physicians talk about unacceptable waiting times to receive reimbursement from their state Medicaid programs. To make matters worse, these low reimbursements came on top of increasingly complex paperwork that their office staff are forced to fill out. Less money and a month late too. Not a recipe for happiness.

But I’m not done yet. Because in addition to getting less money after a longer wait, most physicians were also reluctant to take on many Medicaid patients in their practices because these patients often required much more time and attention than the average patient. In their experience, many physicians felt that the social and behavioral needs of Medicaid patients required a disproportionate share of their time, and of their support staff.

The following picture summarizes the concerns that came up in this study:

Why physicians are hesitant to take Medicaid patients

The quick version of this figure is: the red bars and green bars show how many doctors have more problems with Medicaid patients than commercial, with those really short blue bars illustrating the rare physicians who think commercial patients raise more problems than Medicaid enrollees. The situation doesn’t look very good for Medicaid right now.

Is this simply more proof that the government can’t be trusted with people’s healthcare coverage? Of course not. If this figure compared Medicare to commercial insurance, I expect it would be a pretty even battle. Instead, this figure illustrates just how little public desire there is to take adequate care of the health care needs of poor people. We can’t simultaneously starve a government program of adequate resources and then complain that the program can’t pull its weight. Some states do a much better job with their Medicaid programs than others. We ought to take advantage of the “laboratory of states” and adopt these better practices. We owe that to those citizens among us who are less fortunate than we are.

Meanwhile, this study acts as yet another reminder that we cannot assume that offering people Medicaid coverage will necessarily provide them with adequate access to health care services.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes.

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  • Ron Smith

    Hi, Peter.

    That’s an interesting article. I think a couple more things might have been included.

    In Georgia presently there are three CMOs administering Medicaid. Until almost 2 years ago I was taking all three and my Medicaid patient percentage was 45%.

    Two of them began to more and more find fault with claims so that they had to be resubmitted many times more than once. The third CMO has been great to work with.

    My practice is in McDonough, about 20 miles south of metro Atlanta. These same two CMOs reimbursed me less and than practices in towns just 40 miles further south of us where the Medicaid population was higher. The schemes these two CMOs used to delay and deny payment were clearly part of their standard operations.

    After I stopped taking the Medicaid from these two CMOs as well as any new medicaid patients, my practice percentage dropped to just 12%. Most of the patients we had problems with who were constantly late or missing appointments stopped coming to the practice also.

    I would encourage physicians who continue to have some noble sentiments and duty towards Medicaid patients to realize that for the most part these are not the Medicaid patients of thirty years ago when I started. Many of them have settled for Medicaid as a way of life. They tend not to marry so as to increase their entitlements. We as physicians are being played as fools. A majority of Medicaid patients, I believe, are gaming the system and taking advantage of us.

    The worst thing is that the system encourages it.

    We consistently hear of those bringing new babies to our office who have private insurance. These unscrupulous CMOs are also getting them signed up for Medicaid! Why if you have private insurance can it even be allowed to have Medicaid also?

    I believe it is to get as many Medicaid patients onto physicians’ panels as possible. The more we have, the more the government dictates what we will and will not do.

    Pure and simple, this is a ploy to make all physicians just another government employee. Let me say loudly that… I WILL NEVER WORK FOR THE GOVERNMENT by being their Medicaid slave!

    Now that the wheels of the bus are gone and there is no second chance at a first impression of Obombacare, maybe this will be a more common understanding of what that program is really all about.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • cynholt

      Here’s proof that ObamaCare is no different from Medicaid when it comes to penalizing marriage…

      “ObamaCare’s marriage penalty: Cohabitating couples will pay less for healthcare than married couples”

      http://www.lifesitenews.com/news/obamacares-marriage-penalty-cohabitating-couples-will-pay-less-for-healthca

    • querywoman

      The government has repeatedly expanded Medicaid, especially for children and pregnant women. So naturally the Medicaid pool has expanded to include of lot of young women, who are healthy enough and do work, and their children.
      It has not made significant expansion of Medicaid for sick low income adults.
      I do not think that Medicaid is designed to help sick people. It is designed to help people who are politically sympathetic. When I worked in Texas welfare, I could put some resident alien pregnant women on Medicaid for the duration of their pregnancies. I could not put a 21 year old US citizen male with leukemia on Medicaid. He might have been able to get SSI and Medicaid eventually, but that’s a separate federal program.
      Medicaid can cover what private insurance does not pay, like copayments. With Medicaid, private insurance is considered the first payer.

  • Rachel Phillips

    Ever think about hiring a nurse practitioner or PA to treat the Medicaid patients?

    • Michael Rack

      several problems with that. Assume you have a practice consisting of one doctor and one PA. The income coming in is going to be roughly the same no matter who sees the Medicaid patients (the same income will come in to the practice no matter which of the 2 providers sees the 5 Medicaid and 30 private insurance coming through the door that day).
      Also, if the Medicaid pts notice they are being shunted to the PA, they may (justifiably) complain about discrimination, especially if there are racial disparities between the Medicaid and privately insured populations.

    • ninguem

      What makes you think the nurse practitioners are immune to all the problems summarized here?

  • Kristy Sokoloski

    Interesting article. I especially found the part where it said about the cases of patients on Medicaid more time consuming, and their cases to be more complex than those on commercial insurance. What I am wondering is what makes their cases more complex than the patients who have Medicare or commercial private insurance when it comes to the time taken or the amount of paperwork that has to be filled out.

    • Michael Rack

      More time consuming because there are more Prior authorizations and certificates of medical necessity to fill out.

      • Kristy Sokoloski

        Oh ok, thank you.

    • fatherhash

      i have also heard of physicians complaining that the patients are “needier” and have a sense of entitlement….although the same could be said of the rich on the other end of the spectrum.

      • Kristy Sokoloski

        That would also make sense. The reason I ask this is because there are people who have complicated medical histories that have commercial insurance that have a lot of needs as well. Thank you also.

        • querywoman

          When you have complex needs and commercial insurance, the copays eventually add up, and then you can’t get help from the pharmaceutical companies because you have insurance.

          • Kristy Sokoloski

            Very true indeed about the copays adding up which means that the out of pocket costs as far as what the person pays gets maxed out in a hurry before the insurance will cover at 100% if it’s set up that way. And you are also correct about the help from the pharmaceutical companies.

      • querywoman

        Fatherhash, this where you and I will see eye to eye. Entitlement is a bad problem with the lower income folks. In welfare, I had a grandma who was caring for twin boys who told me she’d like to get them something for Easter, but didn’t have the money.
        I was thinking, “You got help at Christmas, and you want it now, too?”
        Trust me, she had enough money to get them small gifts.
        The poor get large Earned Income Credit tax refunds, which are kickbacks for working, that gives them more money back than they pay in taxes. The upper middle class barely knows about these, since it doesn’t affect them. I didn’t fully understand till I worked for the IRS.
        Now they can get a $4000 tax refund at one time, usually very early in the year, since they pay fees to file and get ‘em quick.
        They blow that money so fast! I always say the average life on an EIC is 10 days!
        When it comes to food stamps, suppose they were getting $500 a month in food stamps and suddenly get a job paying $1200 a month. They[‘re astonished when their food stamps get cut to maybe $150 a month.
        Imagine this all multiplied into the health care system. They will never want to pay a dime for health care.

    • querywoman

      Kristy, as a former welfare worker, I know what they are talking about on Medicaid patients. Many of the poor are irresponsible and don’t plan their lives very well.
      Sure, there are some who are responsible.
      I can imagine them missing appointments, not filling their medicines, running out of meds, and showing up unexpectedly asking for more!
      I don’t know that Medicaid paperwork is all that complicated, but I do know, since I worked for the IRS after public welfare, that it’s easier to work with people who are responsible enough to hold down jobs.

      • Kristy Sokoloski

        The same can also be said for those that are in the middle of the financial spectrum. Especially on the not being able to get to appointments because they may not have a car that works. And this group also often chooses not to comply with medical treatment regimens as we have seen from some other discussion threads. So I am not sure that anyone can say that the poor are irresponsible and don’t plan their lives very well. Some of that poor population that are disabled are on SSI and only get around $700 a month (although I heard recently that is supposed to go up a bit). How is anyone supposed to be able to live on that every month and still be able to get to their doctor’s appointments and continue treating chronic illnesses when that money needs to go other necessities such as keeping a roof over their head, have running water and electricity, and also pay for food (if they can even afford to buy food every week). A lot of people are having to decide which is more important: eating and keeping a roof over one’s head or treating chronic medical conditions so that they don’t get sicker. If you were comfortable with talking in private I would tell you a bit more about the situation with my relative that I have mentioned several times on here to further make my point about how difficult it can be.

        • querywoman

          Money is touchy. I have known people who live on zero per month, also $200 per month.
          SSI and welfare checks are hard to live on unless someone has housing assistance.
          I’ll give you an email address when I figure best one to use.
          I used to have some clients who got maybe $600 mo. SSI, paid $440 rent, and got about $120 month in food stamp.
          People on Medicaid get free medical transportation.

          • Kristy Sokoloski

            I agree with you about money being such a touchy subject. Makes me wonder how someone can survive on $0 a month but yet others live on $200.
            SSI and welfare checks are harder to live on not only because they don’t have housing assistance, but also if they can’t get the food stamps necessary to help them eat. But those figures you gave for the amount someone lives on it makes me wonder then how they are able to pay their car insurance (if they drive but as you said there are those on Medicaid that get free medical transportation but not transportation help for other things) assuming that they have a car, and have electricity and running water.

          • querywoman

            The figures I gave would be for people who ride the bus and walk. It’s hard to maintain a car on SSI, unless a person gets housing assistance.
            Before this thread closes out, the Medicaid “entitled” attitude to which I refer is not usually present in low income adults who have worked, don’t have enough quarters for regular Soc. Sec., and get SSI and Medicaid.
            An increasing amount of healthy young pregnant women who work and earn a fair amount are getting Medicaid through pregnancy and for the children. A lot of those people will never want to pay a copayment.
            The percentage of Medicaid that goes to disabled adults without children is very small.
            Medicaid is not a program for the sick; it’s a program for the politically sympathetic.

          • Kristy Sokoloski

            I am inclined to agree with you about the purpose of Medicaid as it relates to some people. As for them not ever wanting to pay a copay for some of the ones on Medicaid here in my State they are having to pay a copay depending on the particular program. And those copays are like $1. I found that out when I was doing my externship in 2011 at a Family Medicine clinic in order to graduate from my MA program. Unfortunately, it’s not just these people that don’t want to pay copays either.
            My relative doesn’t feel that we should have to pay coinsurance and deductibles but yet that’s part of the way our insurance plan works. She thinks that if the insurance is already paying the doctor for the services that she doesn’t have to do anymore. How do you explain to someone like that about the issue of taking responsibility by doing your part to pay the portion you are supposed to pay for medical services?

          • querywoman

            Nevertheless, in many industrialized nations, doctor visits are free.
            When I had Kaiser in Texas, doctor visits were free and meds a dollar a pop.
            I did pay through my monthly premium.
            That “free” medical care ended up costing me thousands of dollars.
            I have found that doctors take me more seriously when I am paying a substantial amount out of my pocket.
            My third endocrinologist’s nurse hung up on me while I was lamenting my childlessness on the phone and upset me into tears. Neither the doctor nor nurse ever apologized. Nor did they give me sympathy.
            He collected two copays of $15 each. He really socked it to Blue Cross Blue Shield.
            I called the insurance company and asked if he could not be paid. They said no, since services were already provided.
            Texas chose not to charge Medicaid patients a small fee for their meds, since studies in other states showed they would not take them and would flood the emergency rooms, and costs went up.

        • querywoman

          Kristi, contact me at dollsmama at cheerful dot com and we’ll go from there.

          • Kristy Sokoloski

            Thanks, I will be e-mailing you soon.

  • buzzkillerjsmith

    Nutshell: Too much work, not enough money.

    It’s why I left a rural practice in Oregon.

  • T H

    Complexity is a nebulous term: I would submit that most of these patients are not complex medically, but rather where social issues run up on medical issues.

    For example:

    1. Pharmacy pick lists are artificially limited. There are Medicaid programs that have essentially reverted to ‘you can only pick the wal-mart meds.’

    2. Very few or none of the local specialists will take Medicaid. Dermatologists? Adult allergists? Rheumatologists? Care to speak up here?

    3. The paperwork is truly onerous. Between pre-auths, TARs, patients being unexpectedly dropped, physicians being unexpectedly dropped, reviewers being incredibly nit-picky about dotting ‘i’s instead of what’s best for the patient, combative reimbursement 3rd parties, etc… my biggest question isn’t why are so many docs leaving – it’s why are any staying?

    4. A local analysis of the no-show rate of Medicaid patients and CMSP (County Medical Services Program) done by one of the local providers here showed that the Medicaid patients did not show up for their appointments more than 60% of the time. There’s no way to run an effective clinic with that no-show rate.

    @Elvish: Ethics. I’m not sure how you’re using the word. If by ‘ethical’ you mean that physicians should see every patient who attempts to walk through their door regardless of their ability (or willingness) to pay, then I would invite you to stop by any ED in the USA to see how well that is working out.

  • T H

    Feel free to cite examples and, also, please post a link to their published 501c3 financial data. Where I live, there is no women and infants ‘center’: there are three hospitals working like mad to provide basic services and slowly being ground under by the onslaught of patients.

  • ninguem

    There’s no money in Medicaid for an individual physician taking Medicaid.

    Hospitals have all sorts of ways to extract higher payments from Medicaid, not available to the individual physician.

    To start with, those hotel-like accommodation costs you describe are passed through as “facilities fees”.

    • querywoman

      Hospitals can’t turn away laboring women and many other emergencies. Therefore, almost all of them take Medicaid.
      Of my local medical community, and we have medical schools and large hospital chains to serve Medicaid, the only private doctors who take Medicaid are in the higher paying specialties, like obstetrics and other surgery.
      My local hospital systems have clinics that cater to pregnant healthy women on Medicaid. It’s profitable for them. They prefer to push the druggies and complicated cases on the public hospital.
      When an undocumented alien has a baby in an American hospital, the hospital can either eat the expenses or pursue Medicaid payments. The hospitals nagged the feds to give them Medicaid for these women. That’s why it exists.
      A private doctor like a generalist who does not limit the percentage of Medicaid patients in the practice will lose money.

      Doctors who basically charge just for their time to treat routine illnesses cannot accept unlimited Medicaid patients. They never could!
      The only way a private nonsurgeon could make any money off a Medicaid patient would be to run umpteen tests.

      Medicaid patients can get high quality care, though some may question that, at medical schools. A lot of medical students learn on them. Complex problems also help them do procedures to get board certified.

  • Thomas D Guastavino

    Years ago we discovered the sad truth that the patients with the worst injuries and complex problems tended to also be the most uncooperative, most likely to sue, besides having the worst insurance if they had insurance at all. It became a matter of economic survival when we discovered that our better patients with simpler problems were going elsewhere. When we stopped seeing these complex patients our patient flow, satisfaction and return rates improved dramatically.
    Health care seems to be the only business where the harder you work the worse it gets.

  • Michael Rack

    I was looking at it from the point of view of a small practice owned by a doctor (not on salary); your point on salary does make sense from the point of view of a large practice owned by a hospital. Regarding discrimination: a doctor can “discriminate” by not taking medicaid etc, but all patients already within a practice need to be treated equally. If a doc accepts a medicaid patient into his practice, he needs to treat that patient equally (which is a reason why a lot of docs limit the # of medicaid pts they accept).

  • Cyndee Malowitz

    I don’t accept Medicaid and I’m not even a physician. I feel I do my share by accepting uninsured and Medicare patients. Those patients are very thankful for the care I provide.

    • Mika

      All medical providers should be free to serve the less fortunate by whatever means they see as most useful.

    • querywoman

      In Texas, you do lose money on Medicaid patients.
      What kind of county health system does Corpus Christi have?

  • Elvish

    Okay, then medical students, residents and fellows, who are not willing to take medicaid patients in the future, should not be allowed to practise on such patients during the training years.

    • Noni

      Or, medicaid patients are free to go to the academic medical center of their choosing. Private docs (who were historically small business owners) have the freedom not to see those patients as it was bad for business. That’s fair, don’t you think? If you have government provided health insurance you go where the government mandates you to go (or will mandate you to go in the near future)

  • fatherhash

    I wish there was a way to have these “progressives” support most of those costs instead of putting that burden upon society. I wonder if your friend would be willing to donate more of money than she already may be….at certain point, I’d think likely not.

  • fatherhash

    Maybe you get what you pay for. If you want a surgeon of your choice, you pay for that. If you’re getting it for free, you take a resident(which also includes an attending, btw). Beggars can’t be choosers.

    • Elvish

      What ?!
      Beggars can`t be choosers ?!

      They are not beggars, they just happened to be unlucky enough, to live in this sick and money-centred society.

      What a terrible thing to say about the sick and less fortunate ones !

      In medicine, money doesn`t justify the type of treatment, the patient and their disease do. If they require to go to MD Anderson, then they should be able to go, regardless. If not, then, they should be grateful for that and stick to their community hospitals.

      • Thomas D Guastavino

        You clearly believe that we as physicians have an obligation to see Medicaid patients. Fair enough. How would that work exactly? Carrot? Stick?

      • fatherhash

        although the cliche i used may seem a little insensitive, it’s reality. almost no one that i know of works for free(likely including you). all i was trying to say is that if i was getting something for free, i would be appreciative….i try to avoid a sense of entitlement.

        if i have no money, i’d use a resident(if cheap or free)….if i have money i’m willing to spend on the attending surgeon, i’d use him/her. but unlike you, i don’t think i should have a right to force the attending surgeon to operate on me….still not sure how you would like to force that surgeon though.

  • Thomas D Guastavino

    Sorry, I don’t understand your answer. The issue at hand is whether or not physicians have an obligation to see Medicaid patients. If they don’t would you use threats, or incentives?

  • Thomas D Guastavino

    So….if a physician chooses to not see Medicaid patients you would do…….what? Hope you are feeling better.

  • Thomas D Guastavino

    A neccessary first step is for the government to stop acting like a dictator and more like a negotiator in its interactions with the providers.There are a lot of good ideas out there.

  • querywoman

    The fraudsters make it so hard for other doctors.
    I had posted elsewhere about doctors making money from people unfortunate enough to need their services and got blasted.
    You put it in other words. No, the people who exploit the system are not true physicians.

  • querywoman

    I had a welfare supervisor who came from California. He said everyone under 18 can have Medical. That must create a real circus. Then when they grow up they don’t want to pay anything.
    I have heard that undocumented immigrants flood the California public health system, also, and make it hard for real Californians who pay those taxes to get services.

    • Kristy Sokoloski

      The thing with undocumented immigrants flooding the public health system of California is also happening in other States too. It’s a crazy world we live in.

  • querywoman

    Medicine has also changed dramatically.
    What was in the little black bag doctors used to carry? Today even the most simple medical office has a lot of expensive medical equipment.

  • querywoman

    I understand that some people keep irresponsibly having babies, but I wish there wasn’t a price and blame attached to a baby’s life.
    We are all helpless babies once.
    Children’s rights are a socially new entity. Remember, in the past unwanted babies were exposed.
    All this money spent on welfare, medical, and food assistance improved child longevity.