The trouble with Medicaid

Medicaid is the partly state-funded, partly federally-funded health insurance program for low-income families. It's not Medicare - that is the national health insurance for all persons over age 65. The Medicaid program is available state-by-state to certain eligible groups, particularly low-income women, children and their families. In California, the state Medicaid program is called "Medi-Cal," and in 2008, of the 36 million California residents, 16% of the population received health insurance through this program. I happen to think programs like Medi-Cal are important and worthy of state funding. These programs allow women with low income to afford care when pregnant, it allows adults and children to receive basic medical care (vaccines, annual check-ups) and sometimes dental and vision care. However, as you have probably heard, the number of doctors who see patients with Medicaid insurance is decreasing. Why? If a program like this pays for basic health services to women and children in need, why is it such an unpopular program among doctors?

For starters, Medicaid pays doctors far less for providing care than other insurance plans. To add insult to injury, Medicaid fees paid in California were 83% of the Medicaid national average in 2008, ranking California 47th overall among states. Doctors also face a significant complexity to providing care to patients with Medicaid, as there are often specific rules, regulations and paperwork that must be completed to get approval for certain types of care. These issues makes the process of care frustrating, and as a result some physicians may choose to stop seeing Medicaid patients, because there is no rule that says doctors must see patients with every type of insurance in their offices. As a result, sometimes patients who are eligible for Medicaid seek care in emergency rooms, where there is a rule (the national EMTALA legislation) that everyone - regardless of insurance - must be cared for. Patients who come into the ER often have multiple chronic diseases that have gotten worse because they have not seen a regular doctor, and this can be frustrating for both patients and docs alike, since it can feel like there is no one but the ER and hospital to care for these patients on a regular basis.

Yet I still see patients with Medicaid insurance in my office. I have always thought it an important thing for me to provide the same care to patients of all income levels and all insurance types. However, my patience for my own philosophy was tested the other day, when a patient of mine came into my office because she was having trouble breathing. Let's call her Ms. Jones.

Ms. Jones has asthma, in addition to 3 other medical conditions for which she takes a total of 8 medications. Ms. Jones has Medicaid insurance, which helps pay for her regular visits with me and for her medications. She tends to have breathing problems in the springtime, when pollen in the air irritates her lungs and can cause an asthma attack. This was the reason she was seeing me in my office the other day. After examining Ms. Jones, I was concerned that she was on the brink of another attack, and so I prescribed a 5-day course of steroids, a relatively inexpensive medication, in addition to her current inhalers in order to treat her condition and prevent worsening of the attack (which could land her in the hospital).

The next day I called the patient to make sure that she was feeling better, and Ms. Jones told me that she tried to get her medications after our visit, but was told by the pharmacy that the 5-day course of steroid medication could not be dispensed because a Treatment Authorization Request (TAR) had to be approved by the state Medicaid office first. She was told her medications would be available in 1 week. I grew more concerned listening to the patient describe that she was feeling more out of breath than she did in my office, and her inhalers weren't helping. Wanting to prevent a serious asthma attack, which could be solved directly with the prescriptions I had ordered yesterday, I told the patient that I would call her right back after speaking with the pharmacist directly. I spoke with the pharmacy, who educated me that because the patient was already on 8 chronic medications, any additional prescriptions (regardless of why they were needed or how long they would be needed) could only be approved by a Treatment Authorization Request to the Medicaid office. The pharmacist suggested I call the Medicaid office directly to request a TAR override.

So, that is what I did next. I spent the next 30 minutes on the phone, talking to pre-recorded machine voices, attempting to speak to a real person and ask how to override a TAR for medications. Finally, I managed to speak with a representative who told me that the state office no longer does TAR overrides. However, she advised me that the pharmacy might be able to release the medications to the patient, as long as the patient was willing to pay cash for the full cost of the prescription. Nevermind that Ms. Jones is on Medicaid because she makes less than $20,000 per year. At this point, I thought to myself that this is exactly why some doctors don't take Medicaid. They don't want to deal with this frustration. It should be easier than this to get a cheap prescription filled for a patient the same day she needs it - rather than sending the patient to the ER to get the same treatment at triple the cost (not to mention the cost of seeing another doctor who would do exactly what I did yesterday).

I called the patient back. She didn't have any extra cash to pay out-of-pocket for her medications, and she was still feeling the same as she was yesterday. Ms. Jones was not in a situation where she needed emergency services, but I worried that if she didn't get her medications in the next day, she might. So I called another pharmacy - a different pharmacy - and as luck would have it, they were willing to provide the patient with the prescription medications and submit an authorization request to Medicaid so that they would get reimbursed next week for the medications they gave the patient that day. Several days later, Ms. Jones is feeling better and I feel good that because of my work, she didn't have to go to the ER.

What was the cost of my time to Ms. Jones for my efforts? I could have just told Ms. Jones to go to the ER, where she would have faced a long wait, a large bill and received the same treatment I prescribed. I don't get paid less if I send my patients to the ER. I don't get paid more if I spend time helping Ms. Jones get her prescriptions. That day, I didn't have the time, but I made the choice to make time because I felt strongly about the treatment I felt the Ms. Jones needed. Not every doctor has the time to do what I did for Ms. Jones, and doctors throughout California continue to withdraw from the Medicaid program. Who then will care for people like Ms. Jones?

This week, a new study sponsored by the California Health Care Foundation will be presented by researchers from the University of California, San Francisco (UCSF) and the Medical Board of California, examining reasons behind why doctors stop seeing Medicaid patients. It is due to be presented on March 26th at the Capitol in Sacramento. Let us hope that the information helps lawmakers and health policy leaders understand that doctors like me want to see Medicaid patients, but that choice is made difficult by our experiences. If we truly want to be able to provide good health care, our health system must allow the right choice to be the easy choice for everyone - regardless of insurance.