There is only one reason why I still accept Medicaid

To err is human. To really screw things up, you need government.

One half of my patient population and one fourth of my receipts are from Medicaid patients. My state has a mandatory balanced budget, which means in this age of perpetual recession Medicaid runs out of money every year.

Last year, my state capped the monthly brand name prescriptions to 1 for the summer. Apparently the information that asthma inhalers and insulins are brand name didn’t reach the decision makers. Unsurprisingly, taking everyone off of their asthma and diabetes medications from June to September didn’t reduce overall costs. ER visits tend to be expensive. That rule is now removed.

Starting in January, every Medicaid recipient who is not a child, HIV positive or insane will be limited to 5 prescriptions monthly. The state will pay for up to a 90 day supply of any non-classed medication. For patients who are currently taking more than 5 prescriptions, the state is recommending staggering the prescriptions, as in fill 5 in January, 5 in February, and 5 in March to total 15 prescriptions.

For classed medications, the DEA requires monthly prescriptions. Most pain management patients receive between 2 and 3 classed medications monthly. This means that for the Medicaid population who take narcotics, their total prescription budget for the quarter is reduced by a factor of 3 for each classed medication.

To add more to my staff burden, the state requires a PA for almost every medication, including generic medications that are on the Walmart $4 list. This year, they reduced the maximum duration of the PA from 6 months to 2 months, thus ensuring that my staff will need to fill out pages of useless paperwork for every Medicaid patient.

I can’t see how this saves money. The state has to process every paper that I generate. No bureaucratic savings. The patients will of course fill the classed medications first, leaving off medications like blood pressure and diabetic medications. They will again wind up in the ER. No savings there. The entire setup appears to be for the sole purpose of punishing doctors and patients for requiring bureaucrats to work.

There is only one reason why I still accept Medicaid. That reason is that in my state, my prescriptions will not be honored by Medicaid unless I am a Medicaid physician. My Medicaid patients can’t pay cash for their medications. If the rules from Medicaid change to the point that I can’t get my patients the prescriptions that they need even if I am a Medicaid physician, I’m done.

“Tiredoc” is a physician.

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    But remember, single payer will somehow magically work out fine, even though government managed care today is a disaster. My office staff spends just as much time, if not more, dealing with bureaucratic mess from Medicaid than from private insurance. I can tell you I spend more time doing peer to peer with Medicaid than any other payer, including for cases like MRI in kid with previous brain tumor with new neuro symptoms. PAs have become ridiculous with them actually requiring HIPAA breaches (listing diagnoses in unsecure places) to get meds they need. All this for reimbursement which may or may not cover overhead costs of the visit, so for many, I am actually paying to see them. We see these patients in our practice because we are committed to helping all seriously ill people, but after a certain point if we can’t afford to pay our staff, we’ll be done, because if we can’t keep our doors open, we won’t be able to help anyone.

    • Tiredoc

      No kidding. Whenever I get resistance from the insurance company, I know it’s because it’s cheaper. Medicaid? Totally random.

      The one unifying feature of all bureaucracy is the metastasis of barriers between designated desk commanders and actual work.

      Nothing is more demotivating than speaking personally with the head of a government department and being agreed with, then apologized to, and then told no.

  • Margalit Gur-Arie

    Quick question: Is this straight Medicaid fee for service, or are these managed care Medicaid plans that got contracted by the state? or some other beast?

    • Tiredoc

      It’s an odd hybrid. I’m a consulting physician for the designated primary care physician. Because patients are limited to 14 visits per year for any doctor, I usually do all of the preventive care, so they don’t run out of visits. The 5 prescriptions per month is for all prescribers, including the PCP.

      The irony is, I do the same service for the local Board of Health, which pays cash. So, the HIV patients without insurance get seen, I’m recognized as a trusted provider by the actual decision maker. I get paid on time, and the patient gets their meds. I send them my office note, for which I am thanked.

      It would be cheaper for me to accept payment in deer meat and wicker baskets than to take Medicaid, if the state would let me. I’d even do the stupid PAs, if only my prescriptions were filled.

  • NewMexicoRam

    It’s only the beginning…….

  • Ron Smith

    Hi, Tiredoc.

    I feel for you, man. I was at about 45% medicaid when Peachstate and Wellcare started repeatedly rejecting claims, each time with new ‘errors.’ This was just a ploy for these CMOs to retain more money rather than pay me. I dropped them when my practice manager told me about the problem. Though she was a little shaken at first by that decision, it took me all of two seconds to conclude that I was going to go broke and belly up if I didn’t cut them loose.

    Amerigroup, the only CMO I now take for Medicaid, has been a different story for me as a primary care Pediatrician. We still take it but we no longer take new Medicaid patients. I’m done with their nonsense.

    Currently my Medicaid rate has dropped to now probably less than 10 percent over a year and a half. My work load has improved as has the quality of, and appreciation for my care. We stopped all walk-ins without a nurse triage OK and I leave the the office only later than about 5:30 when I’m putzing around the web and my email.

    Of course I do communicate with my patients via email and I do have a very well trained office staff led by a very good practice manager. She has only had to hire three folks to replace staff which she had to let go… in three years.

    For me, the key to leaving Medicaid behind was having a highly motivated, well trained staff, who loves to work together, and who are incentivized. They work the office like a zone defense in the office.

    They implement good practice policy decisions and keep me and my two nurse practitioners moving (mostly me of course, probably because I talk to much to patients sometime). We are a great team.

    I will take those children who have special needs or illness who need my care, no matter what, Though I used to consider that there was a strong moral reason to take Medicaid, I don’t anymore. Most of them could care less about having a relationship with a provider. They consume medicine like food from a drive-through restaurant.

    It didn’t used to be that way when I started 30 years ago. Most of my colleagues I think have increased their Medicaid visits trying to play the numbers game. They think the more patients they see, the better the reimbursement will get. I don’t think so. I think we are going to start seeing a wave of even older docs like myself start filing bankruptcy and moving out of private practice into corporate medicine just to get a paycheck.

    Personally if I can’t practice solo, and without Medicaid, then I’ll say goodbye to medicine. I’ve got other skills that I can and will pursue rather than be dictated to by the government bureaucracy.

    For the sake of my staff and the patients who really need my experienced hand, I want and need to stay. We’ll see.

    Warmest regards,

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

    • buzzkillerjsmith

      My neurology buddy, in private practice for 24 years, is watching his practice go belly up right now. Medi-Cal pays $19 for a level 3 followup, at least that’s what he tells me.

      • GT

        “Medi-Cal pays $19 for a level 3 followup”

        I pay more than that, cash on the spot, to get my Westie (35-lb dog) groomed every 4-6 weeks.

        I am not dissing my dog’s groomer, for she is a lovely lady and does a top job on my dog, but in whose world does “a dog groomer gets paid more than a neurologist” make sense?

        • Tiredoc

          Maybe I should cut my patient’s hair and charge them $100, call it a haircut with “free” doctor visit.

    • Tiredoc

      Thanks. I dropped Medicare and moved this year so my practice is unbalanced. I plan to reweight over the next few years if I can. I tell myself that Medicaid is an advertising expense. If I manage complicated, the referring doctors will be happy and the patients are at least grateful once they’ve exhausted the “Burger King” model of health care.

  • buzzkillerjsmith

    God, what a nightmare.

    New York Times article today stating that most of the new pts signing up at the exchanges are Medicaid.

    • Margalit Gur-Arie

      I was looking at exchange plans and I don’t know if this is a trend or I just happened to look at some that operate this way (all PPO), but practically everything, including generics, “may require pre-auth”, so brace yourself….

  • Thomas D Guastavino

    Does anyone have any clue as to how the ACA will compare to Medicaid?

    • Margalit Gur-Arie

      I can think of one major difference, but it may not be a good one. Since practically all ACA plans have very high deductibles, most of your AR will be in patient collections, particularly for primary care. Depending on your experience with that, you may be happy or not. You may want to consider some form of prepayment for visits.

      • Thomas D Guastavino

        Lovely. Would someone explain to me how any physician would support the ACA not knowing how much we will be paid or what hoops we have to jump through to get it?

  • Anthony D

    What does common sense tell you when you add 30 million people to the current health system with the same facilities and number of doctors. Something will have to give. The ACA was truly put out there as an option for universal/single payer care. It was to cover those that did not have it. But there will be a health cost for the rest of us…

    Reimbursements will be down, docs numbers will be down, hospitals getting paid less… and more people into the system. What does common sense tell you about that?

  • rbthe4th2

    Thank you tiredoc.

  • SarahJ89

    To quote my old boss in the division of state welfare: Every time the politicians talk about saving money they throw more paperwork into the system, which makes the system even less efficient.”

  • Shirie Leng, MD

    That’s crazy talk! All those rules make no sense in any world; medical, fiscal, governmental, philosophical, or, uh, humanical.

  • Tiredoc

    Thanks. I think I roll pretty well with bureaucratic roadblocks, but to be honest this one has me stumped. I’m going to have to drastically alter every Medicaid patients drug regimen, in negotiation with the patient, so they fill what we agree on. I figure I’ll be going home at 8 p.m. for the next 3 months.

  • buzzkillerjsmith

    Oregon. I told you not to stop in Roseburg, didn’t I ? See.

  • querywoman

    Amazing observation from a dead doc typing!

  • querywoman

    In the large urban Texas Counties: Bexar, Dallas, Galveston, Harris, and Tarrant, there are medical schools or other large medical complexes with doctors on salary who see many of the Medicaid patients.
    The church and private hospitals court OB patients with special clinics for the Medicaid money because they can make money off healthy deliveries.
    I am not familiar with the medical wastelands of our majority smaller counties. The Texas Constitution puts the care of indigents on the counties.
    I don’t blame you docs for not doing Medicaid. I am surprised to see so many who write here who do take Medicaid. Maybe the cruddy reimbursements are at tad more generous elsewhere.

  • PamelaWibleMD

    Where in Oregon are you practicing ninguem?

  • John Hunt

    Provision of bedrock services by whom do you mean? The best way to provide services is through free-market capitalism–this is a well proven concept in every other non-commons sector of the economy, and for something as important as health care (which is not a commons!), we shouldn’t be messing with freedom. Then, if you or someone else doesn’t think the free market is serving a particularly individual well (which may well occur), then you and that someone else should do something about it, help that individual,and by doing something I mean something other than just lobbying or voting for the force of the government and its mob to compel other people to deal with the unhappy situation of the individual you are worried about.

    To me, it is long past time for people who vote for slavery and servitude in order to fix perceived injustices to instead give more of themselved directly to fix those injustices instead of demanding others to do what they are unwilling to completely do themselves.

    So says I.

  • Michael Wasserman

    The horrible truth is that we’re stuck in a vise between the government and the insurance industry. Pre-auths are an issue with both. Furthermore, the medigap insurers often don’t pay for over a year. What other business would allow that? Large systems will be the only way to practice, but they will not be controlled by the physicians. It doesn’t look very hopeful. Ironically, Medicare fee-for-service pays 80% within 10 business days…that’s not looking too bad compared to other choices, is it? A practice that only does FFS medicare may actually be one of the few viable options, except that the government will then audit you because they won’t believe that you are accurately billing unless you’re bankrupt. Perhaps the only way out of this is for physicians to just all close their offices.

  • Ron Smith

    Hi, PreMedGirl.

    Re: “I think before you start judging your patients based on their insurance — you need to take a closer look and get to know them. All Medicaid says about a person is that they are poor. I really just can’t believe the picture you painted here. It was/is incredibly offensive.”

    Actually I’ve taken new Medicaid patients up until the last year. That’s almost 30 years of practice. I have more compassion than is appropriate to share except one-on-one. I’m sorry that you took offense (none was intended). I grew up poor too.

    The conclusions not to take the Peachstate and Wellcare CMOs is a different decision. That’s because they weren’t paying… nada, nothing. I can’t pay my bills that way.

    There are patients that are not poor who still need Medicaid. I still do take new disabled or special needs children, regardless of Medicaid, even if I don’t get paid. Currently I accept Medicaid through Amerigroup which has been really a different company to deal with than Peachstate or Wellcare Medicaid CMOs. I’m not presently taking *new* Medicaid patients however, which is a decision that was made within the last twelve months.

    Nothing about the Medicaid population in particular carries a prejudice with me. I’m not that kind of person or physician.

    The particular experiences with some individual Medicaid patients who I know are scamming the system bothers me. I am keen on providing a quality experience that gets patients in on time and out in an hour. I don’t look at insurance before I go in to see a patient and indeed the only time I’m particularly interested is when I’m prescribing for them. I need to know if what I’m prescribing has a remote chance of being rejected by their insurer.

    If you are in the Atlanta area or near McDonough where my office is located, and if and when its time in your training, feel free to call us and do a third year or fourth year rotation or even just come by and visit. I’ll teach you everything that I know about both Pediatrics and the business of medicine. Its the business of medicine that medical students didn’t get trained in when I was a student. I suspect its the same way and you are going to need to know that to survive even if you aren’t solo like me.

    Feel free to email me and chat further. My email address is on my web site and available to all (Medicaid patient’s included). I don’t bite and again this is a real offer to come and see.

    Warmest regards,

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

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