The toxicity of Medicaid

I have noticed over the years that physicians who write about medicine, particularly for the general public, are limited to very specific discussions.  For instance, it is perfectly acceptable to write about the plight of the poor and uninsured.  It is always reasonable to advocate for a single payer system. It is perfectly acceptable to discuss how one downsized in order to make less and “give back” more.  And it is praiseworthy to hold forth on the absolute necessity of primary care.

It is reprehensible to discuss money unless it has to do with intentionally making less of it.  It is judgmental to suggest that patients might, in some way, bring their ills upon themselves.  It is cruel and heartless to advocate for more market solutions.  And it is symptomatic of burnout to suggest that one no longer enjoys practice, or finds dealing with the public to be unpleasant.

To write any of the above negatives is to incur a blizzard of angry letters and suggestions that one leave medicine to the truly compassionate and seek mental health care.

However, I will here boldly violate the above the rules and say that emergency medicine is getting ever more difficult, in part because of Medicaid.  This is extremely relevant since the ACA is dramatically increasing the Medicaid rolls.

By way of disclaimer, many of my favorite patients are dependent on Medicaid.  I love them and I am happy to see them, whether for their child’s earache or their own pneumonia or injury.  Many people truly need the program, and it helps them … at least in the short term.  However, it is hurting medicine — both primary care and emergency care.

(Look at the recent study out of Oregon which showed clearly that Medicaid increases emergency department usage.  It’s an interesting study with mixed results … no change in patients in terms of control of hypertension, diabetes or cholesterol, but there was a decrease in depression and in financially catastrophic health-care costs.)

The problem is multi-faceted. But at the heart of it is the fact that our Medicaid population has no ownership of their health care dollars.  They’re told by government functionaries that they have insurance.  But I have insurance.  And as such, I try my best not to use it because the co-pays are very expensive.  Medicaid patients suffer from no such disincentives.

The problem is, of course, that a relatively small number of “bad eggs” make everyone else look bad as well.  They come to the ER at night with a sick child. I treat the child and say “see your doctor next week if he isn’t better.” “Oh, we have an appointment with him in the morning anyway,” mom responds.  Many of them, unemployed, have no schedule restrictions.  So coming to the ER at 3am is not in any way an impediment to going to the pediatrician the next morning.

Furthermore, some are extremely demanding.  One told me, “I have the right to whatever treatment I want.  I checked it out. And I demand to be admitted until this is figured out!” Well, no.  It was a long, loud discussion over a problem that was non-emergent.

In addition, our Medicaid population has no emergency department co-pay.  Likewise, the Medicaid reimbursement rates would be comical if they weren’t insulting.  (Some years ago our Medicaid rate for a cardiac arrest resuscitation was somewhere around $100.)  A $5 co-pay would truly re-direct a great deal of traffic. And the argument that it would be oppressive is ludicrous in the face of the expensive cell-phones and plans, the cigarettes, drugs, jewelry and vehicles that some of our Medicaid patients sport.  Alas, while Medicaid primary care patients sometimes have a co-pay, EMTALA ensures that will never happen in the ED.

But the problem isn’t just the abuse as listed above.  It’s that this population of patients, who use the ED extensively and for any and every problem, cause the department to be ever crowded with patients who do not deserve the name patient. And yet they complain of things we must evaluate.  They call ambulances for fever, they complain endlessly of chest pain when they have anxiety (with attendant dyspnea, diaphoresis and nausea, of course, all of which direct us to work them up for heart attack.)  Their headaches are always the worst and their depression is frequently suicidal … knowing as they do that commitment to a mental health facility raises the likelihood of the “holy grail” of disability.

In the end, I want to help the sick and injured; especially the poor and their children. But I fear that Medicaid is only growing more toxic to those who have it and those who are paid by it.  It offers little advantage to those who have it (well demonstrated in a recent study from Oregon), it demoralizes those who treat the patients with it (and costs us money since we are hardly excused from expensive liability insurance while accepting it) and it adds so much hay through which we must daily sift to find the needle.

I know. Bad doctor.  Hateful doctor. Let the name-calling begin.  But if nothing else, honest doctor. Deal with it.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • Kristy Sokoloski

    Interesting piece. You are also definitely correct about those that do have the luxury expenses such as the cellphones with expensive plans and the expensive cars. And those would be the ones that should be reported for Medicaid fraud, but I wonder how many of them actually get reported to the authorities for such a thing if it is indeed considered Medicaid fraud. However, some of these same people who do have cellphones do so because of government programs to get a free cellphone with 250 minutes (yep, the ones you see in the commercials on tv for various companies). And one of the programs that people must be on to qualify: Medicaid. The other: food stamps. And then there are others that are on Medicaid because they truly need it but at the same time do not have the kind of luxury expenses that you and others have mentioned. The reason? They can’t afford it. I read about EMTALA when I had to do a paper for school when I was going to school to become a Medical Assistant. That was back in 2011. It’s amazing to me the various problems that this law has caused over the years. I do know that in one State (I think NY but can’t remember right now if that is correct) that they played around with the idea of making it so that people who used the ED for non-emergent care would have to pay something for the use of the ED. Of course it got shot down by a lot of people including having it play out in the media. I think it is still being considered as something to make use of in the future. Not sure who will win that battle. Either way, the whole thing is a mess and there’s no one simple answer to fixing the problem and I wish there was.

    • LynneB

      Did it ever occur to you that a family member might be loaning them the car, or helping them pay for the phone? Why not just make them wear paper suits with no pockets so you can be absolutely sure that as long as they are getting any social assistance they own NOTHING of value SMFH

      • querywoman

        With modern verification system ease, all state welfare system can run checks to see what cars they own now.
        A cell phone is is a possession, just like a diamond necklace, that does not count as a resource for Medicaid.

  • Ron Smith

    Hi, Edwin.

    In Georgia, they found I think that a $0.50 copay reduced inappropriate utilization of office services.

    We will never really reduce the cost of medicaid and the overloading of ERs and Urgent cares until we change the mindset of Medicaid. The more that the government gives the more Medicaid recipients take. It is the same as unemployment benefits where people delay finding jobs just as long as the government will pay them not to look.

    The true medical home for Medicaid is the ERs and Urgent Cares. They own Medicaid.

    The cheapest place to provide medical care which is by nature also better than ERs is in a regular primary care practice. Besides changing the mindset of Medicaid patients, the government should reduce ER and Urgent Care payments and increase primary care reimbursement.

    That’s not saying that what is done in an ER is not good medicine. It is just not the appropriate place for primary care. But Medicaid patients propagate the government’s notion about things in general. Why pay $25 for a hammer when you can pay $125 and get 100 of them. Incentive leads.

    Warmest regards,

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

  • sam

    First time in my life I find myself on Mcare after years of paying crazy high insurance rates. I’ve no desire to run to the ER, doctor or pharmacy at all. In fact if I never set foot in one of those places again I’d be pretty happy. A copay, minimal even would be a good thing IMO.

    Problem for many people is that all they’ve ever known is free care and don’t know how to responsibly use it.

    • Adolfo E. Teran

      I would remove the sugar coating and say they know the system and abuse it.

    • ninguem

      “…..First time in my life I find myself on Mcare after years of paying crazy high insurance rates…..”

      Your crazy high insurance rate is still there, it’s just that someone else is paying it now.

  • SBornfeld

    This obviously is a set of very complex problems. If I read you correctly, the biggest problem is that patients don’t have “skin in the game”. One could argue that anyone who smokes, is obese, has metabolic syndrome has many organs in the game. But still they smoke, still they eat crap.
    You will wait a long time expecting people to be responsible, You are entitled to your opinion that these people maybe don’t deserve you. Maybe you’ll continue helping these people and this is just your “crie de coeur”.
    If that’s the case, I hope it helped you.

  • SherryH

    Whether you receive Medicaid or not, the Emergency Room should be used for emergencies, not for colds or chronic conditions that would be better served at primary care offices or urgent care. Choosing the most expensive choice just because you “can” should be discouraged, and if the only incentive that matters to people is money, than yes, maybe they should be charged some sort of co-pay when coming into the ER with these issues.

  • Thomas D Guastavino

    Unfortunately the ER chaos that currently exists is going to get worse as the Medicaid and the ACA population expands, primaries move toward direct pay models, specialists move to sub-specialties that dont require call and patients with good insurance go to urgentcare centers. Your only hope may be the expansion of use of PAs and Nurse Practitioners.

  • wahyman

    Remarkably long on blame and short on solutions other than co-pays, because healthcare is certainly improved if we keep people away from seeing doctors.

    • stephaniefranklin

      I think the point is that the ED doctor is not the best choice of doctor to see. Primary Care MD or Urgent Care MD are much better choices for many patients who find themselves in the ED.

      • buzzkillersmith

        I am a family doc and have almost no appointments to spare. Neither do any of the other docs in my group. I suspect we are not the only group like this.

        A lot of patients around here, many with Blue Cross, can’t get docs and have to go to the urgent care or the ED. A lot of docs won’t take Medicaid when private insurance pays much, much more. This is the fix we’re in.

        And a lot of us are no longer willing to work 60-70 hours per week to try to fill the hole that American society has dug. Just not gonna do it.

        • querywoman

          Exactly! In spite of all the NPs and PAs out there, and they are sprogging like weed in a cow pasture, most of you docs have more than enough to do!

        • querywoman

          Adding more people to Medicaid won’t open your office or other offices. You are in Kaiserland, aren’t you, and you already walked out on them.

        • querywoman

          Buzz, when a doctor like you has a busy office already and discusses Medicaid, you show a social conscious.
          Just because a “rich” doctor doesn’t take Medicaid, it does not mean that he or she isn’t volunteering elsewhere or giving money to community clinics.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    The best way and maybe the only way to solve Medicaid’s toxicity problems is to drastically reduce the number of people that need charity care, which means drastic reductions in poverty rates. You do that by paying fair wages for labor and by forcing (government chartered) corporations to fairly share productivity gains with productive workers.
    The deterioration of the aberration called Medicaid is a direct result of inequality gone amok. We should know that something is terribly wrong when the Pope is beginning to sound like a lefty.

    • NewMexicoRam

      Utopias do not exist. Never have. Never will. Some have attempted to create them, but they quickly fall apart.
      Skin in the game is the only way to deal with this. Co-pays with Medicaid, even $5, would help reduce overutilization while keeping care affordable.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I agree with the $5 copay and I agree that utopias don’t exist, but just because we will never reach perfection doesn’t mean we should ignore the problem and let everything go to hell in a handbasket.
        And “skin in the game” is not a my favorite analogy for what needs to happen..

      • Dr. Drake Ramoray

        Medicaid in my state has a copay of about $5 but they don’t have to pay it and you can’t turn them away if they don’t pay up front. In our office you can calculate how many visits a patient has had by dividing the dollar amount of their outstanding balance by the co-pay charge.

        • querywoman

          Thank you for jumping in. Medicaid pays the cruddiest of all states in Texas. Bexar. Dallas, Harris, and Tarrant have county hospital districts and medical schools with doctors who take Medicaid.
          I supposed Medicaid really helps in the rural counties.
          We also have John Sealy in Galveston.

        • Adolfo E. Teran

          I agree with the administrative burden with the nonsense and stupid pre auth.
          We stop taking care of Medicaid because we were trying to run a low overhead practice. I would have to hire a person to be in the phone 8 hours a day to deal with them.

    • guest

      Well let’s be fair, the Pope is a Jesuit, and they are famously lefties, so I think his liberalism has more to do with that. That’s not to say that things haven’t gotten pretty bad on the inequality front, however, I am looked forward to seeing what our President has to say about that in the State of the Union address tonight.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        …not as much as I would have liked.

        • guest

          I was hoping for a little more, too.

    • querywoman

      True charity care is the province of the uninsured!

    • PoliticallyIncorrectMD

      How exactly forcing corporations to increase wages would decrease the number of people needing charity care? As wages increase, corporations will slow down hiring / lay people off to save $$$ spent on increasing the wages. Therefore the number of those needing charity care would increase, wouldn’t it?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        No, they won’t. There is a rather new sense of entitlement that corporations have acquired, saying that nothing should interfere with their God given right to profit as much as they can. Labor should be free to bargain collectively (as some physicians here are advocating for doctors). The castration of unions, and a lot of that through their own fault, has led to this imbalance between the power of capital and the power of labor, which we are all suffering from. There is nothing wrong with pizza costing five more cents, if more people have more money to buy pizza with. There is no need to race to the bottom with the cheapest and crappiest product possible, just so that those on welfare can afford it. It’s a vicious cycle.
        And, as physicians, you have to appreciate that, because you are at the receiving end of this degradation in standards of living.

        • PoliticallyIncorrectMD

          Margalit,

          I understand what your beliefs are and suspect we share many. I also came to appreciate your sharp analytical thinking reading this blog.

          “No, they won’t” doesn’t sound like you – more of a wishful thinking than logical explanation you usually offer.

          So, let me ask you again: can you offer any plausible mechanism that will prevent corporations from shrinking the workforce to protect their bottom line when forced to increase wages.

          Respectfully,
          PIMD

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            You are right, there was too much certainty in that sentence :-)
            I don’t see how corporations, which presumably are already operating with as few employees as possible (hence our high productivity), could reduce their workforce and maintain the same output. They could decide to decrease the output, but since most of minimum wage employers are cheap retail and fast food, high volume is how they make money. I would suspect that when all financial scenarios are run, the profit loss (and there will be one) would be smaller if they don’t downsize (and expose themselves to competitive market share grabbing on top of it), than if they just absorb the cost of wage increases.
            Will some smaller businesses fire people? Probably. But maybe “entrepreneurs” with a business plan assuming taxpayers pay for food, shelter and health care of their “employees”, should go out of business, and the sooner the better.

            On a side note, I don’t think raising the federal minimum wage to $10.10 will put a significant dent in this problem. We need to restore bargaining power to labor.

          • PoliticallyIncorrectMD

            Thank you for clarifying. I am afraid the data paint different picture.

            First 3 figures are from Hirsh, Kaufman, Zelensky 2011

            The rest from BLS

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Well, the paper says that they observed “no significant effect of the MW increases on employment or hours”, so that’s good. It looks like the managers found (or looked for) other ways to make up for the “loss”.
            As to the BLS data, I may be missing something, but I don’t see it as indicative of MW causing unemployment. I think unemployment was caused by other events during the years depicted in the first chart, and I can’t see any consistent correlation between the red line and either the blue or the green lines in the second chart. Am I missing something?

          • PoliticallyIncorrectMD

            I would venture to say that the first 3 charts clearly demonstrated that employers have multiple have multiple tools at their disposal to increase productivity (contrary to your statement), should it become necessary. The paper was not designed to demonstrate the correlation between the MW and unemployment.

            As far as the following chart, the correlation is obvious and I would not think attributing it to some obscure confounding factors makes a strong argument.

            Last chart, I agree, may not be the most obvious, but it appears to me that it might be some correlation.

            The bottom line is, it is not clear (at best) if increasing the minimum wage will have positive, neutral or negative affect. Therefore, I am not sure it should be advocated for. Perhaps you have some alternative ideas?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I am attributing it to the 2008 recession, not some obscure factor. Obviously when unemployment goes up sharply in a recession, unskilled labor takes the biggest hit and that’s what that chart shows (to me). Are you suggesting that the sharp upwards trend in unemployment that started in 2008 is somehow due to MW increases?

            Here is the problem I see. The jobs we are creating now are in large part low paying jobs, jobs that cannot be off-shored or replaced by automation. If we don’t raise the minimum wage by a lot more than the measly 10.10, we will end up with a large segment of the population working full time and still being unable to live with dignity, which means that the fewer and fewer middle class taxpayers will have to pay more in welfare, which in turn will impoverish the “middle class” even more. At some point, if allowed to continue on this trajectory, there will be no one left to pay, no one left to “consume”, and hence no jobs at all, but before that happens, there will certainly be catastrophic upheaval.
            Why would we want to do that? The largest one time increase in minimum wages occurred in 1950 (Truman). Corporate taxes used to be sky high compared to current levels,unions were strong, and the country did much better. Now we have a smoke and mirrors “economy” on Wall Street and one fifth of our kids living in poverty and Medicaid pays for half the births. How can this be good for the nation? It doesn’t trickle down. It never did. He was wrong on this one, and we need to fix it before it’s too late.

  • buzzkillersmith

    Medicaid is crappy insurance for pts and for docs, always has been. In this society people get what they have the power to claim, not what really helps out.

    If Medicaid were Medicare, which pays much better, ED docs would suffer less abuse perhaps. Co-pays would help. Don’t hold your breath.

    And it would cost society more money, so there’s that.

    An old family medicine saying is that anyone with a dime to call you can ruin your day. To get seen in the ED you don’t even need that.

    As Dr.L. well knows, a doctor who has no “barriers to entry” is in a bad way. In the ED you are available to everyone with a pulse–or even without a pulse. A tough gig, even worse than primary care. It won’t get better.

    Not to worry. This country feels OK about your hurt.

    • querywoman

      Social services don’t exist for the benefit of the needy. The food stamp program exists to benefit the USDA. Medicaid keeps hospitals from having to eat medical bills.
      Most hospitals love Medicaid for laboring women. It’s a costly one time admission, even though routine childbirth shouldn’t be profitable.

  • Robert Luedecke

    I am very sorry so many people come to the ER who would be better served in physician offices. One way you can help Medicaid patients choose more wisely is to offer them a cash payment if they are able to go for six months without anyone in their family using the ER. If they go once they get a lesser prize. More than that and they get no prize. This way everyone gets skin in the game and no one is excluded because they don’t have money.

    Did you know your state legislature is the one that determines how much Medicaid pays in your state? The feds will pay the same percentage of whatever the state decides to pay docs. If the pay is bad, like in Texas, talk to your legislator.

    • querywoman

      What would really help Medicaid is to bring the reimbursements up to the Medicare level so they can get private docs!

      • Robert Luedecke

        I agree with you entirely and it is very short-sighted of state legislators to put politics above patients.

        • querywoman

          Exactly, Robert. This blog tends to come from the doctor point of view, that Medicaid is low quality care that no one wants it.
          Oh yes, the uninsured want it.
          When I worked in public welfare, the people who weren’t eligible for Medicaid sure did want it. They could get their care at public clinics, but the waiting, especially for the meds, was hard.
          With Medicaid, they can go to a private pharmacy.
          I don’t see a lot of doctors posting here who work the public or semipublic clinics.
          The ACA has done nothing to deliver care to those below what I’ll call the middlepoint of the middle class.

          • buzzkillersmith

            You’re right that Medicaid is a huge improvement for people who were previously uninsured. As we all have said many times at this blog, the ACA is insurance reform, not HC reform. The ACA has huge flaws but decreasing the likelihood of financial catastrophe for people is an advance for this country.

            That said, you are 100% right to note that a lot of these folks will be in for a rude shock when they try to make appts with private docs, the type of docs (me included) who post here. They’re not going to make it to the “middlepoint of the middle class.”

            Many will go the the Community Health Centers, and I suspect (but don’t know for sure) that the CHCs will have improved finances.

            A lot of CHCs are staffed by dedicated, competent professionals. Many are training sites for residents. We just hired an NP from CHC in Tacoma and she is great. I probably should not add that she left because she couldn’t stand it anymore.

          • querywoman

            Working in public welfare is like working in a CHC. After awhile, most of us get to the point where we just can’t take it anymore.
            Having a private doctor usually means not having to wait for hours in a crowded clinic.
            The rude shock already hit over the $600 monthly ACA plans and most didn’t buy it because they couldn’t afford it.

  • guest

    I hate to say it, but you have a point. My treatment team and I have noticed that the families who invariably demand multiple meetings with the doctor, instantaneously returned phones calls from the social worker, and free housing for individuals whom they no longer wish to support, are the families without any payor at all for the services they are using.

    • Patti Carroll-Frey

      Have you ever wondered if those demanding Medicaid patients are speaking up because they are tired of being ignored and turned away in so many parts of the healthcare system? Besides…shouldn’t everyone be allowed to speak up for themselves money or not? And I have worked with an intense population in the past. I have seen it as the case manager.

  • Shirley Girdner

    Considering Medicaid provides for over 9 million persons with disabilities (including 1.5 million children) some of who can not speak, can not hear or can not see and have never been able to go to school or go to work, I think you might be expecting a bit too much to expect them to say ‘thank you’ for saving their lives.

    Yes, I suppose you could say some of those 9 million persons could have “come to view themselves as part of a helpless recipient class who is condemned to a life of boredom and apathy and whose only purpose is to take as much as they can as a measure of success” but it does sound sort of crass to do so,
    You’ll have to excuse me if I don’t sound too sympathetic to the doctors. Perhaps they should pursue a different profession – law, perhaps.

    • DoubtfulGuest

      There are lots of ways to convey ‘thank you’ that don’t require ability or education. I don’t think that’s too much for doctors to expect. They’re thoroughly exhausted much of the time. Saying ‘thank you’ in one way or another also benefits the person saying it. These basic exchanges are one of the few things that connect us all as human beings. If we lower our standards so much as to dispense with ‘thank you’, what do we have left?

      • Shirley Girdner

        “There are lots of ways to convey ‘thank you’ that don’t require ability or education.”
        Oh, for goodness sake, what is that supposed to mean? I’ve been in quite a few emergency rooms and have always been treated well – obviously, because I’m still alive. But to imply a patient is able to say “thank-you” to the doctor/s they have seen is kind of silly. Doctors leave their shift or attend to another patient, and someone else stops by and administers an IV or medication. Frequently a patient is so distressed or in so much pain, they can hardly speak and/or are incoherent. I’ve seldom been able to say “Thank-you” to the ER doctor because as a patient I didn’t even know the last time I would see the doctor. Understandably, they seldom stop by and say “good-by.” Someone else comes in and tells you can leave or be transferred to an observation bed.
        Additionally, most of Dr. Leap’s complaints were centered around the idea that Medicare patients were demanding too much “free” care even though they were sporting other signs of “wealth” like a cell phone, jewels or nice cars. If they are scamming the system they should be reported. However, if someone wants to pursue who is scamming the system, I think you will find that it is also unscrupulous doctors and providers of other medical services. They cheat the government and insurance companies of hundreds of millions of dollars yearly – possibly billions.

        • DoubtfulGuest

          I’d just reflexively thank them every time I see them. Problem solved. I think if a patient is truly incoherent or unconscious, the doctors are not expecting to hear thank you. They’re not stupid. If family/caregivers are present, they can say thank you in those instances. We can say the words aloud, write it in a note, smile gratefully. Children have more options — hug the doctor, touch their hand, whatever.

          Do you have a reputable source for your claim of widespread fraud by medical professionals? I am not necessarily anti-Medicaid. I personally do not closely examine other people’s possessions, and I have mixed feelings about those arguments. But if we’re going to bring up “thank you”, I’d like to examine medical professionals’ underlying feelings of being drained of time and effort with no appreciation for their work. Those feelings sound legitimate to me.

          • Shirley Girdner

            Doctors are reaping millions through fraud and yet you’ll find one here and there that worries about a patient’s cell phone or that they really weren’t at death’s door when they arrived at the ER. You really should do your own research on fraud by doctors and medical professionals, but here’s a start:

            “The state of Missouri recovered more than $47 million in fraudulent claims made by Medicaid providers in 2013.

            That’s about an average year for Attorney General Chris Koster’s Medicaid Fraud Unit. The office has recovered as much as $100 million, and as little as $20 million, in a year.” (Note Medicaid PROVIDERS) and this is one state!

            http://news.stlpublicradio.org/post/mo-medicaid-fraud-unit-recovers-47-million-2013
            and

            http://www.hhs.gov/news/press/2013pres/05/20130514a.html

          • DoubtfulGuest

            Ms. Girdner, I’ll get back with you after I read some more. Generally people here provide sources to back up their own claims. We seem to be looking at the Medicaid issue from completely different angles.

            Despite our disagreement, I really like your profile photo. What kind of insect is that?

          • Shirley Girdner

            As far as I know it’s an assassin bug (a true bug) The photo has no hidden meaning, I just like to take photos, and I consider this bug a welcome insect in the garden because it helps control garden pests.

          • DoubtfulGuest

            They’re neat-looking. I know I’ve seen them around but couldn’t think what they’re called. One of my best friends is an entomologist. Do you have flowers mostly, vegetables — or both?

          • Shirley Girdner

            About half and half.

          • DoubtfulGuest

            Okay, I read the information you linked and a few other sites. I knew fraud was an issue but I didn’t have a sense of numbers. I still don’t know much about fraud on the recipient end of Medicare/Medicaid but there’s that, too. I noticed on the HHS site, there were relatively few providers responsible for large fractions of the total, e.g. > $8 million between just two people who worked together. But the Missouri article showed that the small-time stuff is a problem, too. It seems that some low percentage of doctors are committing fraud. I don’t disagree with you that it’s a problem and it’s an important facet to the discussion that you brought it up.

            I know one doctor in my area is struggling to keep his practice open because most of his patients are on M/M and reimbursements are so low. His specialty is not one that has a lot of procedures. Just a couple of diagnostic tests and those programs have recently made drastic cuts in reimbursement for those tests. That is a problem with the program, not the recipients. But I can understand the doctors’ point of view on some of this. There are others in the same boat as the one I mention. You make some good points as well. I wish I knew a good solution.

    • Tom McFadden

      Who are “they” who should pursue a different profession? Perhaps you should pursue medicine.

      • Shirley Girdner

        Thanks for your kind suggestion, but considering I’m only 80 years old, I think I’ll take a rain check. The “they” are medical professionals whose first concern appears to be to determine if the patient is there because he or she is abusing Medicaid and whose second concern is whether the patients are thankful. It just sounds kind of lawyerly to me.

        • Tom McFadden

          How would you possibly have the first clue that “medical professionals…first concern appears to be to determine if the patient is there because he or she is abusing Medicaid”? Do you think that the physician has a right to know and a responsibility to determine that?…or are you simply satisfied that abuse of the system is fine and should be augmented. Where is the responsibility?

      • querywoman

        Oh wow! Is your solution for everyone to understand medicine to get a job in medicine? You people are a significant minority in the US.
        The rest of us work, vote, pay taxes (everybody pays taxes), and all that other stuff.
        Open your viewpoint to see how the rest of America views doctors.

    • Tom McFadden

      “Is not the critic who counts not the man who points out have a strong man stumbles, or where the doer of deeds could actually have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but he does actually strive to do the deeds; he knows great enthusiasm’s, The great devotions; he spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and at worst if he fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”
      Theodore Roosevelt

      … Or as one of my mentors taught me, “if you want to be the captain, go to captain’s school. “

  • querywoman

    When I worked in Texas welfare, and I left over two years ago, Texas chose not to make our Medicaid patients pay a small copay for their medicines.
    Other states had tried it, and it increased ER expenses when they would not fill their meds.

  • querywoman

    I am not a doctor, but I had plenty of people thank me for their food stamps, Medicaid, and welfare checks.
    Listen to them!

  • querywoman

    Absolutely! When I worked in public welfare, I never paid attention to my client’s clothing or hair, like some of my coworkers, with one exception.
    A grizzly near-homeless man who lived in a motel with his concubine and her grandchild came in wearing a brand new long-sleeve turquoise cotton shirt!
    And he might have got it from a church!
    If he had spent some of his pitiful wages on that shirt, that was fine with me.
    He cared deeply about that child, too! Was pleased when she called him, “Daddy.”

  • querywoman

    Some people lose a job and then go up Medicaid. The Medicaid limits for family income for children is really quite high!
    Murderous father Neil Entwhistle had Medicaid on the baby he killed.

  • querywoman

    Supposedly this is the kind of setup some larger ER’s have – a clinic for the less sick.

  • querywoman

    On paying attention to what other people have and use: the electronic debit cards were supposed to put an end to some of the stigma of food stamps.
    I interviewed a woman in my welfare office. I saw her the next day in a grocery store using my debit card.
    She said, “She didn’t know that someone who worked there can have a card.”
    Yes, if they have enough family members they can.
    I told her it was a bank debit card.
    The truth is it’s nobody’s business what kind of payment card we use in a grocery store.
    I still have a food stamp card myself, with some stamps left from the two months in which I finished paying for dentures, and food stamps used the cost of my dentures to zero out my gross income those two months.
    I knew a medical doctor once who got food stamps for a while after a suicide attempt. Someone else had told her she could get them.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Well said: “the notion that one has the right to the fruits of their labor” has indeed been lost. It has been lost from the bottom up:
    http://www.bloomberg.com/news/2013-11-13/how-mcdonald-s-and-wal-mart-became-welfare-queens.html
    And since the people are being robbed of their fruits by giant corporations, they have no choice but to turn around and rob somebody else, just so they can survive.
    If we want respect for the fruits of labor, let’s make sure that everybody’s fruits are respected, so that everybody has at least a few apples to pay doctors with.

    • Judgeforyourself37

      By this nation allowing huge multi billion corporations to pay what is not enough to keep a cat alive, let alone a human, possibly a single mom with children, Medicaid will be a necessity. Blame the corporations, whose CEOs make multi millions, because we, the taxpayers, are subsidizing THEIR salaries, perks and other benefits.

    • PoliticallyIncorrectMD

      Is this your idea of social justice: “I’ve been robbed so let me turn around and rob someone else”? I think I’ve heard this before: “Expropriate the expropriators!” You might be aware of what the outcome of that social experiment was.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        My idea of social justice, as I said in the last sentence above, is to respect everybody’s fruits.
        No expropriators of any kind, and no special expropriation passes for some, but not others. This is not a chicken and egg situation. It has a fountainhead (pun intended).

  • SC Doc

    The hospitals get more reimbursement in and ER than an Urgent Care from Medicaid. It’s a small difference but when your loosing money on the patients, you take as much as you can get.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Of course those patients exist, and pounding sand sounds like a great venue to relieve frustrations. But we can’t build a system based on the behavior patterns of bad apples, which are there now, and will be there under any circumstances, from free-market to single payer.
    This line of argument is the same as the one coming from those wishing to enslave all doctors because some horrible fellow with an MD somewhere, is cheating Medicare or engaging in some other unethical or outright criminal activity.

  • LynneB

    I am not sure how anyone could come to the conclusion that anyone who had any other option would choose to spend several hours in an ER with sick people coughing and sneezing on them. Some people go to an ER because that is the only medical care that they can receive, i.e. adult with no children in a state without expanded medicaid. Or, maybe they are too ill to wait the 2 or 3 weeks that it would take to get an appointment with a Doc. It’s sad, but in some cases the poor go to the ER because it is within walking distance for them and they have no transportation to go to a doctor’s office.

    Oh..lets solve this with co-pays make sure these people have some skin in the game! In Nevada a single parent with 2 children receives $383 a month cash. Assuming that they are able to find a weekly motel for $100 a week, that means they have a $17 cash deficit on the first day of the month, but that’s ok I guess they can sell food stamps to pay the rest of the rent and the hospital co-pay. And while we are at it, take their phone away and make sure that the car they drive is worth less than $300. How in the world did you people get so stinking mean?

    • querywoman

      A single parent with two kids who lives in a motel is not a typical low income person, though.
      Most of the “poor” in this country live in apartments or houses with running water, toilets, and a means to cook.
      If such a person can get public housing assistance, they may live very comfortably. The many who can’t get housing live with other people: family members, friends, new boyfriends when the kids had different fathers, etc. It’s stressful to live with other people.
      If a person has Medicaid and calls Medicaid in time, they can get medical transportation.

  • Shirley Girdner

    Considering recipients of adoption or foster care assistance under Title IV of the Social Security Act are eligible for Medicaid, it would not be at all surprising that the person (foster or adoptive parent) would have a cell phone and/or a decent automobile, Certainly not all foster or adoptive parents are living in poverty and an ER physician or staff shouldn’t expect them to be. Furthermore, a foster parent is expected to make sure a foster child gets emergency care promptly when needed.

    Not mentioned in Leap’s article is the fact that effective now children who have aged out of the foster care system and were previously receiving Medicaid while in foster care will remain eligible for the full scope of benefits until they turn 26 years old. That, I’d guess, will cause Dr. Leap further angst.

    • querywoman

      There’s some kind of “hands up” program under SSI that gives credit for something like saving for a car.

  • Robert Luedecke

    I am sorry you think this is treating patients like children. If federal law prohibits us from punishing patients that go to the ER too much, we can achieve the same thing by rewarding those who use better judgement. We are giving them a reason to be more careful in deciding whether they need to go to the ER or to a physician’s office for care. Why is that bad?

  • g75401

    Wow…..yet another person who thinks that Americans are inferior to Europeans, Canadians, and Asians. We cannot handle the responsibility of universal access to healthcare and , yet, all those other societies can. Hmmm….maybe we should address just why these people are on Medicaid, the real reason they come to the ED at 3 am (and Yes, I work as an ED doctor and I see these patients), and why we see so much anxiety as the cause of their many complaints. We might just find our worship of that “market based” system may be at fault. Afterall, the real difference between America, Europe, and Canada is that, there, people are people. Here, people are commodities…

  • A.J . Matthews

    This topic about healthcare access, delivery, and utilization is extremely important as we plod ahead in medicine with all of the changes dictated to us by those who don ‘t actually practice medicine. I was an ER moonlighter during my surgery residency, and I have seen firsthand what goes on in real America. Let me state my opinions based on what I have experienced. First, anything perceived as free gets abused. If one doesn’t have to pay for something, what is received is not valued and respected as much as it should be. That is a simple fact. Second, healthcare is not a right. If you don’t believe me, go to a third world country and demand world class medicine for free and see how far you get. On the other hand, a civilized society should take care of the less fortunate as best they can. Third, if patients were better educated on what constitutes an emergency, they might use resources more appropriately. Here in California high school graduates are not required to know anything about health or medicine before they enter the real world. I offer some solutions to the current expensive mess. To begin with, make health education mandatory to get out of high school so that the populace understands that a bad cold is usually not an emergency. Furthermore, make ER visits cost something so that the experience is valued and not abused. Each capable patient or their parent should either have to pay money or donate time for community service for care received. Additionally, we need to have a system of triage so that colds do not make it harder to care for true emergencies. And finally, the government and insurance companies need to pay doctors fairly and in a timely fashion for their work. All the hugs, understanding, empathy, and prayers don’t pay the bills at the end of the day. Just my thoughts as a cog in this dysfunctional medicine machine.

  • Patti Carroll-Frey

    Medicaid is a life-saver for many. For all the negatives you see I bet I could find equal in positive. But your mind is set so you are not going to read the articles that state Medicaid recipients had health benefits and lived. And don’t forget about the privileged entitled rich folks in the ER demanding the world in seconds. It is so much easier to discredit the poor or disabled. As a patient and a nurse I have seen both sides and you need to walk in their shoes awhile. That is all it takes.

    • DoubtfulGuest

      True, I can think of a recent ‘privileged rich person in ED’ example among people I know. I honestly don’t know much about this issue and am trying to get up to speed. Interesting point – thanks.

    • querywoman

      In a very large hospital ER, a nurse told me that some of the wealthy are the most demanding. They think if they pay cash, that they can go first.
      A properly functioning ER triages patients appropriately.

  • A.J . Matthews

    Things I pay taxes for I do not perceive as free. I pay taxes for most of what you mentioned, and when I go to Yosemite each year, I pay to enter the park and to lodge there. I also get fined if I am caught littering. I apologize for not using the phrase “goods and services ” instead of “anything.” I figured that most responders on this site could distinguish healthcare and other services from sunshine and air. But you proved me wrong. Are you trying to pick a fight to defend your fantasy medical system or do you really think that a good sustainable business model consists of offering endless and expensive care to those who are misusing the goods and services without asking anyone to take some degree of responsibility for their actions? Is that same model how you would raise children? Let’s take a responsibility holiday and see how that works. Wait, that’s what we are doing now isn ‘t it?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      You made a statement, stating an absolute truth, and it was inaccurate. I just pointed that out.

      Now, let me point out that many Medicaid recipients work, pay some taxes (may look like a small amount to you, but not so to them), create value for industry, value which is taxed (unless legally evaded), and which contributes to the goods and services we all enjoy for free.

      Are there certain individuals who abuse the system, act irresponsibly, cheat and steal? Yes, there are. Some are on Medicaid rolls while others work on Wall Street or Washington DC or various other high places.I doubt very seriously that the Medicaid ones are costing us the most…
      Are we taking a responsibility holiday? Looks like we are. All of us.

      • PoliticallyIncorrectMD

        So Wall Street is not playing by the rules, how is this relevant to the fact that people abuse Medicaid (which I thought was the topic of this discussion)?

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          It is relevant for illustrating that in every system known to mankind, some people will find a way to abuse something. This does not mean that all systems should be dismantled in their entirety.
          It is also relevant because by comparison, Medicaid abuse is not the worst offender in this country, and “toxicity” is a mighty powerful term.

          • PoliticallyIncorrectMD

            Yes, every system can be abused. Some more than others. I don’t see anything wrong with dismantling those with high abuse potential, especially during the time when half of the country is dependent on one entitlement program or another (conveniently to the powers that be).
            Big corporations may or may not be evil as you paint them, but this is not the discussion here. Medicaid, remember?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Agreed. Half the country is dependent on this or that handout precisely because big corporations, with assistance from a corrupt government, are engaging in wholesale abuse of the system. If you wish to address one of the symptoms (i.e. Medicaid) , that’s fine. I’d rather address the root cause.

  • PoliticallyIncorrectMD

    There is no such thing as positive study with results that are not statistically significant. The whole point for evaluating statistical significance is to accept or reject the results. In this case the results should be rejected. Also, any results can be made statistically significant if you choose large enough sample size. This is not science, just playing games with statistics.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    You’ve got to be kidding :-) Israelis are, how shall I put it, very outspoken. Here they would be defined as plain rude. Yelling and screaming in the waiting room is not unusual. I have some friends that went to Israel on vacation, and the husband had an accident which required hospitalization. They were appalled by the “discourse” in the hospital and the general mayhem, but the doctors here said that the surgery was a masterpiece and 100% recovery is expected in record time.
    Also in Israel, there is no Medicaid. Everybody has the same “insurance”, which helps too. And yeah, doctors do strike when things get bad enough (carefully as to not endanger lives). I like that they can do that….

    • ninguem

      The same Israeli docs, and docs from other countries that might be stereotyped as “outspoken”……Italy? France?……take your pick…..when I see them in the USA, they are appalled at the amount of opiate we throw at patients.

      It’s the inflated expectations.

      At the risk of speaking for Dr. Leape, he would likely be pleased to have people in his ER who **only** engaged in yelling and screaming.

      Remember this is yelling and screaming AND a very real threat of litigation to enforce the inflated expectations.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        You’re right about the litigation thing. They don’t sue doctors that much over there, and I think there isn’t as big of a drug problem, or gunshot problems, or any number of other typical American ER problems. But there is a very strong sense of entitlement regarding comprehensive care. Everything is so much smaller though, and much less diverse… Not sure Israel is a good comparison to the US… Not sure if any other country really is, through no fault of doctors or hospitals or even insurers for that matter.

  • Ncmedic

    Thank you for posting! I am a paramedic and see the abuse of Medicaid everyday. Is calling 911 and having an emergency ambulance respond for a stubbed toe appropriate? How about a swollen zit? Or a 12 year old boy with a wedgie? Also, it is not a rare occasion that I arrive at a residence to find a Mercedes parked in front of a beautiful 4,000 square foot home with large flat screen TVs for a non-emergent issue for a pt that provides a Medicaid card when asked if there is any insurance they would like to use for the trip.

    • Deceased MD

      OMG. I am so glad i am not a paramedic. What is your guess on the Mercedes owner with medicaid?

      • querywoman

        I would assume family member has Medicaid, like college age daughter who has no money and got herself knocked up.
        Whether or not her parents should provide for her is another matter.
        Do you blame her for getting public benefits? Her parent don’t want to be bankrupted, and she is legally an adult.
        When I worked in welfare, I had a young women whose dad in a rich part was paying her rent straight to the landlord, so it didn’t county for my purposes.

      • querywoman

        A rich family could also have a lifelong health-challenged child who got SSI at 18. The family has been careful not to put money in the child’s name, and may be setting up a trust.
        Without Medicaid, the hospital gets to eat the ER expense.

        • Noni

          A rich family could also be working under the table but have no documented income, thus qualifying them for medicaid. My mother in law gets her nails done by a Vietnamese family who live high on the hog because all of their income is undocumented.

          • querywoman

            Yes, that’s common among Hispanics where I live. They don’t leave much of a paper trail. And they want every government benefit they can get.
            US citizens, at least the ones I know, don’t know how to make fake ID’s.
            I had a relative who died was married to a bookie. He’s probably smart enough to declare just the right amount of income to get by.
            The feds got Al Capone on federal tax evasion.

          • querywoman

            Mentioning the bookie, who is an in-law who I only met once, has my fingers typing more.
            He used to be bank veep. After a couple of banks closed up on him, he lived on investments.
            His son with first wife was born with epilepsy, fairly constant seizures, and resultant mild retardation.
            I assume the young man went on SSI and Medicaid at age 18. As an adult, he usually lived in group homes. He could have been visiting one of his parents when he had a seizure.
            I doubt that he had enough gumption on his own to call 911 over something trivial.
            I doubt the paramedics ever minded transporting him.

      • Ncmedic

        I hate to make generalizations such as these, but it’s hard not to when you see the widespread abuse of entitlement programs- and I see it on a daily basis in the line of duty. I walk into these people’s homes and see that they are living very comfortably on the taxpayers’ dime and don’t seem at all motivated to change that. It’s very bothersome to me, especially because I work 72 hours a week and can barely afford to make ends meet….then I look at my paycheck and it adds insult to injury when I see how much I pay in taxes every two weeks….

  • querywoman

    Xactly! You don’t know if someone owns this or that expensive possession.

  • Bob

    If you’ve been around before and after “charitable immunity” died and Medicaid and Medicare were born dislodging neighborhood care and church based facilities you’d understand the causes and the obvious results we will eventually get, as triage becomes the basis for ER care.
    Those shouting rights will take a long time to be seen, while those too far gone will be comforted and treated for pain. Free insurance which has come before makes everyone cherish their health and physicians and use their care more, while more entitlement come into existence and press for every available appointment and going to ER’s when unsuccessful.
    ER’s this year will see, if not treat many more folk, because the number of care givers didn’t increase January 1, 2014 and won’t be able to compensate for the number of caregivers who join the Medicare ranks, work less hours as their newly minted replacements won’t work over 40 hours, and in general find areas where they don’t have to be the good Doctor, only a good doctor..

  • medicontheedge

    Right on! Medicaid clients have NO throttles. NO co-pays. NO reviews of usage. NO skin in the game. It’s “FREE”!
    THAT has to change. They must have co-pays, and reviews of usage, because there is massive misuse and fraud. The insurance that I. as a taxpayer, provide for them, should NOT be a better plan than mine, that is more expensive every year.

  • Joe

    In my opinion, the problem here is far less an issue with Medicaid. The real issue should be EMTALA reform, yet that has gotten pretty short shrift in the article and in the comments.
    On a very distant sidebar, the Pope’s comments about the economy are pretty standard Catholic items. That some have decided to exalt them as novel in this case is more an effort on their part to cast a certain image of Francis that is in dissonance with Catholicism. I can’t deny that the campaign is a rousing success at this point, but check out what the prior two popes have said on the subject. Some of their comments are far more “lefty” than anything from the current guy. Catholic ideas of economics are neither left nor right. They are Catholic.

  • Judith Johnson

    Thanks for your honesty, I agree with you.

  • Gaspere (Gus) Geraci

    Great points, but I posit that those select Medicaid patients will not change, so the system has to change to figure out a better way. Attaching a primary care clinic to the ER and triaging 24/7 may be a solution for higher volume ER’s, but is not a solution when the volume doesn’t justify another provider available. As a Family Doc and ER doc I more than feel the pain and frustration and lived it. At 3 AM, amidst severe traumas and illness, “Tell me again why you’re coming in for this rash you’ve had for three months and isn’t any worse?” Patient, “I was awake, and there’s usually not much of a wait at this time of night…”

  • dontdoitagain

    I’ve saved people’s lives by NOT running over them with a big rig. *I* generally get flipped off for not getting out of their way fast enough. Does that count?

    Also medicaid has a back end to it. It isn’t free, it’s just a bailout for the medical community whereby the government takes over the “accounts receivable” for the patient, just like a collection agency. The BILL is still due and owing but to the government instead of the hospital et al. You guys should be thrilled to death that people like me (taxpayers) are paying your freight.

    Then medicaid goes after any assets the patient may have. The medicaid patients better HOPE that they never get ahead, ’cause if they do the government is waiting to pounce to recoup their “losses”. Like the government has losses. They just grab it from the taxpayers. You get the money, we get the bill, the government is the middle man. You get paid don’t you?

    • querywoman

      I get blasted when I talk about the years I worked in welfare. Gonna write about something else the poor do all the time: sue!
      They get $2000 settlements for slipping on a banana peel, etc. Then they blow the settlements as fast as they can and stimulate the economy.
      I really feel for the lawyers who take these yoyo cases! They have to be hungry to put up with that. I can’t imagine making a living listening to that stuff all the time.
      And some of these types file serial lawsuits.

      I verified some client’s settlement with his lawyer on the phone, which the lawyer politely did, and said, “I won’t be representing him anymore.”
      Remember how George Zimmerman’s trial lawyer dropped him after he got off the hook?

    • querywoman

      It’s so hard, but the best response when a serious vehicular accident is avoided is to be thankful and not do the flipping off and blame and shame!

  • querywoman

    Texas used to “lock in” Medicaid patients who were high users and went from doc to doc or pharmacy to pharmacy. They’d get locked in to a certain doc or pharmacy.
    Now that Medicaid has changed to managed care, I don’t think they do that anymore.
    A Medicaid PCP is responsible for coordinating their care.

  • ninguem

    Those who finished training just when Medicare and Medicaid were started, found themselves riding a gravy train. The system poured money at them.

    The result was, in 1965, cost projections tor the year 2000, were reached by 1970. Then reality hit, and payments have been ratcheted down ever since.

    It’s an old story, “unlimited demand for free stuff”.

    And the fact remains…….I don’t care if 100% of Medicaid recipients are saints walking on water. If my practice took Medicaid, I’d go bankrupt. Period.

    There’s no way around it, pontificate all you want. It’s not a matter of doctors “making too much money”, if I worked for free, if I took any significant amount of Medicaid, I would not be able to pay rent and pay staff and supplies. I would go broke.

    The community health clinics, the hospital-based clinics, they get outside funding sources, grants, and are allowed to pass-through cost. The “facility fees” that so many of use keep banging on about.

    Put simply, these facilities are able to extract higher payments for the same service.

    Whenever I’ve been able to look at the financials of the big places treating Medicaid (nonprofits file IRS Form 990′s, and they’re public documents), it becomes clear, they get more per public assistance patient than I get from private insurance, for the same service.

    So no, don’t expect private physicians to take Medicaid in any significant numbers. It is to the doctor’s credit if the doc takes any Medicaid at all.

    • querywoman

      Most decent private docs can’t take Medicaid unless they limit it to a small percentage of the practice.
      I had a decent FP once whose staff told me would take Medicaid for family members of his patients.

      There was never a gravy train on Medicaid, just Medicare. Most doctors refused Medicaid from the start.

  • Judgeforyourself37

    Perhaps people do not wish to face discrimination due to the fact that they are on Medicaid. It happens, believe me it happens, and it is unprofessional treatment of an ill person. Are there “users” who are problem patients and on Medicaid, of course there are, just as there are demanding, “entitled” people who have the best health insurance and are ultra wealthy. There are rude people in every ethnicity, social strata, income level, color and creed. You cannot generalize, every person is different. However, as a patient educator, I saw many, who were on Medicaid, who were glad that they could finally see a doctor and get needed care. Did some need extra time to enforce what they needed to know, yes, but that is what I was supposed to do. It was not just the Medicaid patient who needed that extra reinforcement, fear, and anxiety, impede one’s ability to absorb information.

    • guest

      I have seen 2 types of medicaid patients. TWO types. One is the nice, grateful, appreciative to have care medicaid patient. The other is the ungrateful, demanding, entitled, never ceasing to stop asking for favors medicaid patient. I can honestly say I have not seen anything in between.

      • querywoman

        I use public transportation, which now accommodates wheelchair users. I saw one guy, strapped in his seat, with some kind of arm problem, who got very hateful with the driver.
        I didn’t know why. I offered to help him. Neither the driver nor I got anywhere with them. Then the driver said she might call the transit police.

        That guy is the ungrateful kind.

  • dougmcguffmd

    Good gosh! Have you ever spoken to a cop, fireman, school teacher? These are some of the most abused and disrespected people in our society. The common thread…they are “free” and government run.

    Google (verb) “The Tragedy of the Commons”.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I am familiar with that tragedy and with its close relative the “moral hazard”. Let me ask an honest question here: what do you suggest we do? Surely we can’t go back to private police and such….

      • PoliticallyIncorrectMD

        How about we start with acknowledging that the problem does exist and the abuse is widespread.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          OK. Let’s do that. What’s next?

          • PoliticallyIncorrectMD

            How about we create an anvironment when patients with non-life threatening illness are discouraged from coming to ED.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I’m good with that. So let’s also get rid of the billboards and TV commercials and apps encouraging paying customers with non life threatening illness to come to the ED. Looks kind of weird otherwise….

          • PoliticallyIncorrectMD

            Completely agree – same rules for everybody.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Does this guy look like his life is in jeopardy?
            http://www.ssmhealth.com/er/gusanddave

          • PoliticallyIncorrectMD

            Looks like the guy had minor trauma. If you follow the links on the page, they suggest you go to their urgent care – very appropriate.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Completely agree.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yep. I’m still in Missouri, so I am familiar with that. The point isn’t that abuse will never happen, and the point isn’t that we shouldn’t do our best to lessen abuse (it will never be zero). The point is that just because abuse happens, doesn’t mean that we should stop trying to help people in need.
    After all, we don’t stop giving all people in pain medication just because some will surely abuse it.

  • DoubtfulGuest

    Also, substantial delays in reimbursement and denial of legitimate claims?

  • Shirley Girdner

    “I find myself trying to determine whether they are a person who is down on his luck who has lost or doesn’t have insurance, or whether they are a person who is taking advantage of the system.”
    Whenever you see a Medicaid patient I would think your dilemma should be trying to determine what illness or symptoms brought the person to you and what treatment they require. Silly me.

    • PoliticallyIncorrectMD

      Why? Becoming a physician one does not stop being a human.

  • querywoman

    How arrogant! They thanked me for certifying them for Medicaid.
    No insurance company provides medical care. They are payment/reimbursement systems only.
    I have thanked for more people for giving them welfare benefits and also for assistance with income taxes thank by doctors who provided me services, usually questionable, at a very high cost.
    When I pay out good money and request treatment for a problem with symptoms, that is not an excuse for a doctor to ignore the problem and try to coerce me into this-or-that preventive services. That’s redistributing my wealth for nothing.
    I have devoted a lifetime to staying alive and fighting the medical profession to do so. Where’s my kudos?

    • Tom McFadden

      You cannot be thanked to give away what is not yours. That is embezzlement.

      • querywoman

        One of the main reasons I maintain my anonymity is the volatility toward the poor whom I have served. Yes, they thanked me. Were there words meaningless?
        Many medical doctors have no problems with the transfer of funds from employee or government-related insurance to them, and have often perpetuated fraud to get more than their fair share,.

        Not many doctors have thanked me for money, including all the times they took my money, ignored my illnesses with symptoms, and tried to coerce me into some preventive measure.
        Then I’d end up at the Emergency Room for what they failed to treat.
        Yet, we lack an efficient complaint system against the medical profession.
        The poor are sitting ducks, easy targets, for criticism.

      • querywoman

        Tom McFadden, the ER by law and the EMLTA serves all. So by your logic, the doctors in the ER are also giving away what is not theirs. It is a service provided by law. And thanking them for what they are legally supposed to do is also embezzlement.
        I wrote my response about having been thanked in the public welfare system for benefits to point out that I believe some Medicaid patients do say thank you for medical servies.

        • Tom McFadden

          The law is called Emergency Medical Treatment & Labor Act (EMTALA) and just because it exists doesn’t mean that it is just or right. It is a self serving political move. Doctors don’t “give away” because of EMTALA. They are REQUIRED to treat those patients who show at the ER. Imagine if this type of law applied to every business. We wouldn’t have any business! You clearly don’t understand the law. The social worker who grants Medicaid privileges is not providing any service and therefore only transfers the liability to someone else. There is something fundamentally wrong with this concept.

          If you want to really understand what goes on in the medical field, start working in it. Being a social worker doesn’t qualify. You have no idea unless you are in it.

          My response did not concern whether or not whether you or I are thanked. It concerns what is ethically fair and just. Whether or not we are thanked is a lesser concern. All the non-physicians and non-nurses trivialize the efforts of the medical workers and their lifetime efforts. Others imply that the entire medical profession is fraudulent or uncharitable. Quoting a government study as fact or proof is laughable as these are frequently known to have incorrect assumptions and therefore incorrect conclusions. Government, in my personal experience, is stunningly inept. This is ridiculously stupid.

          EVERY time a doctor even accepts Medicaid or Medicare, they are accepting charity. I bet you don’t even know why…it’s because an office full of these patients can’t even pay its own bills. Moreover, it’s been that way for over 20 years! It is more than hypocritically ludicrous to get advice from those who have “no stake in the game.” Unless you are actively helping solve the problems, I would suggest that you keep your opinions to yourself. There is ample evidence to show that the system is abused, fraudulent and wasteful on the patient end. There is not an endless pot of money and resources which can be tapped forever. The sooner we realize that, the better off we all will be.

          • querywoman

            Oh wow! You think I don’t know that Medicaid reimbursements are substandard and that the average doctor loses money on them?
            Do you think doctors are the only ones who vote?
            On the internet, there are few secrets about any profession anymore. Yes, doctors do have high average salaries. Look it up!
            There has been an awful lot of fraud from doctors and hospitals, too: over billing, double dipping, etc.! The resources are not unlimited there either! The private and public insurers invent new ways to stay ahead of fraud all the time.
            It gets harder in the modern world of superior computer matching systems all the time, but someone will always cheat.
            Texas Medicaid dentists did tons of baby root canals and put too many braces on children without adequate permission not too long ago.
            In Texas, the reimbursements are so bad that most decent private doctors cannot take Medicaid, unless they limit it to a small percentage of their practices. I have noticed that many obstetricians and surgeons do take Medicaid. Of course, their pay is higher per procedure.
            Some doctors on KevinMD apparently do take Medicaid. It may pay higher in other states.
            The assumption that only medical professionals know about the health care business is wrong and arrogant!
            Medicare is not charity, and the reimbursements are higher. Aren’t you a plastic surgeon? Wow! Optional services for a people that pay big private bucks. Do you do some stuff like accident reconstruction for which you get third party reimbursement?
            I was not exactly a social worker anyway. I was determining financial eligibility for public benefits. I do understand laws. I was getting paid to provide benefits according to law as fairly as I could, just like personnel in an emergency room provides care.
            And supposedly many public clinics and hospitals wouldn’t want to treat our clientele unless they had Medicaid. I don’t know if they did or did not. It’s hard to sort out the truth.
            I started to believe the clientele in my last welfare office that the nearest public clinic turned away people without money when they were busy.
            Government inept? I’ve worked with a lot of inept government workers. I am quite a perfectionist, and it drove me nuts. I worked with college degreed people who let their checks get garnished over student loans without even reading the letters and exploring deferment and forbearance. Of course, most of them never opened their handbooks to look up policy either.
            Is private business any better? After I left public welfare over ten years ago, many public welfare services, like food stamps, were privatized. And then food stamps were delayed three or four months. It took many years for the state of Texas to recover from that.
            My issue was that disadvantaged people often thanked me for my services. I refuse to believe that the same disadvantaged people never thank a medical provider.
            You turned it into a political lecture against me.
            What do ER’s get from the uninsured patient without Medicaid? Zilch? Then write off a much higher bill than the average insurance bill as a loss? I want to know about that one!
            I worked for the IRS briefly after I did state welfare. I never had a problem with taxpayers, most of whom were at least responsible enough to work.
            Unfortunately, and this is my personal opinion, many of the poor in this country are not very responsible and are poor planners. Trying to get them to fill out enough of an application and check all the boxes to get assistance is very difficult! Irresponsibility leads to high ER use, too.
            We also seem to have a problem with low literacy, which some other major industrialized countries don’t have. Maybe we should glamorize learning.
            The medical viewpoint is not the only view of societal problems!

          • querywoman

            Hmm, the equipment and the meds in the ER’s belong to the hospitals, not the doctors. The doctors are just redistributing the property of someone else and contributing their know how of what to do with them. The law requires them to do this for emergent conditions.

            Have you ever thought of spending a night in a homeless shelter? Or a week? Let your beard grow. Wear your oldest clothes. Roll around on the ground some – get dirty! Leave your ID at home. You might find out what it’s like to be judged by your appearance.

            Of course, you would know that you know you could always go back to your home.
            But most people on Medicaid don’t live in shelters.
            My father had a job all my life, but he was homeless some when he was younger. I suspect he knew more about struggling to survive than you ever will.

            I’ll express my opinions just like you do.
            So doctors are overworked? I’ve been overworked on virtually every job that I ever had, whether I made minimum wage or more.
            Solutions? How about raising the literacy level of our lower classes? Many of them flat out don’t want to learn. Teach them about self-reliance. My opinion is they want someone else to do everything for them. Most of them can work a fancy cell phone or big flat screen TV. I can barely do either.
            Self-reliance? I changed my Medicare D for 2014, and I made dang sure I refilled all the meds I could before the end of the year. Sure nuff, I’m having problems with the new Medicare. I never believe insurance till I see it in action.

            Open your eyes to the rest of the world!

  • FEDUP MD

    The frustration I have is that although these cases are a tiny percentage of Medicaid patients, they really have an inordinate impact, in terms of number of visits and morale of health care professionals. Many people have indeed fallen on hard times or are disabled, etc, and Medicaid is necessary for this. However, there is a small but sizable class of people who are professional recipients of government aid, which often is passed down the generations. It also is symptomatic of a major problem in our society, that one gets more benefits by not working than by working. It is very frustrating when someone who has never worked a day in their life comes in with all sorts of nice items like a cell phone, nice car, designer clothes at 3 AM for a hangnail, when blue collar self-employed people who miss the cutoff for Medicaid but can’t afford private insurance are in tears because their appendectomy surgery will bankrupt them. Of course, if they just quit their jobs, everything would be paid for! What a perverse incentive.

    I had one case I particularly remember. A FP physician was married with two kids, one of whom was an autistic teenager who was violent and seriously injured the younger son. He needed to be placed in long term care for his and everyone else’s safety. Insurance of course denied . This guy pulled in about $70K in solo practice and his wife cared for his son. Not nearly enough to pay out of pocket ( I think it was around $150K per year). The only suggestions the social worker could come up with were for the couple to get divorced so mom and kids could go on Medicaid, which would pay.

    Of note, I do live in a state where Medicaid expansion has been blocked, and maybe this would solve some of these issues. Right now there is a big hole in coverage between those with no income who qualify for Medicaid, and those who make enough to qualify for even the subsidized policies. Lots of working class people are being punished for working. Is that the society we want?

    • querywoman

      This is a real prize of a post. Once a Nigerian immigrant nurse who also did ministry told me that only poor people need ministry.
      I live in a town with rich people, and I’ve met plenty of rich people with problems.
      The doctor you wrote about was not a rich doctor, but he had an autistic son over whom he had no control.
      I know a medical doctor, quite aged now, who last one child. His wife had breast cancer. He also has a granddaughter with cerebral palsy.
      He’s probably financially comfy, but he was powerless to fight certain medical problems in his own family.

  • querywoman

    Lots and lots of people do want medical care free. It’s free in Britain, with meds. In Canada, the docs are free, but patients pay for their meds.

  • PoliticallyIncorrectMD

    Dr. Leap,

    Thank you so much for your honesty and calling things what they are. It is so easy for some to speculate about fairness, compassion and justice when they can offer no practical solutions and want others to pick up the tab. It is much harder to speak the truth risking being seen as hateful and insensitive.

    Respectfully,
    PIMD

  • querywoman

    A lot of Medicaid types are gimme now types who can’t plan anything in life.
    They are a small part of the medical scene.

  • querywoman

    I didn’t have the time to waste in public welfare looking at what my clients wore or drove, either.

  • Ron Smith

    Hi, Idaho.

    Its interesting that the number of visits didn’t stop the Medicaid patients from using their maximum number of visits. But what do we expect different from human nature? If our income goes up and so then do our expenses.

    The difference I can see is that you charge $0.50 copay for each visit, not simply allow them a certain number of visits. Abusive Medicaid patients won’t even give that a thought!

    They have to have ‘skin in the game’ (yes I have learned to hate that well-used cliche) or they aren’t phased by it. Everyone else has to put up something to get health care.

    Just $0.50 was proven to be effective in making these patients think carefully before accessing care. All we need is a responsible consideration before accessing something that is so expensive.

    Warmest regards,

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

  • Suzi Q 38

    Oh, but there would be few patients if the patients had to pay.
    Also, I have a hunch that the hospital would have fewer patients.
    If so, less income.
    having an urgent care next to the ER makes perfect sense.

  • Suzi Q 38

    You forgot the homeless, who frequent the ER and just need a shower and a meal.

    • querywoman

      Suzi Q, in Texas, most of the homeless don’t get Medicaid. The ones who get it usually have a child under 18.

      • Suzi Q 38

        This is in California.
        Maybe the homeless do not need Medicaid to get the services of the ER free.

        • querywoman

          I can tell you the private and church hospitals around here get rid of the homeless in the ER as soon as they can.

  • querywoman

    Most people that we saw in public welfare were not really hungry. If we made them a food bank referral, because we could not give them food stamps immediately, and they went to the food bank, they were hungry.
    I have had some people who were truly hungry and needy.
    I had one black man, probably a tad over 50, who had been evicted after a lifetime of working. A police officer had sent him to me for food stamps, and I told him to go to a major shelter.
    He was grateful.
    When I asked him if he wanted to register to vote and use, “General Delivery,” as an address, he said, “Yes, so I still have some rights.”
    I will not thank any doctor who does little more than wrap a blood pressure cuff around me.
    I recently did a short stay in the hospital for pneumonia. With me, it’s who among the medical staff notices my skin lesions. Of course, I get the usual diddly “don’t pick” and “don’t scratch.”
    However, some people did pay close attention. I already have a marvelous dermatologist, finally, and some pay attention to what I tell them.
    I always wonder know if they would make me a referral themselves if I did not have a decent dermatologist.

  • rbthe4th2

    What about not for profits? I’d like to see them.

    • querywoman

      rbthe4th2, you know the not for profits and nonprofits are rolling in the dough.
      Church hospitals in my area expand all the time.
      I think “profit’ is called capital or operating excess for them.

      • rbthe4th2

        The not for profit monopoly is here rolling in it. Big time. The church hospital is struggling because the not for profit dumps to them – the ones who are Medicaid, etc. The one single stand alone just got a boost because everyone knows how the monopoly is and so they got a profitable $$$ making machine group of docs given to them.

        • querywoman

          Heh! Heh! What do you expect? All businesses are about money!
          Mother Theresa was parsimonious in her clinics. She sent a lot more money to HQ Rome than she ever spent in Calcutta.
          Nonprofit hospitals are subject to monitoring to see if their tax-free status is justified.

  • querywoman

    Aren’t the admin salaries more than the average doctor makes?
    I’m surprised that more people don’t rant on KevinMD.com about the insurance executive salaries. That’s where the real wealth is.

  • querywoman

    Texas chose not to require Medicaid recipients to pay a small copay for their meds because it increased medical expenses in other states that did it. Absolutely! Many of these people will do without meds if it costs a small two dollars and then end up sicker!
    Ditto for the emergency rooms.
    At this point, the problem does not appear to be fixable.

  • querywoman

    The irresponsibility has a lot to do with why many doctors don’t take Medicaid. Most of you decent private docs can only do this if you limit the percentage of Medicaid patients you take.

  • querywoman

    If primary care doctors, and I do hate the term, “PCP,” really covered their phones 24 hours, would the patients be running to the ER?
    In the past when I worked, under different health circumstances, I would have loved to have had 24 hour access to a doctor, perhaps some med called in for me.
    Never happened for me most of my adult life. I didn’t have that kind of access.
    I know my current internist, who has treated me in the hospital four times, has an effective answering service. But, if I’m sick after 4 PM or on the weekends, then I go to the ER. Age, diabetes, whatever, makes this necessary for me. But, since I don’t work, I can call in the daytime.
    Does the average American, with taxes, insurance premiums, and out-of-pocket pay the same percentage of income for medical care that the higher taxes Brits do?
    Quality dental care is not available for most people in either country. Do we get the same amount of care in reality?

  • querywoman

    This is interesting. What was she trying to do? Get some attention? I doubt you figured her out.

  • querywoman

    Ha! I worked n public welfare over 9 years. Reno may have a large transient population. I already covered the housing wait list by saying the ones who can’t get housing live with other people.
    You don’t go around questioning people who live in homes about whether or not they get welfare, do you? Like I said, most of the ones who can’t get housing live with other people.
    I had a family with three or four adults and a bunch of kids, maybe 12 in all, who lived in a 3 bedroom apartment. I doubt their landlord knew about them all.
    Me, make it look like the little bit they get is too much? No way!
    The article here is about Medicaid clients, and many lower income working people often get Medicaid for their children. They have homes.

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